A report available online in the Publish Before Print section of the Journal of Neurosurgery suggests that maximum work hour restrictions on medical residents may not be the best route for achieving optimal patient care in the case of neurosurgery.

Since July 2003, when the Accreditation Council for Graduate Medical Education (ACGME) imposed a maximum 80-hour work-week restriction on medical residents, mandatory work-hour restrictions have been in place. Other more encompassing and restricted guidelines—such as the Institute of Medicine’s 2008 recommendation of a 16-hour maximum for consecutive hours—also have been suggested, and elements of these recommendations have been introduced into the new ACGME guidelines that became effective in July 2011.

Critics of longer hours argued that medical errors were more likely to occur when medical residents were fatigued and that a radical drop in resident work hours would serve as a better way to achieve optimal patient care. That may not necessarily be the case in neurosurgery, according to researchers.

Travis Dumont, MD, and colleagues at the University of Vermont College of Medicine report increased complication rates on their neurosurgical service after the ACGME restricted the number of resident work hours.

Relying on information obtained from a prospective database covering a 6-year period, the researchers compared the number and types of complications before and after the ACGME-mandated reduction in resident working hours (time periods July 2000-June 2003; and July 2003-June 2006, respectively).

They found that incidence of morbidity increased from 70 per 1,000 patients in the earlier period to 89 per 1,000 patients after the work hours were restricted; this increase was significant (p = 0.001). Morbid complications considered avoidable or possibly preventable also increased significantly (p = 0.017), from 56 to 66 per 1,000 patients. There was no significant change in mortality rates between the two time periods. Although the authors found no definitive underlying cause for the increase in complications following the ACGME-mandated reduction in work hours, they hypothesize that increased turnover of patients from one resident to another, due to shorter work hours, results in less familiarity with serious cases and may be a reason for the rise in complications.

The message of the paper is that a broad restriction on the number of work hours spent by medical residents should be reexamined. What is appropriate for one specialty may not be appropriate for others. Further studies are warranted.