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Can brain surgery be taught in an 80-hour workweek?

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Posted at 5:06 PM, Oct 08, 2014
and last updated 2014-10-09 08:03:47-04

Dr. Dino Terzic got lucky the other day. In his seventh and final year as a neurosurgery resident at the University of Minnesota, the 32-year-old Bosnian got to operate on a rare type of brain aneurysm that required a special approach through the patient's forehead.

As Terzic prepared to slice into the patient's scalp, he was asked if he'd ever seen this type of flaw in an artery, which occurs in just 2 to 3 percent of aneurysm cases.

"On a video," Terzic replied with a chuckle.

Terzic's hands-on experience shows why the nation's medical schools are beset by a nagging controversy over rules that limit the number of hours residents can work. The rules were adopted a decade ago to avoid the sort of fatigue and medication errors that contributed to the death of 18-year-old Libby Zion in New York in 1984. But now, some medical educators say the rules may be undercutting the training of some U.S. doctors by reducing the number of procedures they perform.

"While we're in residency our goal is to do as many cases as possible," Terzic said.

"It has been a very controversial thing from the beginning, particularly among surgical specialties, because it was unclear to us what the impact would be," said Dr. Stephen J. Haines, director of the U's neurosurgery department.

"Would it really have a benefit to training? Or would the ... decrease in experience of the residents overcome any value of just having a less intense time and sleeping more?"

Haines directed a study, published in August in the Journal of Neurosurgery, which found that regulations barring residents from working more than 80 hours a week made no measurable improvement in major outcomes. He and his colleagues focused on neurosurgery residents because they had among the longest hours before the rules took effect — often more than 120 hours a week — and because they routinely deal with high-risk procedures in which a mistake may kill the patient or cause lasting damage.

"Interestingly, the (duty hour) regulations appear to be associated with an increase in the frequency of postoperative complications and discharge to long-term care facilities," the study says. It's unclear why.

Even so, the accreditation council that oversees physician training in the United States has considered reducing resident duty hours even more, prompting pushback from training departments.

An analysis of 135 studies published in June in the Annals of Surgery concluded that "one-size-fits-all" duty hour restrictions may not fit all specialties. While the restrictions have improved the lives of surgery residents, the authors wrote, their scores on board exams have declined. Worse, the analysts found that limits on duty hours appear to be harming more seriously ill patients, possibly by increasing the number of "handoffs" that take place.

"As soon as you start introducing more people into your care team ... you're not only handing off the patient to someone else to care for, you're handing off the responsibility," said Dr. Andrew Grande, a vascular neurosurgeon and assistant professor at the U. "So that drive to really dig down deep and go that extra mile for that patient — I don't think it's the same."

The U, like nearly all neurosurgery training programs, accepts just two new interns a year for its grueling, seven-year program.

"They are the hardest-working people in the hospital," said Dr. Matthew Hunt, director of the U's neurosurgery residency program.

Rounds usually begin around 5:30 a.m., after a thorough review of what the interns call "The List." It's a digest of the demographics, conditions, medications, lab results, images and strategies for individual patients.

Second-year residents Coridon Quinn, 36, and David Darrow, 28, spend much of their time updating The List. One recent morning, it covered 20 patients, though Quinn said he's seen as many as 40. It must remain perfectly accurate as the other physicians — and their patients' lives — depend on it.

At the U, first-year residents, known as interns, spend five months on neurosurgery, seven months on neurology, general surgery, trauma and ICU training. They spend much of their time in the clinic, learning to make diagnoses and to interact with patients and their loved ones facing dire health problems.

Interns can work no more than 16 hours straight, while other residents must stop at 24. Those restrictions can be tricky in a field in which some operations last 20 hours or more.

The second year of training is particularly difficult: Residents alternate, one month at a time, working the 12-hour overnight shift alone. Although the shift technically starts at 7 p.m., they often start an hour early, sign out at 8 a.m., and continue working a while longer. They visit patients and field often urgent questions from nurses and physicians. When in doubt, they phone the chief resident for advice.

"The first several months we bug the heck out of him," Quinn said.

The residents also conduct research, prepare and attend presentations on current cases, and attend mandatory weekly, three-hour classes on topics such as neuropathology and neuroradiology.

Darrow said nothing can prepare new residents for the heavy responsibilities and long hours.

"Not even close," he said between gulps of coffee. "You're just running all the time."

Nationally, 10 to 20 percent of neurosurgery residents quit in their first two years.

"You can't really tell if this is your thing until you're into it," Terzic said.

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