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Friday, July 1, 2016

How a Rule to Reduce Fatigue Made Neurosurgery Less Safe

Defending a physician’s right to work

The national governing body of physician training, the American Council of Graduate Medical Education, limits the number of hours doctors-in-training can work in a given week. Generally speaking, residents can only be at the hospital for 80 hours over 7 days. This hour limit is blunt and uniform across all types of physicians, from pediatricians to neurosurgeons.

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

Good Intentions vs. Good Medicine

The decision of how many hours can be worked in a given week has been taken away from individual physician training programs and, most importantly, from the actual resident physicians. Seventy percent of neurosurgery residents oppose the duty hour restrictions, but their rights have been trampled, and patients are the ones who suffer as a consequence.

Initially, with the best intentions, the governing council sought to reduce preventable medical errors by reducing fatigue. They targeted reform during a physician’s residency, a 3-7 year period after medical school when a physician learns their specialty. The thought was rather simple: a well-rested doctor-in-training would make fewer mistakes.

The duty hour restriction caused more patient complications. However, in neurosurgery, the data has just not supported the intuition. A landmark study in 2012 found that duty hour restrictions actually caused more complications. Preventable or avoidable bad outcomes increased because of disruptions in continuity of care.

Instead of one physician managing a patient through the critical portions of an initial 24-hour hospitalization, residents now have to trade off with different teams of neurosurgery residents. As with any human-to-human interaction, these patient handoffs are prone to error. Some data points are missed. Patients can be indirectly harmed.

This hasn’t gone unnoticed: surveys show that 93 percent of neurosurgery faculty and residents believe duty hours negatively impact continuity of care.


Treating all specialties the same by definition makes no sense. Even more concerning is that neurosurgery residents might not be allowed to get the training they want and need. A one-size-fits-all restriction for all medical specialties just does not make sense. Unsurprisingly, not all specialties are the same.

Neurosurgery involves microsurgical technique for aneurysm clipping, cranial dissection for brain tumors, and placement of instrumentation in the spine. It is technically demanding. As a result, by nature of the diseases treated, the surgeries tend to be longer (4-6 hours), and some surgeries can routinely take 8-10 hours.

Operative procedures are among the first duties to be dropped when time restrictions are imposed. This is very concerning considering the fact that neurosurgeons operate for a living. A piece in the New England Journal of Medicine noted that when duty hours were tightened in 2011, nearly 41 percent of physicians across all specialties reported a worse educational experience. Only 16 percent saw improvement.

Long hours are also important for sorting and signaling. Medical students self-select into their respective medical fields, and studies have shown that neurosurgery selects for those with increased stamina and mental fortitude. Limiting hours may put a cap on time at work, but they may also create a different culture that leaves residents ill-prepared for the realities of a busy neurosurgical practice.

There are no work-hour restrictions for fully trained neurosurgery faculty. Should we restrict the number of hours they can work? What would that mean for society or for patients?

Restrictions Create a Moral Dilemma

Duty hour regulations violate a classical liberal tenet: I have the right to work with my own property. The burden of proof should always rest on the entity attempting to restrict that inherent right. It is even more frightening because doctors have an obligation to be the best-trained physician possible in order to serve society. Therefore, it should concern us that both senior neurosurgeons and residents largely do not agree with the status quo regulations imposed on them by an outside bureaucracy.

The best education is excellent patient care.If training could be done in less time, it would. No one is suggesting reverting to the 110+ hour weeks 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.

The flexibility of this system needs to be placed in the hands of the individuals who are actually teaching and learning surgery. The decision on how to work and when to work is best determined by the individual resident, or else it should be determined by the organization that represents the field. Neurosurgeons know how to best train neurosurgeons.

Listen to the Surgeons

Organized neurosurgery is not silent on this. 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 need. It empowers the individual and allows them to exercise their right to work.

This position is 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. Yet, the governing council will not change the current hour restrictions.

This has real world implications.

A neurosurgery resident may have a full 12- to 14-hour work day planned, including elective surgical cases and clinical rounding duties in the hospital. It would not be unusual for a brain aneurysm patient to be present to the emergency room in critical condition needing emergent surgery with an intensive and complex aneurysm clipping procedure. The next night it may be a complex pediatric posterior fossa pilocytic astrocytoma. The night after that it might be a traumatic subdural hemorrhage.

We should not be forced into unethical dilemmas. If the resident is close to the duty hour cap, she could be faced with a terrible choice: she can make the unethical decision to go home, abide by the rules, and miss the opportunity to learn how to do a unique and challenging procedure that takes a lifetime to master — or she can make the unethical decision to lie about her duty hours.

Which decision would you want your future neurosurgeon to make? Let’s not force them to choose.

  • Richard Menger MD MPA is a neurosurgeon and a graduate of the Harvard Kennedy School of Government. He is a lead editor of the textbook "Economics, Business, Policy of Neurosurgery." He is currently the Chief of Complex Spine Surgery at the University of South Alabama and is on the faculty of the neurosurgery and political science departments.