Impact of the Accreditation Council for Graduate Medical Education work-hour regulations on neurosurgical resident education and productivity

Abstract

Object. Recently, the Institute of Medicine examined resident duty hours and their impact on patient safety. Experts have suggested that reducing resident work hours to 56 hours per week would further decrease medical errors. Although some reports have indicated that cutbacks in resident duty hours reduce errors and make resident life safer, few authors have specifically analyzed the effect of the Accreditation Council for Graduate Medical Education (ACGME) duty-hour limits on neurosurgical resident education and the perceived quality of training. The authors have evaluated multiple objective surrogate markers of resident performance and quality of training to determine the impact of the 80-hour workweek.Methods. The United States Medical Licensing Examination (USMLE)Step 1 data on neurosurgical applicants entering ACGME-accredited programs between 1998 and 2007 (before and after the implementation of the work-hour rules) were obtained from the Society of Neurological Surgeons. The American Board of Neurological Surgery (ABNS) written examination scores for this group of residents were also acquired. Resident registration for and presentations at the American Association of Neurological Surgeons (AANS) annual meetings between 2002 and 2007 were examined as a measure of resident academic productivity. As a case example, the authors analyzed the distribution of resident training hours in the University of Virginia (UVA) neurosurgical training program before and after the institution of the 80-hour workweek. Finally, program directors and chief residents in ACGME-accredited programs were surveyed regarding the effects of the 80-hour workweek on patient care, resident training, surgical experience, patient safety, and patient access to quality care. Respondents were also queried about their perceptions of a 56-hour workweek.Results. Despite stable mean USMLE Step 1 scores for matched applicants to neurosurgery programs between 2000 and 2008, ABNS written examination scores for residents taking the exam for self-assessment decreased from 310 in 2002 to 259 in 2006 (16% decrease, p < 0.05). The mean scores for applicants completing the written examination for credit also did not change significantly during this period. Although there was an increase in the number of resident registrations to the AANS meetings, the number of abstracts presented by residents decreased from 345 in 2002 to 318 in 2007 (7% decrease, p < 0.05). An analysis of the UVA experience suggested that the 80-hour workweek leads to a notable increase in on-call duty hours with a profound decrease in the number of hours spent in conference and the operating room. Survey responses were obtained from 110 program directors (78% response rate) and 122 chief residents (76% response rate). Most chief residents and program directors believed the 80-hour workweek compromised resident training (96%) and decreased resident surgical experience (98%). Respondents also believed that the 80-hour workweek threatened patient safety (96% of program directors and 78% o...

Patient Safety, Resident Education and Resident Well-Being Following Implementation of the 2003 ACGME Duty Hour Rules

“…Nine studies were of surgical (or surgical subspecialty) in-training examination scores, 49,50,52,54,61,64,69,70,73 and one examined the obstetrics and gynecology in-training examination. 35 These were mostly small single site studies with sample sizes ranging from 28 to 238.…”

“…35,52,54,69,73 Two studies demonstrated a decrease in examination scores between the pre-and post-duty hour periods. 50,70 Operative Experience…”

Review article: Closing the research gap at the interface of learning and clinical practice

“…11 Search of the references of these studies identified another 14 citations. With further analysis, articles were selected wherein interventions relevant to one or more of the three themes were studied, resulting in a final selection of 56 citations Twenty-one studies analyzed transitions in, during, and after residency education; 19 studies addressed the educational effects of duty hour limits, [33][34][35][36][37][38][39][40][41][42][43][44][45][46][47][48][49][50][51] and 16 articles presented research on use of the competencies in teaching and assessing anesthesiology residents. [19][20][21][22][23][24][25][26][27][52][53][54][55][56][57][58] For the theme ''duty hours and the acquisition of competence'', the only articles included were those that assessed the effect of duty hour limits on measures of physician competence and those that studied changes in patient care experience in anesthesiology that could be attributed to the reduction in resident hours.…”

“…In a national study of orthopedic surgery residents, 39 three single institution studies in surgery and otolaryngology, [40][41][42] and an older study of the impact of New York state's duty hour regulation on obstetricsgynecology residents 40 showed no changes in in-training exam performance. Among the three studies that assessed the effect of the duty hour reduction on board certification in surgical programs, declining performance was found in a national study of surgery residents 44 and a single institution study of neurological surgery residents, 45 and no change was found in a second single institution study of surgery residents. 41 Commentaries have expressed concern about the educational effect of duty hour limits in anesthesiology.…”

Surgical Activity of First-Year Canadian Neurosurgical Residents

“…In 2010, it will be revised to 42 months with the primary goal of more adequately preparing competent residents to perform basic neurosurgical procedures given the changing 'work-hour' and training restrictions [9][10][11] . Similarly, American neurosurgical training is a minimum of six years with a minimum of 42 months of clinical neurosurgery 12 .…”