As neurosurgery residency program director at Cushing Hospital, Dr. Burr was accustomed to balancing the demands of a clinical practice and administrative duties. Never before, however, had he found himself at the center of such keen public scrutiny on the long hours worked by surgery residents.
A letter from a consumer watchdog group had been circulated among the hospital’s academic medical leadership. The letter complained that the hospital’s surgery residents—particularly those in general surgery, neurosurgery, and cardiothoracic surgery—were working unsafe hours and that patient care at Cushing was suffering due to physician sleep deprivation. The group indicated that they would soon be launching a media campaign about this topic.
Dr. Burr believed that his residents provided excellent care to all patients, and, while he acknowledged that neurosurgery residency required an especially grueling and demanding schedule, his program made every attempt to comply strictly with the Accreditation Council for Graduate Medical Education (ACGME) duty-hour regulations. However, this had become increasingly difficult. As of 2011, first-year residents (previously the backbone of the on-call schedule) could no longer take overnight call without direct supervision. The previous year, one resident had quit for personal reasons, which meant the remaining residents had to pick up the slack. Dr. Burr was grateful that the ACGME had approved his request for a 10 percent increase in duty hours to 88 hours per week. Such requests are granted to a handful of programs, most of them in neurosurgery, based on demonstration of “sound educational rationale.” But there was no guarantee this request would be renewed.
In recent weeks, Dr. Burr had come under pressure to defend his duty-hour arrangement from an ethical as well as an educational standpoint. Some of his fellow faculty members, who trained before resident work-hour regulations, believed that the education of future neurosurgeons was suffering and preferred that he publicly fight attempts to further restrict duty hours. They argued that neurosurgery was an exception to the general rule, owing to the long cases, complex anatomy, critically ill patients, small numbers of residents, and stamina of those who self-select as neurosurgery trainees. Other faculty, however, had opined that the danger of errors from overfatigued residents and loss of public trust outweighed the possible educational benefits. Meanwhile, other graduate medical education committee (GMEC) members at Cushing questioned whether the neurosurgery program truly merited an extension to 88 hours per week on educational grounds.
In the clinical teaching environment, every patient encounter has two equally vital purposes: first, to deliver excellent care to the individual patient and, second, to train a professional, skilled, and ethical clinician who will care independently for thousands of patients during the course of a career (and who may, in turn, become a clinical educator) .
In neurological surgery, the technical demands, lengthy duration of interventions, and the extraordinarily high-stakes clinical outcomes demand exceptional focus and personal dedication . Hence, the contemporary practice of neurological surgery is not compatible with the rigid duty-hour limits applied to current ACGME trainees. It is therefore axiomatic that one goal of training must be to prepare neurological surgeons to practice safely and effectively within a realistic duty-hour schedule before they practice without supervision. This training must build stamina, as well as provide the experience, judgment, and professionalism necessary to self-regulate fatigue, triage urgent clinical problems, and function effectively in a complex interdisciplinary care environment .
Without duty-hour exceptions, we have a system in which senior residents, typically in their mid-thirties, practice for years under artificial duty-hour restrictions and then, on a single day, are withdrawn from formal supervision and required to self-regulate. Alternatively, a carefully designed, focused, and specialty-specific duty-hour exception program can allow high-stakes and high-demand disciplines, such as neurological surgery, to prepare residents in graded fashion, under supervision, to cope with realistic practice environments.
The ACGME has created clear and compelling standards for the consideration of duty-hour exceptions for both entire specialties and individual programs. These exceptions should enhance the educational environment and improve educational outcomes. Moreover, exceptions may not compromise safe practice and excellent patient outcomes (and in fact should directly or indirectly promote them). Exceptions should be continuously monitored and systematically re-evaluated.
The 10 percent (88-hour) exception rule is specific to individual rotations within a residency program based on an educational rationale. It allows residents to participate in the longitudinal care of patients with evolving, complex neurological problems requiring surveillance, decision making, and sustained or prolonged intervention (a common experience in practice that residents might otherwise be deprived of). It also allows residents to engage fully in the live clinical environment without sacrificing participation in didactic and case-based conferences that provide the critical framework for experiential learning.
The ACGME has made other exceptions in the duty-hour regulations in order to promote professionalism and effective, safe learning in the clinical environment . For example, final-year trainees (who have extensive experience with high-level performance and fatigue monitoring and mitigation) may exceed single-shift duty limits to care for a patient with a rare disease or condition, the management of which is necessary for their training. Each episode must be justified and tracked in writing.
The case scenario reveals problems, not with the conception or value of duty-hour exceptions, but with their implementation. First, the scenario identifies various manpower pressures on the clinical neurosurgery service at the academic hospital in question, arising from the resignation of one program trainee and from modifications to the ACGME duty-hour regulations in 2011. Manpower needs in general, and a failure to design duty and rotation schedules compliant with the core 2011 regulations, are not valid justifications for exceptions.
It is possible to create program-specific call and duty schedules that comply with the 2011 regulations and also maintain educational quality and operative case volumes. For example, our program at Oregon Health and Science University in Portland succeeded in eliminating chronic compliance problems by shifting to a three-person night float system specifically for neurological surgery residency . Any further restriction in duty hours that reduces the overall engagement of residents with clinical care, however, would not only restrict their individual experiences but also fundamentally alter the central role of residents in the care delivery process (which is the heart of their professional education).
Responding to manpower needs unrelated to the education and training mission through the addition of midlevel practitioners (physician assistants and nurse practitioners) should be the responsibility of academic hospital leadership. Because graduate medical education dollars flow through academic hospital administrations, the decision makers for educational program resources and clinical program support should, in theory, be closely linked and aligned in providing these resources. In practice, this linkage remains inconsistent at best. In the case scenario, conflict among program faculty about the wisdom and necessity of effective duty-hour compliance also reveals a failure, at least in part, of the departmental and program leadership in managing change.
The duty-hour debate is far too frequently divided into extreme perspectives. Some experts and educators believe stricter regulations and broader interventions are always better. Unfortunately, there is little evidence that even the current standards have improved clinical outcomes and some evidence that they have reduced both readiness to practice and academic productivity in trainees [6, 7]. Furthermore, indirect evidence garnered from administrative databases suggests that, in some specialties, including neurological surgery, the implementation of duty-hour restrictions may have worsened clinical outcomes, presumably due to reduced continuity of care and increased handoff errors .
By contrast, many traditionalists eschew any limits on or standards for resident duty hours. This position ignores not only well-recognized safety problems of severe fatigue [9, 10] but also the terrible toll on surgery trainees that can result from excessive stress and unreasonable, extreme duty shift lengths. This toll includes broken marriages, impaired parenting, fatigue-related medical and vehicular injuries, and suicide . These considerations are not hypothetical and are known to virtually every trainee of my own generation. As an “intern” on a subspecialty surgical service in the early 1990s, while near the end of a 136-hour week of nearly continuous in-hospital duty, I made a simple and entirely fatigue-related error that nearly caused a catastrophic outcome in a young child. That and similar experiences of friends and colleagues inform my own perspective on duty hours. As surgery educators and mentors, we must find a reasonable and sustainable middle ground to improve our specialty and serve the trainees entrusted to us.
There is accumulating evidence in favor of reasonable, tested, and—where possible—evidence-based regulations that reflect legitimate differences between stages of training and specialties. Such regulations should be clear and enforceable to avoid a slippery slope and cynical abuse by a small minority of programs that might jeopardize the overall enterprise. For practical reasons, some quantifiable metrics such as hours spent doing a particular activity are likely to remain part of the regulations. Wherever possible, however, regulations should be closely linked to more intrinsically important measures, such as patient safety and clinical outcomes . The widespread engagement of US hospitals in the quality movement may provide data and opportunities to design more meaningful duty, supervision, and professionalism standards for graduate medical education [13, 14].
Ultimately, I believe duty-hour exceptions should be maintained and rationally expanded. The principal problems with the exceptions today are their narrow scope and their underutilization. Currently, fewer than 10 percent of neurological surgery programs have active duty-hour exceptions (unpublished data, Accreditation Council for Graduate Medical Education neurological surgery residency review committee, 2014). Given the potential of approved duty-hours exceptions to promote professionalism in practice, all programs should attempt to rigorously comply with the basic duty-hour regulations in order to become eligible for meaningful and educationally focused exceptions.
Finally, the limited existing duty-hour exceptions are misnamed. Rather than “exceptions,” we should describe them as desired “enhancements” to a system designed to promote excellence in a cohort of highly capable and talented adult learners. The duty-hour regulations and approved exceptions to them should embody fundamental principles of professionalism and personal accountability, drive independence, and help create a self-regulating, self-improving, and excellence-seeking generation of physicians and surgeons.
- Grady MS, Batjer HH, Dacey RG. Resident duty hour regulation and patient safety: establishing a balance between concerns about resident fatigue and adequate training in neurosurgery. J Neurosurg. 2009;110(5):828-836.
- Dacey RG Jr. Our continuing experience with duty-hours regulation and its effect on quality of care and education. J Neurosurg Spine. 2014;21(4):499-501.
Fontes RBV, Selden NR, Byrne RW. Fostering and assessing professionalism and communication skills in neurosurgical education [published online ahead of print August 26, 2014]. J Surg Educ.doi:10.1016/j.jsurg.2014.06.016.
Nasca TJ, Day SH, Amis ES Jr; ACGME Duty Hour Task Force. The new recommendations on duty hours from the ACGME Task Force. N Engl J Med. 2010;363(2):e3. doi:10.1056/NEJMsb1005800.
- Ragel BT, Piedra M, Klimo P, et al. An ACGME duty hour compliant 3-person night float system for neurological surgery residency programs. J Grad Med Educ. 2014;6(2):315-319.
- Norby K, Siddiq F, Adil MM, Haines SJ. The effect of duty hour regulations on outcomes of neurological surgery in training hospitals in the United States: duty hour regulations and patient outcomes. J Neurosurg. 2014;121(2):247-261.
- Spencer AU, Teitelbaum DH. Impact of work-hour restrictions on residents’ operative volume on a subspecialty surgical service. J Am Coll Surg. 2005;200(5):670-676.
- Babu R, Thomas S, Hazzard MA, et al. Morbidity, mortality, and health care costs for patients undergoing spine surgery following the ACGME resident duty-hour reform: clinical article. J Neurosurg Spine. 2014;21(4):502-515.
- Gerdes J, Kahol K, Smith M, Leyba MJ, Ferrara JJ. Jack Barney award: the effect of fatigue on cognitive and psychomotor skills of trauma residents and attending surgeons. Am J Surg. 2008;196(6):813-819.
Sugden C, Athanasiou T, Darzi A. What are the effects of sleep deprivation and fatigue in surgical practice? Semin Thorac Cardiovasc Surg. 2012;24(3):166-175.
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Parker SL, McGirt MJ, Asher AL, Selden NR. Quality improvement in neurological surgery graduate medical education. Neurosurg Clin N Am. In press.
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