In Reply: On-Call Workload Differences in Neurosurgery: Resident Call “Weather” and a Departure From Colored Cloud Labels

To the Editor: Thank you for the opportunity to respond to the letter by Dr Nguyen et al.1 We appreciate Dr Nguyen and colleagues' thorough reading of our work in Neurosurgery on workload differences in on-call neurosurgery residents.2 Their brief report furthers our understanding of workload variability in an under-studied area of neurosurgery training, for which we are so grateful. We are pleased to offer our detailed responses: Study Design: Nguyen et al tabulated similar data, focusing on consult number, urgent/emergent surgery, and bedside procedures, like our study. They additionally collected data on endovascular alerts, which neurosurgery does not respond to at our hospital, and whether orthopedic surgery was on the spine call. The latter, from anecdotal experience, likely confers significant week-on-week variability, making it a worthwhile point of inclusion, but this data were difficult to reliably retrieve retrospectively for our study. Their briefly described statistical approach differed from ours, offering a valuable and alternative angle to the question at hand. Our study directed a one-to-one comparison of residents within a class to determine whether one's workload was consistently significantly different. By contrast, Nguyen, et al used Kruskal-Wallis testing to compare residents' actual call shifts with the “expected.” Comparing Workload Between Hospitals: Nguyen et al.1 report data from 3 months of call but distributed between an unclear number of residents. In contrast, we examined 3 cohorts of 3 residents across 12 months total. While they report a higher average number of consults per call (6.6 per call vs 3.9 in our study), it is unknown whether this is per-12 hour or per-24 hour call. Even so, there are countless factors affecting consult frequency at a given hospital and variability between hospitals should be expected. Regarding training residents, the question of how much is enough, akin to case minimums, remains up for debate. We are grateful to Dr Nguyen for sharing this important additional data point toward answering that question. Beyond consult number, our on-call residents performed bedside procedures at a higher frequency (0.44 vs 0.3), potentially suggesting a higher acuity of consults through the emergency department or transfer, though emergencies per call shift were similar (0.5). Orthopedic surgery on the spine call reduces consult volume is an expected, but notable, as more factors underlying a “difficult” on-call shift should be defined. Objective Workload Differences Between Residents: Almost mirroring our findings, Nguyen et al report both a stormy resident, who saw a greater-than-expected number of consults and indicated more urgent surgeries, and sunny resident, who saw fewer though note both fell shy of statistical significance. Even so, by identifying this—through alternative methodology no less—they provide valuable external validation to our conclusion that objective differences in workload can indeed exist between residents. Perspective: We appreciate and agree with Dr Nguyen and colleagues' perspective on the behaviors and potential psychological impact of the sunny and stormy labels. We found their suggestions of surveying consulting services and unwrapping the weather labels, that is, understanding character traits giving rise to such labels, to be particularly valuable. Neurosurgery training is ever-evolving and in part for that reason, has almost entirely lacked quantitative analysis. Outcomes of training remain difficult to define—what is a successful resident and what is competence in a procedure—so the importance of primary data to inform those outcomes is diminished. Within residency, far greater attention is given to operative competency and case numbers, leaving the quantitative experience of the junior “on-call” phase almost entirely neglected. We thank Dr Nguyen for furthering the discussion on this understudied area and commend their extension of our work.