I'm Evan McNeil, and next week I'll be finishing my second year of medical school here at Dartmouth. My goal today is to tell you in five minutes or less everything that I've learned about the Night Float call format and neurosurgical resident training, from national trends to our own experience with Night Float. I completed this project with generous correspondence with Jennifer Hong, who is an assistant professor of neurosurgery here at Dartmouth. I do not have any conflicts of interest or financial disclosures for you. There are two general formats to handle primary resident in-house overnight coverage. For the purposes of this presentation, we're going to call those two formats Traditional and Night Float. Traditional call sees residents take turns staying in the hospital for 24 hours at a time. Night Float, a newer format popular in other specialties, assigns one resident to adapt to a nocturnal sleep schedule for several days to weeks, working nights only during that time. Our project had three primary goals in considering Night Float in neurosurgery. The first aim is to assess how popular Night Float is nationally. To accomplish this, I emailed all neurosurgery program coordinators nationwide and then picked up the phone and called the ones who didn't respond. The results of the program coordinator survey found that 39% of programs have adopted some form of Night Float call. In general, programs with smaller call pools, typically those with smaller class sizes, were more likely to be early adopters of the Night Float call format. This makes sense because Q5 or Q6 overnight call is much less burdensome than Q3 or Q4, which may be necessary at smaller programs. Of programs who had adopted Night Float, the most important cited reason for switching was to increase duty hour compliance. A second aim of our project is to assess how switching to Night Float changes residence experience in the OR. Dartmouth-Hitchcock switched to a Night Float call format from traditional 24-hour call in July 2016. This created a natural experiment to assess the effects of Night Float on residence experience. Because fewer surgeries occur overnight and those that do are more likely to be emergent, there may be concern that working night shift may diminish residence experience in the operating room. To assess this, I accessed all 12,000 op notes since 2014 and tallied up how many minutes each resident spent in the operating room. Other details of the operation were also recorded. Then, the years since Night Float were compared to the preceding three years. More senior residents actually found more time to be in the OR once Night Float was adopted. The average yearly nights on call and number of emergency surgeries did not change for any postgraduate year with the introduction of Night Float. Our third and final aim is to assess how the switch to Night Float impacted duty hour violations. Recall that the number one cited reason for programs to switch to Night Float was for potentially improved duty hour compliance. So how did duty hour violations change at Dartmouth once we switched to Night Float? To assess this, violations data was collected from 2013 through 2019. For residents participating in Night Float for our program PGY-2-5, a non-significant decrease in total violations and 80-hour week violations was observed after switching to Night Float. There was, however, a non-significant increase in violations for the 1-7 days off rule. 24-plus-4-hour shift length violations were obviously eliminated now that residents no longer take 24-hour call. But these violations were the rarest even before Night Float. Resident satisfaction is difficult to quantify, but our residents seem to prefer Night Float. Okay, take-home points. Night Float is a viable alternative call format for overnight coverage for neurosurgical residencies. And while Night Float is quite popular in other specialties, only 39% of neurosurgical programs currently use some form of Night Float. Our own experience with transitioning to Night Float at Dartmouth showed that there was no diminished operative experience for the residents. In fact, there may have been enhanced OR time for more senior residents. As for a change in ACGME duty hour violations, our results were modest but encouraging with a non-significant improvement after adopting Night Float. Feel free to contact me at the email on the screen with any questions. Or if you'd like to share your own program's experience with Night Float. Thank you very kindly for your attention.

Evan McNeil

Night Float call format

neurosurgical resident training

Jennifer Hong

research collaboration