Neurosurgeons applaud newly-released draft standards for supervision, duty hours of medical residents

The American Association of Neurological Surgeons (AANS), American Board of Neurological Surgery (ABNS), Congress of Neurological Surgeons (CNS), and Society of Neurological Surgeons (SNS) applaud the newly-released draft standards to revise the national requirements for the supervision and duty hours of medical residents. The Accreditation Council for Graduate Medical Education (ACGME) task force, charged with reassessing resident training program standards, issued the new recommendations based on a 16-month scientific review. They build on the recommendations made by the Institute of Medicine (IOM) in 2008.

“Neurosurgery training is among the longest of all medical specialties and we were worried that additional restrictions in resident work hours would create a new generation of surgeons with reduced surgical experience and expertise, because they would have less exposure to complex surgical cases and direct patient care”

The ACGME task force assessed the data on fatigue and medical errors and proposes that the recommended maximum weekly work hours stay the same as its current standard (last issued in 2003) - of 80 hours per week averaged over four weeks. "As the nation's neurosurgeons, we too are concerned about resident fatigue and its impact on patient care, so we did support the ACGME rules that were implemented in 2003," comments AANS President James T. Rutka, MD, PhD. "However, we voiced our concerns to the task force that further restrictions in resident duty hours had the potential to harm patients with neurosurgical disorders if our residents could not be adequately trained for this complex specialty field of medicine."

"Neurosurgery training is among the longest of all medical specialties and we were worried that additional restrictions in resident work hours would create a new generation of surgeons with reduced surgical experience and expertise, because they would have less exposure to complex surgical cases and direct patient care," adds CNS President Gerald E. Rodts, MD. Neurosurgical training requires a minimum of six years after medical school, and requires residents to master the most complex system in the human body. Neurosurgical procedures are lengthy and neurosurgeons treat critically ill patients who often come to the hospital on an urgent or emergency basis.

ABNS Chairman Charles L. Branch, Jr., MD, further notes, "We had stressed to the task force that a single set of work hour rules may not be appropriate given the differences among specialties (medical vs. surgical) and the year of training (first year vs. chief resident). Neurosurgical practice is unique and duty hour standards must reflect this fact. We applaud the task force for recognizing that a 'one size fits all' set of standards for residents simply doesn't make sense. These new standards are mindful of the special needs of surgical subspecialties." Furthermore, Dr. Branch points to the emphasis placed on allowing intermediate and senior trainees an opportunity to stay longer (greater than the 16 hours; and over 24 hours) for educational purposes and for patient care.

The new ACGME draft standards also include several significant changes to resident training including: more detailed directives for levels of supervision necessary for a first-year resident vs. more experienced residents; reducing duty periods of first-year residents to no more than 16 hours a day; setting stricter requirements for duty hour exceptions; expanding program and institutional requirements regarding handovers of patient care; and setting more specific requirements for alertness management and fatigue mitigation strategies (designed to ensure both continuity of patient care and resident safety).

"The degree of supervision is spelled out in more detail in these new standards and conform to the way we, as neurosurgeons, have been doing business for years. We see first-hand the price that patients pay from medical errors resulting from confusing handoffs between residents and a lack of continuity of care in complex cases. These new standards should help to 'shut' this revolving door in patient care," states SNS President Allan H. Friedman, MD. "We believe these proposals recognize that future neurosurgical patient safety will be best maintained by training the finest residents in a manner that maintains a complete and productive educational program. These new standards should indeed ensure a balance of patient safety and the best learning environment possible for all of the nation's residents. The ACGME task force has created a new comprehensive set of resident standards that should be a win-win for both residents and patients across the country."

Dr. Friedman further explains that these new standards acknowledge that graduates of residencies need to be made "practice ready" and this can only be achieved with attention to case volumes and graded responsibilities toward the end of the residency period. He comments, "There are less than 4,000 practicing neurosurgeons serving thousands of hospitals in the United States and any further restrictions on the neurosurgical workforce would have certainly reduced patient access to neurosurgical care. We need to provide a framework that allows for the best-trained physicians to continue providing the best medical care in the world. The nation's neurosurgeons think these new standards set the stage for this."