Since July 2003, when the Accreditation Council for Graduate Medical Education imposed a maximum 80-hour work-week restriction on medical residents, mandatory work-hour restrictions for medical residents have been in place.
Other more encompassing and restricted guidelines – such as the Institute of Medicine’s 2008 recommendation of a 16-hour maximum for consecutive hours – also have been suggested, and elements of these recommendations have been introduced into the new ACGME guidelines that became effective in July of this year.
Critics of longer hours argued that medical errors were more likely to occur when medical residents were fatigued and that a radical drop in resident work hours would serve as a better way to achieve optimal patient care. That may not necessarily be the case in neurosurgery, according to two reports available online in the Publish Before Print section of the Journal of Neurosurgery as well as department articles slated for publication in the February 2012 issue of AANS Neurosurgeon.
Travis Dumont, MD, and colleagues at the University of Vermont College of Medicine report increased complication rates on their neurosurgical service after the ACGME restricted the number of resident work hours.
There was no significant change in mortality rates between the two time periods. Although the authors found no definitive underlying cause for the increase in complications following the ACGME-mandated reduction in work hours, they hypothesize that increased turnover of patients from one resident to another, due to shorter work hours, results in less familiarity with serious cases and may be a reason for the rise in complications.
Aruna Ganju, MD, and colleagues at Northwestern University Feinberg School of Medicine conducted a study examining the effect of fatigue on seven neurosurgical residents’ skills. Residents performed simulation exercises designed to test their psychomotor and cognitive skills. They undertook a variety of ring-transfer tasks – which simulated the types of tasks required in a laparoscopic procedure and could test the proficiency of neurosurgeons – in a rested state (pre-call) and in a sleep-deprived state (post-call, following a 24-hour on-call period of in-house responsibility). Each set of exercises (rested and sleep-deprived) was repeated at least three times by each participant.
The residents’ cognitive errors, smoothness of tool movement, and time needed to complete each task were all recorded and analyzed. No significant difference in surgical proficiency between the pre-call and post-call states was found, although proficiency decreased 13.1 percent. The authors compared their results to those of a similar study involving general surgery residents. In that study, surgical proficiency decreased significantly (27.3 percent) in sleep-deprived residents.
The message of the papers is that a broad restriction on the number of work hours spent by medical residents should be reexamined. What is appropriate for one specialty may not be appropriate for others.
Dr. Choi notes that a close partnership between faculty and residents is critical to future neurosurgical advancement and improvement, as faculty involvement is vital to helping residents achieve and excel. The author concludes that while “there is much that is broken with this new ACGME-mandated system, the commitment of neurosurgical trainees remains a beacon of hope,” and that commitment to patient care will help the specialty overcome and advance in the area of improving resident education.