To leave or to lie? Are concerns about a shift-work mentality and eroding professionalism as a result of duty-hour rules justified?

Understanding the Cures Act Information Blocking Rule in cancer care: a mixed methods exploration of patient and clinician perspectives and recommendations for policy makers

BACKGROUND

The 21^st Century Cures Act Interoperability and Information Blocking Rule was created to increase patient access to health information. This federally mandated policy has been met with praise and concern. However, little is known about patient and clinician opinions of this policy within cancer care.

METHODS

We conducted a convergent parallel mixed methods study to understand patient and clinician reactions to the Information Blocking Rule in cancer care and what they would like policy makers to consider. Twenty-nine patients and 29 clinicians completed interviews and surveys. Inductive thematic analysis was used to analyze the interviews. Interview and survey data were analyzed separately, then linked to generate a full interpretation of the results.

RESULTS

Overall, patients felt more positive about the policy than clinicians. Patients wanted policy makers to understand that patients are unique, and they want to individualize their preferences for receiving health information with their clinicians. Clinicians highlighted the uniqueness of cancer care, due to the highly sensitive information that is shared. Both patients and clinicians were concerned about the impact on clinician workload and stress. Both expressed an urgent need for tailoring implementation of the policy to avoid unintended harm and distress for patients.

CONCLUSIONS

Our findings provide suggestions for optimizing the implementation of this policy in cancer care. Dissemination strategies to better inform the public about the policy and improve clinician understanding and support are recommended. Patients who have serious illness or diagnoses such as cancer and their clinicians should be included when developing and enacting policies that could have a significant impact on their well-being. Patients with cancer and their cancer care teams want the ability to tailor information release based on individual preferences and goals. Understanding how to tailor implementation of the Information Blocking Rule is essential for retaining its benefits and minimizing unintended harm for patients with cancer.

Association between patient care ownership and personal or environmental factors among medical trainees: a multicenter cross-sectional study

BACKGROUND

Patient care ownership (PCO) is crucial to enhancing accountability, clinical skills, and medical care quality among medical trainees. Despite its relevance, there is limited information on the association of personal or environmental factors with PCO, and thus, authors aimed to explore this association.

METHODS

In 2021, the authors conducted a multicentered cross-sectional study in 25 hospitals across Japan. PCO was assessed by using the Japanese version of the PCO Scale (J-PCOS). To examine the association between personal (level of training, gender, and department) or environmental factors (hospital size, hospital type, medical care system, number of team members, number of patients receiving care, mean working hours per week, number of off-hour calls per month, and perceived level of the workplace as a learning environment) and PCO after adjusting for clustering within hospitals, the authors employed a linear mixed-effects model.

RESULTS

The analysis included 401 trainees. After adjusting for clustering within hospitals, it was confirmed that the senior residents had significantly better J-PCOS total scores (adjusted mean difference: 8.64, 95% confidence interval [CI]: 6.18-11.09) than the junior residents and the perceived level of the workplace as a learning environment had a positive association with J-PCOS total scores (adjusted mean difference per point on a global rating of 0-10 points: 1.39, 95% CI: 0.88-1.90). Trainees who received calls after duty hours had significantly higher J-PCOS total scores than those who did not (adjusted mean difference: 2.51, 95% CI: 0.17-4.85). There was no clear trend in the association between working hours and PCO.

CONCLUSIONS

Seniority and the perceived level of the workplace as a learning environment are associated with PCO. An approach that establishes a supportive learning environment and offers trainees a reasonable amount of autonomy may be beneficial in fostering PCO among trainees. The study findings will serve as a useful reference for designing an effective postgraduate clinical training program for PCO development.

Estimation of Surgical Resident Duty Hours and Workload in Real Time Using Electronic Health Record Data

OBJECTIVE

To explore the use of electronic health record (EHR) data to estimate surgery resident duty hours and monitor real time workload.

DESIGN

Retrospective analysis of resident duty hours logged using a voluntary global positioning system (GPS)-based smartphone application compared to duty hour estimates by an EHR-based algorithm. The algorithm estimated duty hours using EHR activity data and operating room logs. A dashboard was developed through Plan-Do-Study-Act cycles for real-time monitoring of workload.

SETTING

Single tertiary/quaternary medical center general surgery residency program with approximately 90 categorical, preliminary, and integrated residents at eight clinical sites.

PARTICIPANTS

Categorical, preliminary, and integrated surgery residents of all clinical years who volunteered to pilot a GPS application to track duty hours.

RESULTS

Of 2,623 work periods by 59 residents were logged with both methods. EHR-estimated work periods started later than GPS logs (median 0.3 hours, interquartile range [IQR] -0.1 - 0.3); EHR-estimated work periods ended earlier than GPS logs (median 0.1 hours, IQR -0.7 - 0.3); and EHR-estimated duty hour totals were less than totals logged by GPS (median -0.3 hours, IQR -0.8 - +0.1). Overall correlation between weekly duty hours logged by EHR and GPS was 0.79. Correlations between the 2 systems stratified from PGY-1 through PGY-5 were 0.76, 0.64, 0.82, 0.87, and 0.83, respectively. The algorithm identified six 80-hour workweek violations (averaged over 4 weeks), while GPS logs identified 8. EHR-based duty hours and operational data were integrated into a dashboard to enable real time monitoring of resident workloads.

CONCLUSIONS

EHR-based estimation of surgical resident duty hours has good correlation with GPS-based assessment of duty hours and identifies most workweek duty hour violations. This approach allows for dynamic workload monitoring and may be combined with operational data to anticipate and prevent duty hour violations, thereby optimizing learning.

The role of organizational factors in how efficiency-thoroughness trade-offs potentially affect clinical quality dimensions – a review of the literature

Purpose

The purpose of this paper is to increase knowledge of the role organizational factors have in how health personnel make efficiency-thoroughness trade-offs, and how these trade-offs potentially affect clinical quality dimensions.

Design/methodology/approach

The paper is a thematic synthesis of the literature concerning health personnel working in clinical, somatic healthcare services, organizational factors and clinical quality.

Findings

Identified organizational factors imposing trade-offs were high workload, time limits, inappropriate staffing and limited resources. The trade-offs done by health personnel were often trade-offs weighing thoroughness (e.g. providing extra handovers or working additional hours) in an environment weighing efficiency (e.g. ward routines of having one single handover and work-hour regulations limiting physicians' work hours). In this context, the health personnel functioned as regulators, balancing efficiency and thoroughness and ensuring patient safety and patient centeredness. However, sometimes organizational factors limited health personnel's flexibility in weighing these aspects, leading to breached medication rules, skipped opportunities for safety debriefings and patients being excluded from medication reviews.

Originality/value

Balancing resources and healthcare demands while maintaining healthcare quality is a large part of health personnel's daily work, and organizational factors are suspected to affect this balancing act. Yet, there is limited research on this subject. With the expected aging of the population and the subsequent pressure on healthcare services' resources, the balancing between efficiency and thoroughness will become crucial in handling increased healthcare demands, while maintaining high-quality care.

Learning to manage uncertainty: supervision, trust and autonomy in residency training

Sociologists have debated whether and how medical trainees are socialised to deal with uncertainty for decades. Recent changes in the structure of medical education, however, have likely affected the ways that resident physicians learn to manage uncertainty. Through ethnographic case studies of academic medical centres in Switzerland and the United States, this article provides new insights into the processes through which residents learnt to manage uncertainty. These processes included working under supervision, developing relationships of trust with supervisors and gaining autonomy to practise independently. As a result, residents developed different attitudes towards uncertainty. Residents at the Swiss medical centre tended to develop a more pragmatic attitude and viewed uncertainty as something to be addressed and controlled. On the other hand, residents at the American medical centre tended to develop an acceptive attitude towards uncertainty. More broadly, residents learnt to reproduce their supervisors' attitudes towards uncertainty. This article therefore provides new perspectives on continuity and the reproduction of social phenomena in medical education.

Understanding and managing uncertainty in health care: revisiting and advancing sociological contributions

In this collection we revisit the enduring phenomenon of uncertainty in health care, and demonstrate how it still offers coherence and significance as an analytic concept. Through empirical studies of contemporary examples of health care related uncertainties and their management, our collection explores the different ways in which uncertainty may be articulated, enacted and experienced. The papers address a diverse range of healthcare contexts - Alzheimer's disease, neonatal surgery, cardiovascular disease prevention, cancer, addiction (use of alcohol and other drugs during pregnancy), mental health/disorders and medical education - and many tackle issues of contemporary relevance, such as an ageing population, and novel medical interventions and their sequelae. These empirical papers are complemented by a further theoretical contribution, which considers the role of 'implicit normativity' in masking and containing potential ethical uncertainty. By mapping themes across the collection, in this introduction we present a number of core analytical strands: (1) conceptualising uncertainty; (2) intersections of uncertainty with aspects of care; (3) managing uncertainty; and (4) structural constraints, economic austerity and uncertainty work. We reflect on the methodological and theoretical stances used to think sociologically about uncertainty in health care, and the strengths, silences and gaps we observe in the collection. We conclude by considering the implications of the insights gained for 'synthesising certainty' in practice and for future research in this area.

Compliance with the Accreditation Council for Graduate Medical Education duty hours in a general surgery residency program: Challenges and solutions in a teaching hospital

BACKGROUND

The inception of work hour restrictions for resident physicians in 2003 created controversial changes within surgery training programs. On a recent Accreditation Council for Graduate Medical Education survey at our institution, we noted a discrepancy between low recorded violations of the duty hour restrictions and the surgery resident's perception of poor duty hour compliance. We sought to identify factors that lead to duty hour violations and to encourage accurate reporting among surgery trainees.

METHODS

The A3/Lean methodology, an industry-derived, systematic, problem-solving approach, was used to investigate barriers to accurate reporting of duty hours by residents within the Department of Surgery at our academic institution. In partnership with our office of Graduate Medical Education, we encouraged a 6-month period where residents were asked to record duty hour accurately and to provide honest, descriptive explanations of violations without punitive effects on residents or the program. We performed a 6-month before-and-after analysis of duty hours violations after the A3/Lean implementation. Quantitative analysis was used to elucidate trends in violations by post graduate year and rotation. Qualitative evaluation by key thematic areas revealed resident attitudes and opinions about duty hour violations.

RESULTS

Residents reported concern for personal and programmatic, punitive measures, desire to retain control of their education, and frustration with the administrative burden after violations as deterrents to honest duty hour reporting. The intervention was successful in changing logging behavior with 10 total violations prior to A3 meeting and 179 violations afterward (P = .003). This change was driven largely from an increase in short break violations (4 vs 134, P = .021). Analysis of violations revealed trends by post-graduate year, rotation, and weekend cross-coverage. Key findings including less than anticipated violations of the 80-hour work week despite high rates of short break violations. The ability to participate in procedures voluntarily and a sense of professional responsibility emerged as the prevailing themes among surgery residents describing violations.

CONCLUSION

Systematic evaluation of duty hour reporting within a surgery training program can identify structural and cultural barriers to accurate reporting of duty hours. Accurate reporting can identify program-specific trends in duty hour violations that can be addressed though programmatic intervention.

Association of residency work hour reform with long term quality and costs of care of US physicians: observational study

OBJECTIVE

To determine whether 30 day mortality, 30 day readmissions, and inpatient spending vary according to whether physicians were exposed to work hour reforms during their residency.

DESIGN

Retrospective observational study.

SETTING

US Medicare.

PARTICIPANTS

20% random sample (n=485 685) of Medicare beneficiaries aged 65 years or more admitted to hospital and treated by a general internist during 2000-12.

MAIN OUTCOME MEASURES

30 day mortality, 30 day readmissions, and inpatient Medicare Part B spending among patients treated by first year internists who were fully exposed to the 2003 Accreditation Council for Graduate Medical Education (ACGME) work hour reforms during their residency (completed residency after 2006) compared with first year internists with partial or no exposure to reforms (completed residency before 2006). Senior internists not exposed to reforms during their residency served as a control group (10th year internists) for general trends in hospital care: a difference-in-difference analysis.

RESULTS

Exposure of physicians to work hour reforms during their residency was not associated with statistically significant differences in 30 day mortality, 30 day readmissions, or inpatient spending. Among 485 685 hospital admissions, 30 day mortality rates during 2000-06 and 2007-12 for patients of first year internists were 10.6% (12 567 deaths/118 014 hospital admissions) and 9.6% (13 521/140 529), respectively, and for 10th year internists were 11.2% (11 018/98 811) and 10.6% (13 602/128 331), for an adjusted difference-in-difference effect of -0.1 percentage points (95% confidence interval -0.8% to 0.6%, P=0.68). 30 day readmission rates for first year internists during 2000-06 and 2007-12 were 20.4% (24 074/118 014) and 20.4% (28 689/140 529), respectively, and for 10th year internists were 20.1% (19 840/98 811) and 20.5% (26 277/128 331), for an adjusted difference-in-difference effect of 0.1 percentage points (-0.9% to 1.1%, P=0.87). Medicare Part B inpatient spending for first year internists during 2000-06 and 2007-12 was $1161 (£911; €1024) and $1267 per hospital admission, respectively, and for 10th year internists was $1331 and $1599, for an adjusted difference-in-difference effect of -$46 (95% confidence interval -$94 to $2, P=0.06).

CONCLUSIONS

Exposure of internists to work hour reforms during their residency was not associated with post-training differences in patient mortality, readmissions, or costs of care.

Residents' perspective on professionalism in the learning environment

All accrediting organizations for medical education in the US require teaching hospitals to ensure the learning environment fosters professionalism behaviors of trainees and faculty. This study analyzes the learning environment of professionalism from the perspective of residents. An on-line anonymous survey that explored the learning climate of professionalism was sent to all residents at the University of Virginia in 2013-14. Residents rated their personal commitment, their residency program's, and the institution's commitment to demonstrating professionalism behaviors, described professionalism education, reasons for not participating in curricular offerings, the quality of role modeling, and barriers to professionalism. Nearly half the residents completed the survey (47%, N = 365/771). Residents rated their personal commitment and commitment of their residency program significantly greater than the institution's commitment to demonstrating professionalism.(p < 0.001) They noted only 25% of faculty modeled these behaviors all the time; and more than half stated poor role modeling impacted their attitudes about the importance of professionalism. Other areas in need of improvement include communicating with patients with cultural differences, and inter-professional teamwork. Despite accreditation requirements for learning environments, residency curricula, and faculty development programs to promote professionalism, residents perceive their commitment to professionalism greater than the institution where they work.

Relationships Between the ACGME Resident and Faculty Surveys and Program Pass Rates on the ABIM Internal Medicine Certification Examination

PURPOSE

The Accreditation Council for Graduate Medical Education (ACGME) has surveyed residents since 2003, and faculty since 2012. Surveys are designed to assess program functioning and specify areas for improvement. The purpose of this study was to assess the association of the ACGME's resident and faculty surveys with residency-program-specific performance on the American Board of Internal Medicine (ABIM) certification exam.

METHOD

Data were available from residents and faculty in 375 U.S. ACGME-accredited internal medicine programs from the 2012-2013, 2013-2014, and 2014-2015 academic years. Analysis of variance and correlations were used to examine the relationship between noncompliance with ACGME program requirements as assessed by the resident and faculty surveys, and ABIM program pass rates.

RESULTS

Noncompliance reported on the resident and faculty surveys was highest for programs not meeting the ACGME program requirement of an 80% pass rate on the ABIM certification examination. This relationship was significant for overall noncompliance, both within the resident (P < .001) and faculty (P < .05) surveys, for many areas within the two surveys (correlations ranged between -.07 and -.25, and P values ranged between .20 and < .001), and for the highest levels of noncompliance across areas of the resident (P < .001) and faculty (P < .04) surveys.

CONCLUSIONS

ACGME resident and faculty surveys were significantly associated with ABIM program pass rates, supporting the importance of these surveys within the ACGME's Next Accreditation System.

"You Have to Know the End of the Story": Motivations to Follow Up After Transitions of Clinical Responsibility

PURPOSE

Physicians routinely transition responsibility for patient care to other physicians. When transitions of responsibility occur before the clinical outcome is known, physicians may lose opportunities to learn from the consequences of their decision making. Sometimes curiosity about patients does not end with the transition and physicians continue to follow them. This study explores physicians' motivations to follow up after transitioning responsibilities.

METHOD

Using a constructivist grounded theory approach, the authors conducted 18 semistructured interviews in 2016 with internal medicine hospitalist and resident physicians at a single tertiary care academic medical center. Constant comparative methods guided the qualitative analysis, using motivation theories as sensitizing constructs.

RESULTS

The authors identified themes that characterized participants' motivations to follow up. Curiosity about patients' outcomes determined whether or not follow-up occurred. Insufficient curiosity about predictable clinical problems resulted in the choice to forgo follow-up. Sufficient curiosity due to clinical uncertainty, personal attachment to patients, and/or concern for patient vulnerability motivated follow-up to fulfill goals of knowledge building and professionalism. The authors interpret these findings through the lenses of expectancy-value (EVT) and self-determination (SDT) theories of motivation.

CONCLUSIONS

Participants' curiosity about what happened to their patients motivated them to follow up. EVT may explain how participants made choices in time-pressured work settings. SDT may help interpret how follow-up fulfills needs of relatedness. These findings add to a growing body of literature endorsing learning environments that consider task-value trade-offs and support basic psychological needs of autonomy, competency, and relatedness to motivate learning.

Resident perceptions of the impact of duty hour restrictions on resident-attending interactions: an exploratory study

BACKGROUND

The institution of duty hour reforms by the Accreditation Council for Graduate Medical Education in 2003 has created a learning environment where residents are consistently looking for input from attending physicians with regards to balancing duty hour regulations and providing quality patient care. There is a paucity of literature regarding resident perceptions of attending physician actions or attitudes towards work hour restrictions. The purpose of this study was to identify attending physician behaviors that residents perceived as supportive or unsupportive of their compliance with duty hour regulations.

METHODS

Focus group interviews were conducted with residents exploring their perceptions of how duty hour regulations impact their interactions with attending physicians. Qualitative analysis identified key themes in residents' experiences interacting with faculty in regard to duty hour regulations. Forty residents from five departments in two hospital systems participated.

RESULTS

Discussion of these interactions highlighted that attending physicians demonstrate behaviors that explicitly or implicitly either lend their support and understanding of residents' need to comply with these regulations or imply a lack of support and understanding. Three major themes that contributed to the ease or difficulty in addressing duty hour regulations included attending physicians' explicit communication of expectations, implicit non-verbal and verbal cues and the program's organizational culture.

CONCLUSIONS

Resident physicians' perception of attending physicians' explicit and implicit communication and residency programs organization culture has an impact on residents' experience with duty hour restrictions. Residency faculty and programs could benefit from explicitly addressing and supporting the challenges that residents perceive in complying with duty hour restrictions.

Self-care as a professional imperative: physician burnout, depression, and suicide

PURPOSE

Burnout has been identified in approximately half of all practicing physicians, including anesthesiologists. In this narrative review, the relationship between burnout, depression, and suicide is explored, with particular attention to the anesthesiologist. Throughout this review, we highlight our professional imperative regarding this epidemic.

SOURCE

The authors searched the existing English language literature via PubMed from 1986 until present using the search terms physician burnout, depression, and suicide, with particular attention to studies regarding anesthesiologists and strategies to address these problems.

PRINCIPAL FINDINGS

Burnout and depression have increased among physicians, while the rate of suicide has remained relatively the same. There are many factors associated with burnout and depression as well as many causes. Certain individual factors include sex, amount of social support, and mental health history. Systems factors that play a role in burnout and depression include work compression, demands of electronic health records, production pressure, and lack of control over one's professional life. Medical license applications include questions that reinforce the stigma of psychological stresses and discourage physicians from seeking appropriate care.

CONCLUSION

The concept of physician well-being is multidimensional and includes factors related to each physician as an individual as well as to the working environment. Anesthesiologists must actively engage in self-care. Anesthesiology practices and healthcare organizations should evaluate the balance between demands they place on physicians and the resources provided to sustain an engaged, productive, and satisfied physician workforce. National efforts must be rallied to support physicians seeking help for physical and psychological health problems.

What Is Known: Examining the Empirical Literature in Resident Work Hours Using 30 Influential Articles

BACKGROUND

Examining influential, highly cited articles can show the advancement of knowledge about the effect of resident physicians' long work hours, as well as the benefits and drawbacks of work hour limits.

OBJECTIVE

A narrative review of 30 articles, selected for their contribution to the literature, explored outcomes of interest in the research on work hours-including patient safety, learning, and resident well-being.

METHODS

Articles were selected from a comprehensive review. Citation volume, quality, and contribution to the evolving thinking on work hours and to the Accreditation Council for Graduate Medical Education standards were assessed.

RESULTS

Duty hour limits are supported by the scientific literature, particularly limits on weekly hours and reducing the frequency of overnight call. The literature shows declining hours and call frequency over 4 decades of study, although the impact on patient safety, learning, and resident well-being is not clear. The review highlighted limitations of the scientific literature on resident hours, including small samples and reduced generalizability for intervention studies, and the inability to rule out confounders in large studies using administrative data. Key areas remain underinvestigated, and accepted methodology is challenged when assessing the impact of interventions on the multiple outcomes of interest.

CONCLUSIONS

The influential literature, while showing the beneficial effect of work hour limits, does not answer all questions of interest in determining optimal limits on resident hours. Future research should use methods that permit a broader, collective examination of the multiple, often competing attributes of the learning environment that collectively promote patient safety and resident learning and well-being.

Professionalism in the Twilight Zone: A Multicenter, Mixed-Methods Study of Shift Transition Dynamics in Surgical Residencies

PURPOSE

Duty hours rules sparked debates about professionalism. This study explores whether and why general surgery residents delay departures at the end of a day shift in ways consistent with shift work, traditional professionalism, or a new professionalism.

METHOD

Questionnaires were administered to categorical residents in 13 general surgery programs in 2014 and 2015. The response rate was 76% (N = 291). The 18 items focused on end-of-shift behaviors and the frequency and source of delayed departures. Follow-up interviews (N = 39) examined motives for delayed departures. The results include means, percentages, and representative quotations from the interviews.

RESULTS

A minority (33%) agreed that it is routine and acceptable to pass work to night teams, whereas a strong majority (81%) believed that residents exceed work hours in the name of professionalism. Delayed departures were ubiquitous: Only 2 of 291 residents were not delayed for any of 13 reasons during a typical week. The single most common source of delay involved a desire to avoid the appearance of dumping work on fellow residents. In the interviews, residents expressed a strong reluctance to pass work to an on-call resident or night team because of sparse night staffing, patient ownership, an aversion to dumping, and the fear of being seen as inefficient.

CONCLUSIONS

Resident behavior is shaped by organizational and cultural contexts that require attention and reform. The evidence points to the stunted development of a new professionalism, little role for shift-work mentalities, and uneven expression of traditional professionalism in resident behavior.

Association of Resident Duty Hour Restrictions on Mortality of Nervous System Disease and Disorder

BACKGROUND

The impact of the 2003 residency duty hour reform on patient care remains a debated issue.

OBJECTIVE

Determine the association between duty hour limits and mortality in patients with nervous system pathology.

METHODS

Via a retrospective cohort study using the Nationwide Inpatient Sample from 2000-2010, the authors evaluated in-hospital mortality status in those with a primary discharge level diagnosis of disease or disorder of the nervous system. Odds ratios were calculated, and Bonferroni corrected P values and confidence intervals were determined to account for multiple comparisons relating in-hospital mortality with teaching status of the hospital by year.

RESULTS

The pre-reform (2000-2002) and peri-reform (2003) periods revealed no significant difference between teaching and nonteaching hospital mortality (P > .99). The post-reform period (2004-2010) was dominated by years of significantly higher mortality rates in teaching hospitals compared to nonteaching hospitals: 2004 (P < .001); 2006 (P = .043); 2007 (P = .042); and 2010 (P = .003). However, data for 2005 (P ≥ .99), 2008 (P = .80), and 2009 (P = .09) did not show a significant difference in mortality.

CONCLUSIONS

Teaching and nonteaching hospital mortality was similar in patients with nervous system pathology prior to the duty hour reform. While nonteaching institutions demonstrated steadily declining mortality over the decade, teaching hospital mortality spiked in 2004 and declined at a more restricted rate. The timing of these changes could suggest a negative correlation of duty hour restrictions on outcomes of patients with nervous system pathology.

Exposing physicians to reduced residency work hours did not adversely affect patient outcomes after residency

In 2003, work hours for physicians-in-training (residents) were capped by regulation at eighty hours per week, leading to the hotly debated but unexplored issue of whether physicians today are less well trained as a result of these work-hour reforms. Using a unique database of nearly all hospitalizations in Florida during 2000-09 that were linked to detailed information on the medical training history of the physician of record for each hospitalization, we studied whether hospital mortality and patients' length-of-stay varied according to the number of years a physician was exposed to the 2003 duty-hour regulations during his or her residency. We examined this database of practicing Florida physicians, using a difference-in-differences analysis that compared trends in outcomes of junior physicians (those with one-year post-residency experience) pre- and post-2003 to a control group of senior physicians (those with ten or more years of post-residency experience) who were not exposed to these reforms during their residency. We found that the duty-hour reforms did not adversely affect hospital mortality and length-of-stay of patients cared for by new attending physicians who were partly or fully exposed to reduced duty hours during their own residency. However, assessment of the impact of the duty-hour reforms on other clinical outcomes is needed.

A primer on medical education in the United States through the lens of a current resident physician

Physician training and standards for medical licensure differ widely across the globe. The medical education process in the United States (US) typically involves a minimum of 11 years of formal training and multiple standardized examinations between graduating from secondary school and becoming an attending physician with full medical licensure. Students in the US traditionally enter a 4-year medical school after completing an undergraduate bachelor's degree, in contrast to most other countries where medical training begins after graduation from high school. Medical school seniors planning to practice medicine in the US must complete postgraduate clinical training, referred to as residency, within the specialty of their choosing. The duration of residency varies depending on specialty, typically lasting between 3 and 7 years. For subspecialty fields, additional clinical training is often required in the form of a fellowship. Many experts have called for changes in the medical education system to shorten medical training in the US, and reforms are ongoing in some institutions. However, physician education in the US generally remains a progression from undergraduate premedical coursework to 4 years of medical school, followed by residency training with an optional subspecialty fellowship.

A primer on medical education in the United States through the lens of a current resident physician

Physician training and standards for medical licensure differ widely across the globe. The medical education process in the United States (US) typically involves a minimum of 11 years of formal training and multiple standardized examinations between graduating from secondary school and becoming an attending physician with full medical licensure. Students in the US traditionally enter a 4-year medical school after completing an undergraduate bachelor's degree, in contrast to most other countries where medical training begins after graduation from high school. Medical school seniors planning to practice medicine in the US must complete postgraduate clinical training, referred to as residency, within the specialty of their choosing. The duration of residency varies depending on specialty, typically lasting between 3 and 7 years. For subspecialty fields, additional clinical training is often required in the form of a fellowship. Many experts have called for changes in the medical education system to shorten medical training in the US, and reforms are ongoing in some institutions. However, physician education in the US generally remains a progression from undergraduate premedical coursework to 4 years of medical school, followed by residency training with an optional subspecialty fellowship.

Duty Hour Reporting: Conflicting Values in Professionalism

BACKGROUND

Duty hour limits challenge professional values, sometimes forcing residents to choose between patient care and regulatory compliance. This may affect truthfulness in duty hour reporting.

OBJECTIVE

We assessed residents' reasons for falsifying duty hour reports.

METHODS

We surveyed residents in 1 sponsoring institution to explore the reasons for noncompliance, frequency of violations, falsification of reports, and the residents' awareness of the option to extend hours to care for a single patient. The analysis used descriptive statistics. Linear regression was used to explore falsification of duty hour reports by year of training.

RESULTS

The response rate was 88% (572 of 650). Primary reasons for duty hour violations were number of patients (19%) and individual patient acuity/complexity (19%). Junior residents were significantly more likely to falsify duty hours (R = -0.966). Of 124 residents who acknowledged falsification, 51 (41%) identified the primary reason as concern that the program will be in jeopardy of violating the Accreditation Council for Graduate Medical Education (ACGME) duty hour limits followed by fear of punishment (34, 27%). This accounted for more than two-thirds of the primary reasons for falsification.

CONCLUSIONS

Residents' falsification of duty hour data appears to be motivated by concerns about adverse actions from the ACGME, and fear they might be punished. To foster professionalism, we recommend that sponsoring institutions educate residents about professionalism in duty hour reporting. The ACGME should also convey the message that duty hour limits be applied in a no-blame systems-based approach, and allow junior residents to extend duty hours for the care of individual patients.

Quantitative and qualitative perceptions of the 2011 residency duty hour restrictions: a multicenter, multispecialty cross-sectional study

BACKGROUND

July 2011 saw the implementation of the newest duty hour restrictions, further limiting the working hours of first year residents and necessitating a variety of adaptations on the part of residency programs. The present study sought to characterize the perceived impact of these restrictions on residency program personnel using a multi-specialty and multi-site approach.

METHODS

We developed and administered a survey to internal medicine and general surgery residency programs at three academic medical centers within an urban region. The survey combined quantitative and qualitative components to gain a broader understanding of the impact of the newest regulations. Quantitative responses were compared between Internal Medicine and General Surgery programs with Student t-tests. Other comparisons were performed using ANOVA or Kruskal-Wallis testing as appropriate. For all comparisons, the threshold for significance was set at 0.01. Two independent reviewers coded all qualitative data and assigned one or more themes based on content. Descriptive statistics were calculated and the diversity of themes identified. No between-group comparisons were conducted with the qualitative data.

RESULTS

We found significant differences in the overall perceptions of duty hour restrictions across specialty (internal medicine more positive than general surgery) and across position (first year residents more positive than senior residents and faculty). Notably, individuals who trained at osteopathic medical schools reported significantly more negative views of the duty hour restrictions than those who had trained at allopathic or international medical schools, suggesting an influence of undergraduate medical training. The complementary qualitative data offered insights into the perceived strengths and weaknesses of the duty hour restrictions, as well as actionable suggestions that could help to improve residency program function.

CONCLUSION

This study characterizes responses to the new duty hour restrictions from a variety of perspectives. Our findings show that individual (type of undergraduate medical education, role in graduate medical education) and program-wide (e.g., specialty) factors contribute to participant satisfaction with DHR. This research highlights the value of a mixed methods approach in the study of duty hour restrictions, with our qualitative arm yielding rich data that complemented and expanded upon the insights derived from the quantitative data.

Effects of the reduction of surgical residents' work hours and implications for surgical residency programs: a narrative review

BACKGROUND

The widespread implementation of resident work hour restrictions has led to significant alterations in surgical training and the postgraduate educational experience. We evaluated the experience of surgical residency programs as reflected in the literature from 2008 onward in order to summarize current challenges and identify key areas in need of further research.

METHODS

We searched MEDLINE and EMBASE for English-language articles published from January 2008 to December 2011 related to work hour restrictions in surgical residency programs, including those pertaining to personal well-being, education and training, patient care, and faculty experiences.

RESULTS

We retrieved 240 unique abstracts and included 24 studies in the current review. Of the 10 studies examining effects on operating room experience, 4 reported negative or mixed outcomes and 6 reported neutral outcomes, although non-compliance was demonstrated in 2 of these studies. Effects on surgical faculty perceptions were consistently reported as negative, while the effect on patient outcomes and professionalism were found to be neutral and unchanged.

CONCLUSIONS

Further studies are needed to characterize operative experience at varying levels of training, particularly in the context of strict adherence to new work hours. Research that examines the effect of the work hour limitations on professionalism and non-operative educational activities, such as reading and simulation-based training, as well as sign-over practices, would also be of benefit.

Duty hours as viewed through a professionalism lens

Understanding medical professionalism and its evaluation is essential to ensuring that physicians graduate with the requisite knowledge and skills in this domain. It is important to consider the context in which behaviours occur, along with tensions between competing values and the individual’s approach to resolving such conflicts. However, too much emphasis on behaviours can be misleading, as they may not reflect underlying attitudes or professionalism in general. The same behaviour can be viewed and evaluated quite differently, depending on the situation. These concepts are explored and illustrated in this paper in the context of duty hour regulations. The regulation of duty hours creates many conflicts that must be resolved, and yet their resolution is often hidden, especially when compliance with or violation of regulations carries significant consequences. This article challenges attending physicians and the medical education community to reflect on what we value in our trainees and the attributions we make regarding their behaviours. To fully support our trainees’ development as professionals, we must create opportunities to teach them the valuable skills they will need to achieve balance in their lives. [P]rofessionalism has no meaningful existence independent of the interactions that give it form and meaning. There is great folly in thinking otherwise. Hafferty and Levinson (2008)[1] Understanding and evaluating professionalism is essential to excellence in medical education and is mandated by organizations that oversee medical training [2]. Historically, attention has been focused largely on the professionalism of individual students or residents, at least for the purposes of evaluation. Yet there is now a growing appreciation that professionalism can be defined, understood, and evaluated from multiple perspectives [3]. Importantly, context has been recognized as critical to shaping trainees’ behaviours, and hence as important to our understanding of them [4]. A restriction in duty hours for trainees is clearly an important environmental and contextual factor to consider in evaluating professional behaviour. In this paper I will review some key issues with respect to understanding and evaluating professionalism, and then discuss these in the context of duty hour reform. Readers should note that this is not intended to be a comprehensive review of the literature of either professionalism or duty hour reform, but rather a critical narrative review that uses selected articles.

Resident perspectives on duty hour limits and attributes of their learning environment

BACKGROUND

Residents are stakeholders in the debate surrounding duty hour restrictions, yet few studies have assessed their perspective on their programs' efforts to comply with them.

OBJECTIVES

This paper explores learners' perceptions of the attributes of their programs in relation to duty hour compliance, and looks for evidence whether residents view duty hour limits as important to patient safety.

METHODS

A grounded-theory framework was used to analyze learners' comments about programs' compliance with US duty hour limits. Data were collected by ACGME in 2011, using resident consensus lists of program strengths and opportunities for improvement generated prior to accreditation site visits. The data set for this analysis encompasses 112 core and 69 subspecialty programs where these lists mentioned duty hours.

RESULTS

The analysis compared programs where residents viewed duty hour compliance as a strength, and programs where it was identified as an opportunity for improvement. Programs in the first group were characterized by clinical efficiency, responsiveness to problems, and a collegial environment that contributed to residents' ability to meet clinical and learning goals within the restrictions. These attributes were lacking in the second group, and residents also commented on onerous duty hour reporting. Learners did not associate duty hour compliance with patient safety, and the few comments in this area centred almost exclusively on the presence or absence of supervision when junior residents first assumed clinical duties.

CONCLUSION

The findings have practical implications for programs that wish to enhance their learning and patient care environment, and suggest areas for future research.

Organizational interventions in response to duty hour reforms

BACKGROUND

Changes in resident duty hours in Europe and North America have had a major impact on the internal organizational dynamics of health care organizations. This paper examines, and assesses the impact of, organizational interventions that were a direct response to these duty hour reforms.

METHODS

The academic literature was searched through the SCOPUS database using the search terms "resident duty hours" and "European Working Time Directive," together with terms related to organizational factors. The search was limited to English-language literature published between January 2003 and January 2012. Studies were included if they reported an organizational intervention and measured an organizational outcome.

RESULTS

Twenty-five articles were included from the United States (n=18), the United Kingdom (n=5), Hong Kong (n=1), and Australia (n=1). They all described single-site projects; the majority used post-intervention surveys (n=15) and audit techniques (n=4). The studies assessed organizational measures, including relationships among staff, work satisfaction, continuity of care, workflow, compliance, workload, and cost. Interventions included using new technologies to improve handovers and communications, changing staff mixes, and introducing new shift structures, all of which had varying effects on the organizational measures listed previously.

CONCLUSIONS

Little research has assessed the organizational impact of duty hour reforms; however, the literature reviewed demonstrates that many organizations are using new technologies, new personnel, and revised and innovative shift structures to compensate for reduced resident coverage and to decrease the risk of limited continuity of care. Future research in this area should focus on both micro (e.g., use of technology, shift changes, staff mix) and macro (e.g., culture, leadership support) organizational aspects to aid in our understanding of how best to respond to these duty hour reforms.

Association of the 2011 ACGME resident duty hour reforms with mortality and readmissions among hospitalized Medicare patients

IMPORTANCE

Patient outcomes associated with the 2011 Accreditation Council for Graduate Medical Education (ACGME) duty hour reforms have not been evaluated at a national level.

OBJECTIVE

To evaluate the association of the 2011 ACGME duty hour reforms with mortality and readmissions.

DESIGN, SETTING, AND PARTICIPANTS

Observational study of Medicare patient admissions (6,384,273 admissions from 2,790,356 patients) to short-term, acute care, nonfederal hospitals (n = 3104) with principal medical diagnoses of acute myocardial infarction, stroke, gastrointestinal bleeding, or congestive heart failure or a Diagnosis Related Group classification of general, orthopedic, or vascular surgery. Of the hospitals, 96 (3.1%) were very major teaching, 138 (4.4%) major teaching, 442 (14.2%) minor teaching, 443 (14.3%) very minor teaching, and 1985 (64.0%) nonteaching.

EXPOSURE

Resident-to-bed ratio as a continuous measure of hospital teaching intensity.

MAIN OUTCOMES AND MEASURES

Change in 30-day all-location mortality and 30-day all-cause readmission, comparing patients in more intensive relative to less intensive teaching hospitals before (July 1, 2009-June 30, 2011) and after (July 1, 2011-June 30, 2012) duty hour reforms, adjusting for patient comorbidities, time trends, and hospital site.

RESULTS

In the 2 years before duty hour reforms, there were 4,325,854 admissions with 288,422 deaths and 602,380 readmissions. In the first year after the reforms, accounting for teaching hospital intensity, there were 2,058,419 admissions with 133,547 deaths and 272,938 readmissions. There were no significant postreform differences in mortality accounting for teaching hospital intensity for combined medical conditions (odds ratio [OR], 1.00; 95% CI, 0.96-1.03), combined surgical categories (OR, 0.99; 95% CI, 0.94-1.04), or any of the individual medical conditions or surgical categories. There were no significant postreform differences in readmissions for combined medical conditions (OR, 1.00; 95% CI, 0.97-1.02) or combined surgical categories (OR, 1.00; 95% CI, 0.98-1.03). For the medical condition of stroke, there were higher odds of readmissions in the postreform period (OR, 1.06; 95% CI, 1.001-1.13). However, this finding was not supported by sensitivity analyses and there were no significant postreform differences for readmissions for any other individual medical condition or surgical category.

CONCLUSIONS AND RELEVANCE

Among Medicare beneficiaries, there were no significant differences in the change in 30-day mortality rates or 30-day all-cause readmission rates for those hospitalized in more intensive relative to less intensive teaching hospitals in the year after implementation of the 2011 ACGME duty hour reforms compared with those hospitalized in the 2 years before implementation.

Decisions about knowledge in medical practice: the effect of temporal features of a task

A classic question of social science is how knowledge informs practice. Research on physicians' decisions about medical knowledge has focused on doctors' personal capabilities and features of the knowledge corpus, producing divergent findings. This study asks, instead, How is decision making about the use of knowledge influenced by features of work? From observations of one team's decisions in multiple clinical and administrative contexts, the author argues that making decisions is contingent upon temporal features of physicians' tasks. Physicians receive feedback at different speeds, and they must account for these speeds when judging what they can prioritize. This finding explains doctors' perceived uncertainty in other studies as a product of the long feedback loop in tasks, and their certainty or pragmatism as a product of shorter feedback loops. In these latter scenario's, physicians consider and deploy scientific knowledge after--and not before, as is usually assumed--determining a fruitful plan of action.

When do doctors follow patients' orders? Organizational mechanisms of physician influence

Physicians, like other professionals, are expected to draw from specialized knowledge while remaining receptive to clients' requests. Using nationally representative U.S. survey data from the Community Tracking Study, this paper examines the degree to which physicians are influenced by patients' requests, and how physicians' workplaces may mediate acquiescence rates through three mechanisms: constraints, protection, and incentives. We find that, based on physicians' reports of their responses to patients' suggestions, patient influence is rare. This influence is least likely to be felt in large workplaces, such as large private practices, hospitals, and medical schools. We find that the protection and incentives mechanisms mediate the relationship between workplace types and physician acquiescence but more prescriptive measures such as guidelines and formularies do not affect acquiescence. We discuss these findings in light of the ongoing changes in the structure of medicine.

Survey of internal medicine physicians trained in three different eras: reflections on duty-hour reform

OBJECTIVES

To survey internal medicine physicians and residents who have completed residency in three different eras of medical training regarding their experiences during their intern year and their perceptions of duty-hour reform.

METHODS

An online survey was administered to 268 residents, fellows, and staff physicians who had completed or were completing residency during one of three eras of training: before the 80-hour work week, after the 80-hour work week (instituted in 2003), and after the 16-hour limit on continuous shifts for interns (instituted in 2011). The survey assessed experiences during their intern year of residency and perceptions regarding resident duty-hour reform.

RESULTS

The majority of respondents (n = 32; 54%) indicated that duty-hour restrictions would result in residents being less prepared for their future careers. In addition, 36% (n = 21) of respondents anticipated a decrease in the quality of patient care under the restricted duty hours. A total of 41% (n = 24) were undecided regarding the impact of duty-hour reform on patient care. Respondents reported time spent on independent study, research, and conference attendance did not increase following the institution of duty-hour restrictions.

CONCLUSIONS

Survey responses indicated that after 18 months of experience with the Accreditation Council for Graduate Medical Education duty-hour restrictions, physician opinions were mixed and a substantial number remain undecided regarding the impact of duty-hour restrictions on resident career preparedness and the quality of patient care.

Twelve tips for overnight teaching

BACKGROUND

The European Working Time Directive and the United States' duty hour restrictions have changed resident physicians' schedules, specifically increasing overnight shifts and decreasing overall time spent in the hospital. As residents' perception of night shifts is that they have little educational value, efforts to improve educational opportunities and night attending teaching are desirable. However, resources about and recommendations for best practices for overnight teaching by faculty are scarce.

AIM

To provide 12 tips to highlight strategies intended to optimize attending physicians' overnight teaching skills and strategies.

METHOD

The tips provided are based on our experiences and reflections as in-house faculty supervising residents working overnight, by our experience and group discussions as medical educators, and the available literature.

RESULTS

The 12 tips presented offer specific strategies to optimize attending physicians' overnight teaching for resident physicians, specifically highlighting the unique logistics, pedagogy and follow-up of overnight teaching.

CONCLUSION

Preparation for teaching is important in any environment, but understanding the unique timing and circumstances associated with overnight teaching is vital to ensure that overnight teaching is effective. Acknowledging and addressing the physical and cognitive obstacles associated with overnight teaching and learning is necessary to maximize the educational value of overnight teaching.

Duty-hour limits and patient care and resident outcomes: can high-quality studies offer insight into complex relationships?

Long hours are an accepted component of resident education, yet data suggest they contribute to fatigue that may compromise patient safety. A systematic review confirms that limiting duty hours increases residents' hours of sleep and improves objective measures of alertness. Most studies of operative experience for surgical residents found no effect, and there is evidence of a limited positive effect on residents' mood. We find a mixed effect on patient safety, although problems with supervision, rather than the limits, may be responsible or contibute; evidence of reduced continuity of care and reduced continuity in residents' clinical education; and evidence that increased workload under the limits has a negative effect on patient and resident outcomes. We highlight specific areas for research and offer recommendations for national policy.

Training for efficiency: work, time, and systems-based practice in medical residency

Medical residency is a period of intense socialization with a heavy workload. Previous sociological studies have identified efficiency as a practical skill necessary for success. However, many contextual features of the training environment have undergone dramatic change since these studies were conducted. What are the consequences of these changes for the socialization of residents to time management and the development of a professional identity? Based on observations of and interviews with internal medicine residents at three training programs, we find that efficiency is both a social norm and strategy that residents employ to manage a workload for which the demand for work exceeds the supply of time available to accomplish it. We found that residents struggle to be efficient in the face of seemingly intractable "systems" problems. Residents work around these problems, and in doing so develop a tolerance for organizational vulnerabilities.

Redesign of an internal medicine ward rotation: operational challenges and outcomes

INTRODUCTION

In anticipation of the 2011 ACGME duty hour requirements, we redesigned our internal medicine resident ward experience. Our previous ward structure included a maximum 30-hour duty period for postgraduate year-1 (PGY-1) residents. In the redesigned ward structure, PGY-1 residents had a maximum 18-hour duty period.

METHODS

We evaluated resident conference attendance and duty hour violations before and after implementation of our new ward redesign. We administered a satisfaction survey to residents and faculty 6 months after implementation of the new ward redesign.

RESULTS

Before implementation of the ward redesign, 30-hour continuous and 80-h/wk duty violations were each 2/year, and violations of the 10-hour rest between duty periods were 10/year for 74 residents. After implementation of the ward redesign, there were no 30-hour continuous or 80-h/wk duty violations, but violations of the 10-hour rest between duty periods more than doubled (26/year for 75 residents). Duty hours were reported by different mechanisms for the 2 periods. Conference attendance improved. Resident versus faculty satisfaction scores were similar. Both groups judged overall professional satisfaction as slightly worse after implementation.

CONCLUSION

Our ward rotation redesign eliminated 30-hour continuous and 80-h/wk duty violations as well as improved conference attendance. These benefits occurred at the cost of more faculty hires, decreased resident elective time, and slightly worse postimplementation satisfaction scores.

The Accreditation Council for Graduate Medical Education resident duty hour new standards: history, changes, and impact on staffing of intensive care units

OBJECTIVES

The Accreditation Council for Graduate Medical Education recently released new standards for supervision and duty hours for residency programs. These new standards, which will affect over 100,000 residents, take effect in July 2011. In response to these new guidelines, the Society of Critical Care Medicine convened a task force to develop a white paper on the impact of changes in resident duty hours on the critical care workforce and staffing of intensive care units.

PARTICIPANTS

A multidisciplinary group of professionals with expertise in critical care education and clinical practice.

DATA SOURCES AND SYNTHESIS

Relevant medical literature was accessed through a systematic MEDLINE search and by requesting references from all task force members. Material published by the Accreditation Council for Graduate Medical Education and other specialty organizations was also reviewed. Collaboratively and iteratively, the task force corresponded by electronic mail and held several conference calls to finalize this report.

MAIN RESULTS

The new rules mandate that all first-year residents work no more than 16 hrs continuously, preserving the 80-hr limit on the resident workweek and 10-hr period between duty periods. More senior trainees may work a maximum of 24 hrs continuously, with an additional 4 hrs permitted for handoffs. Strategic napping is strongly suggested for trainees working longer shifts.

CONCLUSIONS

Compliance with the new Accreditation Council for Graduate Medical Education duty-hour standards will compel workflow restructuring in intensive care units, which depend on residents to provide a substantial portion of care. Potential solutions include expanded utilization of nurse practitioners and physician assistants, telemedicine, offering critical care training positions to emergency medicine residents, and partnerships with hospitalists. Additional research will be necessary to evaluate the impact of the new standards on patient safety, continuity of care, resident learning, and staffing in the intensive care unit.