Imagine Your Surgeon Wasn’t Allowed to Train Enough

A governing body of residents limited shift hours. But its good intentions to keep physicians fresh could also leave them ill-prepared.

The national governing body of physician training, the American Council of Graduate Medical Education (ACGME), limits the number of hours doctors in training can work in a given week. Generally speaking, on average, residents can be at the hospital for only 80 hours over a seven-day period. This hour limit is blunt and uniform across all types of physicians, from pediatricians to neurosurgeons.

This regulation and interference from a national governing body of medicine creates less confident physicians, destroys a resident physician’s right to work, and can put patients at risk.

The decision of how many hours residents can work in a given week has been taken away from individual physician training programs—and, most importantly, from the actual resident physicians. Seventy-two percent of residents in my field (neurosurgery) oppose at least portions of the duty-hour restrictions. Yet, their rights have been trampled, and patients are the ones who could suffer as a consequence.

Initially, with good intention, the ACGME sought to reduce preventable medical complications by reducing fatigue in residents. In 2003, they targeted reform during a physician’s residency, a three-to-seven-year period after medical school when a physician learns their specific specialty’s craft. The thought was rather simple: a well-rested doctor-in-training would make fewer mistakes.

However, in neurosurgery, data have not supported the intuition. A landmark study in 2012 noted that duty-hour restrictions actually caused more complications. Preventable or avoidable bad outcomes increased because of disruptions in continuity of care.

Instead of one resident physician managing a patient through the critical portions of an initial 24-hour hospital course, several residents now had to “trade off” to different teams of neurosurgery residents. As with any human-to-human interaction, these patient handoffs are prone to error. Some key patient data can be missed in the transfer from caregiver to caregiver. As a result, patients can be indirectly harmed.

This has become so ingrained in our culture that 93 percent of neurosurgery faculty and residents say duty-hour restrictions negatively affected continuity of care, per a survey in the academic journal Neurosurgery.

Even more concerning is that neurosurgery residents may not be allowed to get the training they personally desire. A one-size-fits-all duty-hour restriction for all medical specialties just does not make sense; not all medical specialties are the same.

Neurosurgery involves microsurgical technique for aneurysm clipping, cranial dissection for brain tumors, and placement of instrumentation in the spine. It can be technically demanding. As a result, by nature of the diseases treated, the surgeries tend to be longer (three to six hours), and some surgeries can routinely take eight to ten hours.

Writing in the New England Journal of Medicine, Drs. Brian Drolet, Derrick Christopher, and Staci Fischer noted that operative procedures are among the first duty to be dropped when hours restrictions are implemented. This is concerning considering that neurosurgeons perform operations for a living. Their piece noted that when duty hours were tightened in 2011, nearly 41 percent of physicians across all specialties reported a worse educational experience. Only 16.3 percent saw improvement.

Most importantly, it’s about signaling. Limiting hours breeds a shift mentality. Medical students self-select into their respective medical fields. Studies have illustrated that neurosurgery selects for those with increased stamina and mental fortitude (humility implied). Limiting hours may put a cap on time at work, but it also breeds a different culture. This transformation could mislead students into the specialty and leave residents ill-prepared for the realities of a busy neurosurgical practice.

These restrictions create a moral dilemma. Duty-hour regulations are indicative of an oppression of a classical liberal tenet: I have the right to exercise my own property, to work. It has been admittedly hard to determine the exact impact of duty-hour restrictions on physicians and patient outcomes. Yet, the burden of proof should rest on the entity attempting to remove that inherent right. This is even more frightening as doctors have an obligation to be the best-trained physicians possible to serve society. Therefore, it should cause great concern that both senior neurosurgeons and neurosurgery residents have raised caution regarding duty-hour work regulation created by an outside entity.

If training could be done in less time, it would be. Absolutely no one is suggesting a regression to the 110-plus-hour weeks that some of our senior mentors endured. We also need to look more closely at exactly how hours in the hospital are being utilized. The goal should be to maximize education through excellent patient care.

Flexibility of this rigid system needs to be placed in the hands of the individuals actually teaching and learning surgery. The decision of how to work and when to work is best determined by the individual resident. If it is deemed the individual is incapable of making that decision it should be determined by the organization of people who represent the field. Neurosurgeons know how to best train neurosurgeons.

The organized neurosurgery community is not without opinion. They have put forth an outstanding and thorough position paper on the topic illustrating how they think future residents can best be trained. It limits hours to combat fatigue, but it involves a much more flexible training algorithm. It allows future surgeons to get the training they want and desire. It empowers the individual and allows them the ability to exercise their right to work.

It’s also backed by data. The FIRST Trial evaluated an experimental flexible duty-hours system in certain general surgery resident programs. Although controversial, the study noted that residents in the flexible duty-hours program were less likely to perceive the negative effects of duty-hours on patient safety, continuity of care, and resident education.

All of this has real world implications. A neurosurgery resident may have a full 12-to-14-hour work day planned with elective surgical cases, clinic, and rounding duties in the hospital. It would not be unusual for a brain aneurysm patient to present to the emergency room in critical condition needing urgent surgery for a complex middle cerebral artery aneurysm clipping procedure. The next night it may be an emergent incomplete spinal cord injury with a fracture dislocation of the thoracic spine. The night after that it might be a pediatric traumatic subdural hemorrhage.

If the resident is consistently close to the duty-hour cap, he or she could be faced with a vicious choice: make the unethical decision to go home, abide by the duty-hours, and miss the opportunity to learn how to do a unique and challenging case that takes a lifetime to master, or make the unethical decision and lie about duty-hours.

If you were in need of care, which decision would you want your neurosurgeon to have made?

Written by Richard Menger and published by The Weekly Standard ~ February 8, 2018.

Richard Menger, MD MPA is a neurosurgery resident at LSU Health Sciences. He is a graduate of the Harvard Kennedy School of Government and a member of the AEI Enterprise Club. This is work published through the Foundation for Economic Education. These opinions are the author’s alone and not that of a specific institution or organization.

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