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

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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% of chief residents) and access to quality care (82% of program directors and 87% of chief residents). When asked about the effects of a 56-hour workweek, all program directors and 98% of the chief residents indicated that resident training and surgical education would be further compromised. Most respondents (95% of program directors and 84% of chief residents) also believed that additional work-hour restrictions would jeopardize patient care.

Conclusions

Neurological surgery continues to attract top-quality resident applicants. Test scores and levels of participation in national conferences, however, indicate that the 80-hour workweek may adversely affect resident training. Subjectively, neurosurgical program directors and chief residents believe that the 80-hour workweek makes neurosurgical training and the care of patients more difficult. Based on experience with the 80-hour workweek, educators think that a 56-hour workweek would further compromise neurosurgical training and patient care in the US.

Abbreviations used in this paper: AANS = American Association of Neurological Surgeons; ABNS = American Board of Neurological Surgery; ACGME = Accreditation Council for Graduate Medical Education; IOM = Institute of Medicine; USMLE = United States Medical Licensing Examination; UVA = University of Virginia.

Article Information

Address correspondence to: John A. Jane Sr., M.D., Ph.D., Department of Neurological Surgery, University of Virginia Health Sciences Center, Box 800212, Charlottesville, Virginia 22908. email: jaj6r@hscmail.mcc.virginia.edu.

© AANS, except where prohibited by US copyright law.

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Figures

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    Graph demonstrating national trends in USMLE Step 1 scores over the past 10 years. Red line indicates a statistically significant increase in the Step 1 scores for applicants matching into neurosurgery training programs. Blue line represents scores for US medical graduates. The x axis represents the year; the y axis, the USMLE scores.

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    Graph depicting a statistically significant decrease in the mean ABNS written examination scores for junior residents taking the examination for self-assessment between 2002 and 2006. The x axis represents the year; the y axis, the ABNS score.

  • View in gallery

    Graph showing no statistical change in the ABNS written examination scores for residents taking the exam for credit after the 2003 institution of work-hour regulations. The x axis represents the year; the y axis, the ABNS score.

  • View in gallery

    Graph demonstrating the number of podium (solid circles) and poster (hollow circles) presentations at the AANS annual meetings by residents in US ACGME-accredited residency programs since the establishment of work-hour rules. Despite the overall increase in registrations, the number of presentations by residents has stayed relatively constant.

  • View in gallery

    Bar graphs demonstrating the responses of 122 chief residents (right side of each graph) and 110 program directors (left side of each graph) in ACGME-accredited neurosurgical programs to a 6-question survey about the effects of the 80-hour workweek on aspects of resident education, patient care, and surgical training.

  • View in gallery

    Bar graphs revealing the responses of 122 chief residents (right side of each graph) and 110 program directors (left side of each graph) in ACGME-accredited neurosurgical programs to a 6-question survey about the effects of the proposed 56-hour workweek on aspects of resident education, patient care, and surgical training.

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