1. Requirements, Case Logs, Duty Hours
2011
Neurological Surgery
Arthur L Day, MD
University of Texas Medical School at Houston
Houston, TX

2. types of requirements 1. common ACGME
2. specialty specific RRC neurosurgery

3. new definition: resident levels
PGY TERM
PGY Junior Level
PGY Intermediate
≥ PGY-3 Senior (final years)

4. fundamental clinical skills (PGY 1)
1. organized so that residents participate in clinical and didactic activities to:
a. develop the knowledge, attitudes and skills needed to
formulate principles and assess, plan, and initiate treatment
of patients with surgical and medical problems;
b. be involved in the care of patients with surgical and medical
emergencies, multiple organ system trauma, and nervous
system injuries and diseases;
c. gain experience in the care of critically ill surgical and
medical patients;
d. participate in the pre-, intra-, and post-operative care of
surgical patients; and,
e. develop basic surgical skills and an understanding of
surgical anesthesia, including anesthetic risks and the
management of intra-operative anesthetic complications.

5. fundamental clinical skills (PGY 1) (cont’d)
2. structured education in general patient care (as determined by the program director) to include rotations in:
a. surgery
b. critical care
c. trauma
d. other related rotations
residents should have a maximum of six months of
neurological surgery.

6. fundamental clinical skills (PGY1) (cont’d)
during the first 36 months of education,
residents must have a minimum of three
months of structured education in an
ACGME - accredited Neurology program.

7. fundamental clinical skills (PGY1) (cont’d)
moonlighting not permitted
maximum consecutive duty - 16 hrs
should have 10/must have 8 hrs free between duty periods.

8. fundamental clinical skills (PGY1) (cont’d)
demonstrated competency
a. supervised directly
b. supervised indirectly
(1) immediately available
(in-house,another location
(2) available by telephone

9. Changes - Duty Hour Standards
Effective July 1, 2011
Current Duty Hour Standards
New Duty Hour Standards
Maximum Hours of Work per Week
80 hours/wk, averaged over
four weeks.
80 hours/wk, averaged over four weeks,
inclusive of all in-house call activities and all
moonlighting.
Moonlighting
Internal moonlighting counts
toward 80-hour/wk limit.
PGY-1 residents permitted to
moonlight (extra call/extra pay).
External and internal moonlighting count
towards the 80-hour/wk limit.
PGY-1 residents not permitted to moonlight

10. Changes - Duty Hour Standards (cont.)
Current Duty Hour Standards
New Duty Hour Standards
Mandatory Time Free of Duty
one day in seven free from all
educational and clinical
responsibilities, averaged over a
four-week period inclusive of call.
Minimum one day free of duty every week
(averaged over four weeks). At-home call
cannot be assigned on free days.
Maximum Duty Period Length
Maximum duty, including in-house
call: 30 hours (24+6 for transition
and education).
Maximum duty PGY-1: 16 hrs.
Maximum duty PGY-2 and above: 28 hrs
( for transition and education).
Alertness management strategies and
strategic napping.
No new patients after 24
continuous duty.
No additional clinical duties after 24 hrs.
May remain to provide care to a single pt.:
(i) hand over care of other patients to team;
(ii) document reasons for remaining.
Program director must track episodes of
additional duty.

11. Changes - Duty Hour Standards (cont.)
Current Duty Hour Standards
New Duty Hour Standards
Minimum Time Off between Scheduled Periods
10-hour time period between daily
duty periods and after in-house
call.
Should have 10; must have 8 hrs free
between duty periods.
At least 14 hours free of duty after 24 hours
of in-house duty.
New Duty Hour Standards
Residents in final years of education must be prepared to enter the unsupervised
practice of medicine and care for patients over irregular or extended periods.
Preparation must occur within the context of the 80-hour, duty period length, and
one-day-off-in seven standards.
Residents in their final years should have 8 hours free of duty between
scheduled duty periods; may be times when resident must remain to care for
their patients or return to hospital with fewer than eight hours free of duty.
These circumstances must be monitored by Program director.

12. Current Duty Hour Standards New Duty Hour Standards
Night call schedules
Current Duty Hour Standards
New Duty Hour Standards
Maximum Frequency - In-House Night Float
Night float not addressed in current
standards.
No more than 6 consecutive nights of night
float.
Night float should be limited to four months
per year, and must not exceed six months
per year.
Maximum Frequency In-House
On-Call
In-house call no more frequently
than every third night, averaged
over a four-week period.
PGY-2 residents and above in-house call
must be no more frequently than every third
night (averaged over a four-week period).

13. New Duty Hour Standards
“at home” call
At Home Call
New Duty Hour Standards
Residents are permitted to return to the hospital while on at-home call to care for new or established patients.
At-home call must not be so frequent as to preclude rest and reasonable personal time for each resident.
For residents called into the
hospital from home, the hours
spent in-house are counted toward
the 80-hour limit.
While it must be included in the 80-hour weekly maximum, this will not initiate a new “off-duty period”.
At-home call not subject to every
third night or 24+6 limit.
Residents must be provided with one day in
seven completely free from all educational
and clinical responsibilities, averaged over
a four-week period.

14. educational goals and objectives –
must be outlined for each rotation
The curriculum must contain the following educational components:
clear educational rationale and objectives - for programs that extend beyond 72 months, approval by the sponsoring institution and RRC prior to implementation
2. program educational goals distributed to residents and faculty annually
competency-based goals and objectives for each assignment/educational level
a. distributed to residents and faculty annually (written or electronic form)
b. reviewed by/with the resident at the start of each rotation
regularly scheduled didactic sessions
delineation of resident responsibilities for patient care, progressive responsibility for patient management, and supervision of residents over the continuum of the program
integration of ACGME 6 Competencies into curriculum
residents’ scholarly activities

15. program case load – increased resident complement
INDEX CASES: correlated with institutional report and rotating national case average %)
1. Adult Aneurysms – Craniotomy and Endovascular
Brain Tumors (intra-axial and/or extra axial) – Craniotomy
Sellar/Parasellar tumors – Transsphenoidal approach (Endoscopic or Microsurgical)
Trauma – Total Cranial Procedures
Carotid (endarterectomy/endovascular)
All subcervical instrumentation
Peripheral Nerve Disorders – All Types
2. Pediatric Brain Tumors (intra-axial and/or extra axial) - Craniotomy
Dysraphism - Spinal Procedures (all types)
3. Both Epilepsy (Diagnostic and/or Therapeutic) – Craniotomy
Movement disorder – Stimulation /Stereotactic Lesion

16. program case load – increased resident complement
CASE CATEGORIES: correlated with resident log
CRANIAL craniotomy – brain tumor
craniotomy – trauma
craniotomy/endovascular – intracranial vascular lesion (aneurysm, AVM,etc) 40
craniotomy – pain (MVD for trigeminal neuralgia, hemifacial spasm, etc) 5
transphenoidal (endo/microscopic) - sellar/parasellar tumors 15
extracranial vascular procedures (endarterectomy/stenting, etc.) 5
radiosurgery
functional procedures - movement disorders, etc ( stim/destruct) 10
VP shunt
SPINAL ACD with instrumentation (disk disease) 25
/P NERVE C-spine fracture operative stabilization procedures 10
Lumbar discectomy
Thoracic/Lumbar instrumentation fusion
Peripheral nerve procedures
PEDIATRIC craniotomy – brain tumor
spinal procedures (dysraphism, etc)
BOTH craniotomy – epilepsy (adult or pediatric) 10
TOTAL

17. New Duty Hour Standards
Changes in Duty Hour Standards (cont.)
New Duty Hour Standards
ACGME DUTY HOUR STANDARD WEBSITE
ACGME DUTY HOUR FAQ
SPECIALTY-SPECIFIC DUTY HOUR DEFINITIONS
**Neurological Surgery – Pages

18. Program Requirements - training duration
neurosurgery residency - 72 months
two educational formats: PGY 1-6 and PGY 1-7.
programs can be approved for up to 84 months
72 months for clinical and didactic education
12 months of research or advanced training.
4. the resident must complete all years of education for which the program is accredited.

19. training duration (cont’d)
programs that extend the residency beyond 72 months
must present a clear educational rationale consonant
with the program requirements and the objectives of
the residency.
The program director must obtain the approval of the
sponsoring institution and the Review Committee prior
to implementation and at each subsequent
accreditation review of the program.

20. training duration (cont’d)
6. before entry into the program, each resident must be
notified in writing of the required length of the program.
this period may not be changed for a particular resident
during his or her program unless there is a significant
break in his or her education, or the resident needs
remedial education

21. other curriculum requirements
1. the program must provide 42 months
of clinical neurological surgery at the
sponsoring institution or one of its
approved participating sites.
a minimum of 21 months of neurological surgery education must occur at the sponsoring institution.

22. other curriculum requirements (cont’d)
the remaining time not devoted to clinical neurology and neurosurgery should be spent in the study of:
a. the basic sciences
b. neuroradiology
c. neuropathology, or
d. other appropriate subject matter related
to the neurosciences.
these topics should be agreed upon by individual residents and the program director.
the program director should consult the ABNS for certification requirements concerning any training conducted outside the approved sites of the program.

23. other curriculum requirements (cont’d)
the program must provide residents with direct and progressively responsible patient management experience as they advance through training.

24. chief resident requirements (cont’d)
month period of time as chief resident on the neurological surgery clinical service in the sponsoring institution or its approved participating sites.
a. must have major or primary responsibility for patient management with faculty supervision.
b. should also have administrative responsibility as designated by the program director.
c. the specific portion of the clinical training that
constitutes the 12 months of chief residency must be
specifically designated as the chief residency
experience and must be identified at the time of
program review.