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tem only one resident may be credited for each case.
There is no system in place for measuring the number
of cases residents had to leave before completion
due to work hour restrictions or other commitments.
Results
During the period from July 1, 2003, to June 28, 2004,
seven violations were reported by the University of
Oklahoma resident duty hour database. In two
instances, residents had entered the wrong information.
Four instances were termed “frame of reference”
violations. Examination revealed that these
incidents did not violate ACGME or university rules,
but were in fact related to which four-week period
(or “frame”) the program chose to recognize. The
other violation involved switching from at-home call
to in-house call and confusion about the hour calculation
in these different situations.
We calculated that junior residents averaged 71.2
hours per week while on the neurosurgery service,
52.1 hours per week during the research year, and
58.2 hours per week while on electives. Senior residents
averaged 66.8 hours per week, excluding call
taken from home.
From July 2002 through June 2003, 1,601 major
operative procedures were performed in the neurosurgery
department (Table 1). Residents were unable
to assist with 146 of these cases, or 9.1 percent. Each
resident performed an average of 242.5 cases. From
July 2003 through June 2004, 1,517 major operative
procedures were performed in the neurosurgery
department. The department performed fewer operations
during the second year of the study
(2003–2004) in part due to the departure of one
attending neurosurgeon near the end of the study
period. Residents were unable to be present for 240
cases, or 15.8 percent. Each resident covered an average
of 212.8 cases. The difference was evaluated by chisquare
test and found to be significant (p < 0.0001).
We then analyzed the operative experience of
chief residents (Figure 1). During the year before the
study, chief residents performed 90.2 percent of all
operations at which a resident was present, or 81.9
percent of the caseload of the entire service. In the
year after work hour restrictions were implemented,
however, the chiefs performed only 81.5 percent of the
cases that had a resident present, or 68.6 percent of the
service’s overall caseload. This data was evaluated via
chi-square testing, and a significant decline was shown
in chief resident operative experience for both percent
TABLE 1
Resident Operative Cases Before and After ACGME
Resident Work Hour Restrictions
2002-2003 2003-2004
Total Cases 1,601 1,517
Cases Covered by Residents 1,455 1,277
Cases Not Covered by Residents 146 240
Junior Resident Cases 143 236
Chief Resident Cases 1,312 1,041
of resident-covered cases and percent of all cases they
performed (p < 0.0001 in both analyses).
Discussion
Resident work hour restrictions have forced training
programs to monitor the hours of their trainees.
Prior investigations have yielded mixed reviews of
the restrictions and their impact on surgical training.
Studies have shown that program directors, practicing
surgeons and senior residents do not generally
believe that training has improved as a result of the
limited work hours (4,10,12–14). Evidence suggests
that, on the whole, current surgical trainees believe
that work hour reductions have improved their quality
of life (3). In one study of otolaryngology program
directors, 45 percent of respondents felt that
the restrictions had resulted in increased faculty
workload (8). Still another study showed that signs of
“burnout” were unaffected by the decreased work
hours (6). Some programs have reported difficulty in
maintaining the new work hour limits due to factors
such as level 1 trauma status (4) and activities
deemed to be “noneducational” (2).
In general, neurosurgery residents and program
directors have reported that ACMGE guidelines have
had a negative impact on training and continuity of
care (4). On the other hand, in some studies more
residents have reported an improved quality of life
without a negative impact on training (7). Two
reports that evaluated general surgery programs
showed that for their specialty the number of cases
preformed by chief residents was unaffected by the
work hour restrictions (11,1).
Our study is limited in that the data obtained is
from only one institution and only covers a two-year
period. The aforementioned lack of surveillance of
residents who must leave cases early is another
Continued on page 16
Received: Sept. 16, 2005
Accepted: Oct. 10, 2005
AANS Bulletin
14:14–16, 2005
Key Words:
resident duty hours,
neurosurgical residency,
neurosurgical training
Abbreviations:
ACGME, Accreditation
Council for Graduate
Medical Education
Volume 14, Number 4 • AANS Bulletin 15