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

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

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

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.

Decision Tree

Workload

ViolationComplianceAssuming Start Here

Accurate Under-report

EducationPatient Care

Attending Influence

Senior Resident Influence

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

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?

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.

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

Methods

Exclusion Criteria– Visiting resident from another program– Principle responsibilities non-clinical over past 6

months– Research resident/fellow

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

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

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

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

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

Results

80% of all respondents reported exceeding hours restrictions at least once within the past 6 months

Results

49% of all respondents admitted under-reporting their work hours to their program director

Results

Concerns validated by respondents include: – Patient care (80%)

– Educational experience (47%)

– Faculty expectations (31%)

– Senior resident expectations (30%)

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)

Discussion

Standardized national work hours restrictions have created an ethical dilemma for residents– 49% of residents surveyed felt compelled to under-

report their hours

Discussion

Dominant factor contributing to non-compliance was concern for patient care

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

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

Future Study

Focus groups to exhaust possible factor pool

Institution specific pressures and factors

Sampling/administration methods

Issues of confidentiality

Multi-institutional sample

Future Study

Workload

ViolationCompliance

Accurate Under-report

EducationPatient Care

Attending Influence

Senior Resident Influence

Intervention

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.

Thank You