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Work Hours Restrictions as an Ethical Dilemma for Residents
Robert O. Carpenter, M.D.
Mary T. Austin, M.D.
John L. Tarpley, M.D.
Kimberly D. Lomis, M.D.
Department of Surgery Vanderbilt University Medical Center Nashville, Tennessee
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Background
National Interest
Federal Efforts at Regulation– New York State Regulations– International Standards– Congressional Legislation
Desire for Internal Regulation– AMA– Potential Implications in Medical Practice
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BackgroundWork-Hours Regulations
One 24 hour period out of hospital in 7 days
Limit of 24 hours on call followed by 6 hours for closure/continuity of care
Ten hours off and out of hospital between shifts
Maximal average of 80 hours per seven day period
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Background
An underlying assumption of these changes is that residents desire to work fewer hours.
While this is certainly true in principle, it may not hold true in daily practice for all residents or specialties.
We propose that the restrictions have created an ethical dilemma for residents.
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Decision Tree
Workload
ViolationComplianceAssuming Start Here
Accurate Under-report
EducationPatient Care
Attending Influence
Senior Resident Influence
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Hypotheses
Many residents are not in compliance
Those not in compliance face a dilemma: – Report non-compliance – Report work hours inaccurately
Multiple factors will contribute to their decision
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Secondary Questions
Are surgical residents more likely than non-surgical residents to exceed work hour limitations?
Are surgical residents more likely than non-surgical residents to under-report work hours?
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Methods
A pilot survey was designed to assess potential factors that influence the number of hours residents work and the number of hours they report.
Approval was obtained from the IRB and Office of Graduate Medical Education prior to enrollment of any subjects.
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Methods
The program directors of Pediatrics, Internal Medicine, and General Surgery supported the participation of their residents.
A voluntary, anonymous survey– Residents in these four programs– Approved program-specific conferences– 16 months after regulations were implemented
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Methods
Exclusion Criteria– Visiting resident from another program– Principle responsibilities non-clinical over past 6
months– Research resident/fellow
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Within the past 6-months: ____ I have exceeded hours quotas (T/F) ____ I have felt compelled to work beyond hours quota to optimize
patient care (T/F) ____ I have felt compelled to work beyond hours quota to further my
educational experience (T/F) ____ I have felt compelled to work beyond hours quota to fulfill faculty
expectations (T/F) ____ I have felt compelled to work beyond hours quota to fulfill senior
resident expectations (T/F) ____ I have under-reported hours (T/F)
Methods: The Survey Tool
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Methods
Statistical analysis with Intercooled STATA 8.2– Responses reported as proportions by program and
subdivided by PGY level
– Program data consolidated into a variable designating either surgical or non-surgical status
– Binary categorical variables were then tested using Pearson’s Chi-squared test with p<0.05 selected as a marker of significance
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Demographics
Of 265 eligible residents, 170 were surveyed
137 of 170 of those surveyed responded (80.6% response rate)– 53 Surgical Residents– 84 Non-surgical Residents
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Demographics
2 respondents excluded for incomplete answers– M40
Failed to answer under-reporting question Answered True to all other questions except faculty
expectations
– S19 No PGY level indicated Answered False to all questions
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Demographics
51
43
26
5 3 4 1 2
0
10
20
30
40
50
60
All Residents
PGY Level of Respondents
PGY 1
PGY 2
PGY 3
PGY 4
PGY 5
PGY 6
PGY 7
PGY 8/Fellow
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Results
80% of all respondents reported exceeding hours restrictions at least once within the past 6 months
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Results
49% of all respondents admitted under-reporting their work hours to their program director
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Results
Concerns validated by respondents include: – Patient care (80%)
– Educational experience (47%)
– Faculty expectations (31%)
– Senior resident expectations (30%)
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Surgical vs. Non-surgical Residents
Were more likely to exceed work-hour restrictions– (89% versus 74%, p = 0.037)
Were more likely to under-report their hours – (73% versus 38%, p <.001)
Had greater concern about educational experience– (79% versus 28%, p< .001)
Were more influenced by senior resident expectations– (50% versus 17%, p <.001)
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Discussion
Standardized national work hours restrictions have created an ethical dilemma for residents– 49% of residents surveyed felt compelled to under-
report their hours
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Discussion
Dominant factor contributing to non-compliance was concern for patient care
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Discussion
In order to improve compliance, institutions must provide:– Appropriate ancillary services– Improved training of care teams – Improved resident education:
Safety programs Team leadership and communication Dangers of fatigue
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Limitations
Single institutional study
Limited to four programs
Pilot study with binomial responses and outcomes – Limited degree of analysis possible– Type/frequency of violation not clarified
Potential sources of error– Selection Bias– Social Desirability
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Future Study
Focus groups to exhaust possible factor pool
Institution specific pressures and factors
Sampling/administration methods
Issues of confidentiality
Multi-institutional sample
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Future Study
Workload
ViolationCompliance
Accurate Under-report
EducationPatient Care
Attending Influence
Senior Resident Influence
Intervention
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Acknowledgments
Fred Kirchner, M.D.– Associate Dean GME
Marie Griffin, M.D., MPH
Tom Elasy, M.D., MPH
John L. Tarpley, M.D.– PD General Surgery
John Sergent, M.D.– PD Internal Medicine
Chief Residents IM– Eric Sumner, M.D.– Megan Gaffney, M.D.– Christopher Ellis, M.D.– Brian Smith, M.D.
Rebecca Swan, M.D.– PD Pediatrics
Chief Resident Peds– Thomas Byars, M.D.
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Thank You