1. 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

2. 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

3. Background Work-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

4. 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.

5. Decision Tree Workload ViolationCompliance Assuming Start Here AccurateUnder-report Education Patient Care Attending Influence Senior Resident Influence

6. 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

7. 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?

8. 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.

9. 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

10. Methods Exclusion Criteria – Visiting resident from another program – Principle responsibilities non-clinical over past 6 months – Research resident/fellow

11. 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

12. 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 Pearsons Chi-squared test with p<0.05 selected as a marker of significance

13. 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

14. Demographics Surgical Residents – 71% capture rate Non-surgical Residents – 45% capture rate

15. 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

16. Demographics

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

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

19. Results Concerns validated by respondents include: – Patient care (80%) – Educational experience (47%) – Faculty expectations (31%) – Senior resident expectations (30%)

20. 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)

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

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

23. 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

24. 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

25. Future Study Focus groups to exhaust possible factor pool Institution specific pressures and factors Sampling/administration methods Issues of confidentiality Multi-institutional sample

26. Future Study Workload ViolationCompliance AccurateUnder-report Education Patient Care Attending Influence Senior Resident Influence Intervention

27. 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.

28. Thank You