Jagannathan Jay, Vates G Edward, Pouratian Nader, Sheehan Jason P, Patrie James, Grady M Sean, Jane John A
Departments of Neurological Surgery, University of Virginia Health Sciences Center, Charlottesville, Virginia, USA.
J Neurosurg. 2009 May;110(5):820-7. doi: 10.3171/2009.2.JNS081446.
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.
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.
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.
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.
最近，医学研究所审视了住院医师值班时长及其对患者安全的影响。专家们提出，将住院医师工作时长减至每周56小时会进一步减少医疗差错。尽管一些报告表明，削减住院医师值班时长可减少差错并使住院医师生活更安全，但很少有作者专门分析毕业后医学教育认证委员会（ACGME）的值班时长限制对神经外科住院医师教育及所感受到的培训质量的影响。作者评估了住院医师表现和培训质量的多个客观替代指标，以确定每周80小时工作制的影响。
从神经外科医师协会获取了1998年至2007年（工作时长规定实施前后）进入ACGME认证项目的神经外科申请者的美国医师执照考试（USMLE）第一步数据。还获取了该组住院医师的美国神经外科委员会（ABNS）笔试成绩。对2002年至2007年期间美国神经外科医师协会（AANS）年会的住院医师注册情况及发言进行了审查，以此作为住院医师学术产出的一项衡量指标。作为一个案例，作者分析了弗吉尼亚大学（UVA）神经外科培训项目在实行每周80小时工作制前后住院医师培训时长的分布情况。最后，就每周80小时工作制对患者护理、住院医师培训、手术经验、患者安全及患者获得优质护理的影响，对ACGME认证项目的项目主任和总住院医师进行了调查。还询问了受访者对每周56小时工作制的看法。
尽管2000年至2008年期间神经外科项目匹配申请者的USMLE第一步平均成绩保持稳定，但参加自我评估考试的住院医师的ABNS笔试成绩从2002年的310分降至2006年的259分（下降16%，p<0.05）。在此期间，完成学分笔试的申请者的平均成绩也没有显著变化。尽管住院医师注册参加AANS会议的人数有所增加，但住院医师提交的摘要数量从2002年的345篇降至2007年的318篇（下降7%，p<0.05）。对UVA经验的分析表明，每周80小时工作制导致值班时长显著增加，而用于参加会议和手术室工作的时长则大幅减少。共获得110名项目主任（回复率78%）和122名总住院医师（回复率76%）的调查回复。大多数总住院医师和项目主任认为每周80小时工作制损害了住院医师培训（96%）并减少了住院医师的手术经验（98%）。受访者还认为每周80小时工作制威胁到患者安全（96%的项目主任和78%的总住院医师）及获得优质护理的机会（82%的项目主任和87%的总住院医师）。当被问及每周56小时工作制的影响时，所有项目主任和98%的总住院医师表示住院医师培训和外科教育将进一步受到损害。大多数受访者（95%的项目主任和84%的总住院医师）还认为进一步限制工作时长会危及患者护理。
神经外科继续吸引着高素质的住院医师申请者。然而，考试成绩和参加全国性会议的程度表明，每周80小时工作制可能会对住院医师培训产生不利影响。主观上，神经外科项目主任和总住院医师认为每周80小时工作制使神经外科培训和患者护理变得更加困难。基于每周80小时工作制的经验，教育工作者认为每周56小时工作制会进一步损害美国的神经外科培训和患者护理。
