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Original Article |

Persistent Noncompliance With the Work-Hour Regulation FREE

Parissa Tabrizian, MD; Uma Rajhbeharrysingh, MD; Sergey Khaitov, MD; Celia M. Divino, MD
[+] Author Affiliations

Author Affiliations: Division of General Surgery, Department of Surgery, Mount Sinai School of Medicine, New York, New York.


Arch Surg. 2011;146(2):175-178. doi:10.1001/archsurg.2010.337.
Text Size: A A A
Published online

Objective  To investigate the reason for noncompliance with the work-hour regulation by surgical residents.

Design  Nationwide anonymous survey (November 1, 2007, to March 1, 2008).

Setting  Academic center.

Participants  Surgical residents throughout the United States.

Main Outcome Measures  Incidence of noncompliance remains high and reasons for noncompliance are multifactorial.

Results  The first 141 questionnaires returned were included in this analysis. Responders consisted of postgraduate year (PGY)–1 (32.6%), PGY-2 (19.1%), PGY-3 (17.7%), PGY-4 (13.5%), and PGY-5 (17.0%) surgical residents. Many residents were categorical (79.4%), male (61.7%), and married (53.2%). Ninety-eight percent of residents were aware of the work-hour regulation, with 72.1% of residents in favor of it. However, noncompliance with the work-hour regulation was 64.6%, with 21.1% of residents working more than 90 h/wk (average, 86.6 h/wk). The most problematic regulations to follow were “at least 10 hours of rest between duty hours” (36.9%), “24-hour limit of continuous care plus 6 additional hours for continuity of care and educational objectives” (26.1%), and “80-hour work limit over 4 weeks” (22.7%). Education and continuity in patient care were the main reasons associated with noncompliance. Noncompliance was highest in trauma (25.2%) and vascular surgery (16.3%) residents. In addition, 65.2% of the attending physicians do not agree with implementing work-hour regulation standards in the surgical faculty.

Conclusions  The survey demonstrates that noncompliance with the work-hour regulation is prevalent. The reasons for noncompliance are multifactorial. These findings will help restructure training programs in the efforts to increase compliance with the work-hour regulation.

Figures in this Article

The modern American surgical residency in the early 20th century established by Halsted has undergone a fundamental shift since Libby Zion's case in 1984.13 It has led to the formation of the Ad Hoc Advisory Committee on Emergency Services, more commonly known as the 405 (Bell) Regulations.2,4,5 The major reasons behind these changes were patient safety, resident well-being, and resident education.3,6,7

On July 1, 2003, requirements approved by the Accreditation Council for Graduate Medical Education (ACGME) were implemented nationwide.8 These guidelines include (1) a limit of 80 hours of work per week over 4 weeks, (2) at least 10 hours of rest between duty periods, (3) a 24-hour limit of continuous care plus 6 additional hours of education and continued care, (4) an average of 1 day in 7 days that is free from patient care and educational obligations over 4 weeks, and (5) an average of in-house call no more than once every 3 nights over 4 weeks.9 Compliance has improved during the past 8 years; however, violations are still documented.10,11 As evidenced by the numerous articles published since approval of the requirements, this topic remains a dilemma.

This study addressed the reasons for noncompliance among surgical residents and documented the effects of the work-hour regulation on the surgical faculty.

We designed a questionnaire subdivided in 16 structured categories (November 1, 2007, to March 1, 2008). General surgery residents from 74 nationwide academic programs were surveyed, and responses were anonymous. The program directors of each institution were contacted and all agreed to participate. The offices of each institution distributed the survey to their residents (N = 1258).

The participants were required to provide information about their residency status, their most common cause of noncompliance, rotations in which they are having difficulty meeting the restrictions, and general knowledge of the work-hour regulation.

To perceive the effects of the work-hour regulation on the surgical faculty, a structured 5-category anonymous questionnaire was distributed to the surgical faculty (N = 106) at the Mount Sinai Medical Center in New York.

Most attitudinal questions were formatted as 5-point Likert scales. The χ2 test was used for result analysis and validation.

Institutional review board approval was obtained for this study.

The first 141 questionnaires returned were included in this study and reviewed. Most responses were submitted by surgical residents in New York (23.4%), Illinois (14.2%), and Minnesota (13.3%). Respondents consisted of postgraduate year (PGY)–1 (32.6%), PGY-2 (19.1%), PGY-3 (17.7%), PGY-4 (13.5%), and PGY-5 (17.0%) residents. Many residents were categorical (79.4%), male (61.7%), and married (53.2%). Residents reported working an average of 86.6 h/wk. The sample characteristics are outlined in Table 1.

Table Graphic Jump LocationTable 1 Sample Characteristics of the 141 Responding Surgical Residents

Ninety-eight percent of residents were aware of the work-hour regulation, with 72.1% of residents in favor of it (Figure 1). The restrictions provided by the ACGME were perceived as fair by 68.1% of the respondents and compliance was considered important by 85.7%. However, noncompliance with the work-hour regulation was highest among PGY-5 residents, at 71.2% (Figure 2). Twenty-one percent of residents reported working more than 90 h/wk.

Place holder to copy figure label and caption
Figure 1

Percentage of 141 surgical residents who agree or disagree with the 80-hour work week restriction according to postgraduate year (PGY) level.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2

Percentage of 141 surgical residents who remain compliant with the 80-hour work week restriction. PGY indicates postgraduate year.

Graphic Jump Location

The regulations that residents found most difficult to remain compliant with were “at least 10 hours of rest between duty hours” (36.9%), “24-hour limit of continuous care plus 6 additional hours for continuity of care and educational objectives” (26.1%), and “80-hour work limit over 4 weeks” (22.7%). As outlined in Table 2, education and continuity in patient care were the main reasons associated with noncompliance. Lack of ancillary staff, although not the predominant reason for noncompliance, was of concern by 39.4% of the respondents. Fifty-eight percent of the respondents did not consider fear of the program director or residency program as a factor for remaining compliant. Senior personnel were not the cause of noncompliance according to 69.0% of the residents. Work hours were most frequently violated on the trauma (25.2%), vascular (16.3%), and general surgery (14.1%) services.

Table Graphic Jump LocationTable 2 Survey Response Among Surgical Residents Regarding Cause of Noncompliance

In addition, we investigated the effects of the work-hour regulation on the surgical faculty at our institution. Fifty-four questionnaires were returned and reviewed, yielding a response rate of 50.9%. Fifteen surgical specialties were addressed; the most common were general surgery (21.2%), laparoscopic surgery (13.4%), colorectal surgery (13.2%), and vascular surgery (13.1%). The lengths of time employed as an attending physician were less than 1 year (8.2%), 1 to 5 years (21.5%), 5 to 10 years (26.2%), 10 to 20 years (22.1%), and more than 20 years (22.0%). Thirty-five percent of the attending physicians did not agree with the current work-hour regulation. Many (65.2%) did not agree with implementing work-hour regulations in the surgical faculty (Figure 3).

Place holder to copy figure label and caption
Figure 3

Perceived attitudes on introducing the work-hour regulations for 54 attending physicians.

Graphic Jump Location

The impact of the work-hour regulations mandated by the ACGME has created concern.1215 Our survey shows that noncompliance with the work-hour regulation is prevalent. Quality of surgical education, as well as continuity in patient care, were the major factors contributing to the high rate of noncompliance among surgical residents.

Although compliance was perceived to be important (85.7%), 70.7% of surgical residents work more than the 80 h/wk maximum proposed by the ACGME. These findings were highest among PGY-5 residents and show that significant schedule changes must be implemented to comply with the new regulations.

Violations were highest among PGY-5 residents (71.2%). The regulation that residents found most difficult to remain compliant with was getting at least 10 hours of rest between duty hours (36.9%). While the concept of work-hour restrictions is supported by most residents (72.1%), noncompliance remains high. Concern about reduced exposure to challenging clinical problems and operative cases, as well as a sense of responsibility to the patients/work, remains problematic. In addition, 35.2% of the surgical faculty believe that decreasing work hours would be detrimental to residents' education. In our opinion, ensuring operative volume, minimizing tasks that serve no educational or clinical value, encouraging operative simulator-based systems, implementing standardized or computerized “sign-outs,” and multiple levels of redundancy in patient care should be considered to ensure a higher quality surgical education.

Noncompliance was highest in trauma (25.2%), vascular surgery (16.3%), and general surgery (14.1%) services. Recognizing the affected specialty and increasing house-staff members in particular rotations should be considered as a possible solution.

The concept of introducing work-hour regulations among surgical faculty was opposed by 65.2% of the respondents. The faculty was less supportive of such restrictions as the length of employment increased. This may be explained by a more traditional mentality and resistance to change among senior surgical staff.

The survey demonstrates that noncompliance with the work-hour regulation remains high and the reasons are multifactorial. These findings will help restructure training programs in the efforts to increase compliance with the work-hour regulation. The effect of future duty-hour restrictions among surgical residents and faculty remains a dilemma.

Correspondence: Celia M. Divino, MD, Department of Surgery, The Mount Sinai Medical Center, 5 E 98th St, PO Box 1259, 15th Floor, New York, NY 10029 (celia.divino@mountsinai.org).

Accepted for Publication: November 30, 2009.

Author Contributions:Study concept and design: Tabrizian, Khaitov, and Divino. Acquisition of data: Tabrizian and Rajhbeharrysingh. Analysis and interpretation of data: Tabrizian, Khaitov, and Divino. Drafting of the manuscript: Tabrizian, Rajhbeharrysingh, and Khaitov. Critical revision of the manuscript for important intellectual content: Tabrizian and Divino. Statistical analysis: Tabrizian. Administrative, technical, and material support: Tabrizian. Study supervision: Divino.

Financial Disclosure: None reported.

Chao  LWallack  MK Resident work hour regulations: comments from New York. Curr Surg 2003;60 (3) 271- 273
PubMed Link to Article
Wallack  MKChao  L Resident work hours: the evolution of a revolution. Arch Surg 2001;136 (12) 1426- 1432
PubMed Link to Article
Lingenfelser  TKaschel  RWeber  AZaiser-Kaschel  HJakober  BKüper  J Young hospital doctors after night duty: their task-specific cognitive status and emotional condition. Med Educ 1994;28 (6) 566- 572
PubMed Link to Article
Asch  DAParker  RM The Libby Zion case: one step forward or two steps backward? N Engl J Med 1988;318 (12) 771- 775
PubMed Link to Article
Bell  RH  Jr Alternative training models for surgical residency. Surg Clin North Am 2004;84 (6) 1699- 1711, xii
PubMed Link to Article
Lockley  SWCronin  JWEvans  EE  et al. Harvard Work Hours, Health and Safety Group, Effect of reducing interns' weekly work hours on sleep and attentional failures. N Engl J Med 2004;351 (18) 1829- 1837
PubMed Link to Article
Mozurkewich  ELLuke  BAvni  MWolf  FM Working conditions and adverse pregnancy outcome: a meta-analysis. Obstet Gynecol 2000;95 (4) 623- 635
PubMed Link to Article
Zagoria  RAccreditation Council for Graduate Medical Education, The ACGME and the residency review committee: external program review. Acad Radiol 2003;10(suppl 1)S10- S15
PubMed Link to Article
Lieberman  JDOlenwine  JAFinley  WNicholas  GG Residency reform: anticipated effects of ACGME guidelines on general surgery and internal medicine residency programs. Curr Surg 2005;62 (2) 231- 236
PubMed Link to Article
Philibert  IFriedmann  PWilliams  WTACGME Work Group on Resident Duty Hours; Accreditation Council for Graduate Medical Education, New requirements for resident duty hours. JAMA 2002;288 (9) 1112- 1114
PubMed Link to Article
Landrigan  CPRothschild  JMCronin  JW  et al.  Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med 2004;351 (18) 1838- 1848
PubMed Link to Article
Whang  EEMello  MMAshley  SWZinner  MJ Implementing resident work hour limitations: lessons from the New York State experience. Ann Surg 2003;237 (4) 449- 455
PubMed
Landrigan  CPBarger  LKCade  BEAyas  NTCzeisler  CA Interns' compliance with Accreditation Council for Graduate Medical Education work-hour limits. JAMA 2006;296 (9) 1063- 1070
PubMed Link to Article
Niederee  MJKnudtson  JLByrnes  MCHelmer  SDSmith  RS A survey of residents and faculty regarding work hour limitations in surgical training programs. Arch Surg 2003;138 (6) 663- 671
PubMed Link to Article
Carlin  AMGasevic  EShepard  AD Effect of the 80-hour work week on resident operative experience in general surgery. Am J Surg 2007;193 (3) 326- 330
PubMed Link to Article

Figures

Place holder to copy figure label and caption
Figure 1

Percentage of 141 surgical residents who agree or disagree with the 80-hour work week restriction according to postgraduate year (PGY) level.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2

Percentage of 141 surgical residents who remain compliant with the 80-hour work week restriction. PGY indicates postgraduate year.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3

Perceived attitudes on introducing the work-hour regulations for 54 attending physicians.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1 Sample Characteristics of the 141 Responding Surgical Residents
Table Graphic Jump LocationTable 2 Survey Response Among Surgical Residents Regarding Cause of Noncompliance

References

Chao  LWallack  MK Resident work hour regulations: comments from New York. Curr Surg 2003;60 (3) 271- 273
PubMed Link to Article
Wallack  MKChao  L Resident work hours: the evolution of a revolution. Arch Surg 2001;136 (12) 1426- 1432
PubMed Link to Article
Lingenfelser  TKaschel  RWeber  AZaiser-Kaschel  HJakober  BKüper  J Young hospital doctors after night duty: their task-specific cognitive status and emotional condition. Med Educ 1994;28 (6) 566- 572
PubMed Link to Article
Asch  DAParker  RM The Libby Zion case: one step forward or two steps backward? N Engl J Med 1988;318 (12) 771- 775
PubMed Link to Article
Bell  RH  Jr Alternative training models for surgical residency. Surg Clin North Am 2004;84 (6) 1699- 1711, xii
PubMed Link to Article
Lockley  SWCronin  JWEvans  EE  et al. Harvard Work Hours, Health and Safety Group, Effect of reducing interns' weekly work hours on sleep and attentional failures. N Engl J Med 2004;351 (18) 1829- 1837
PubMed Link to Article
Mozurkewich  ELLuke  BAvni  MWolf  FM Working conditions and adverse pregnancy outcome: a meta-analysis. Obstet Gynecol 2000;95 (4) 623- 635
PubMed Link to Article
Zagoria  RAccreditation Council for Graduate Medical Education, The ACGME and the residency review committee: external program review. Acad Radiol 2003;10(suppl 1)S10- S15
PubMed Link to Article
Lieberman  JDOlenwine  JAFinley  WNicholas  GG Residency reform: anticipated effects of ACGME guidelines on general surgery and internal medicine residency programs. Curr Surg 2005;62 (2) 231- 236
PubMed Link to Article
Philibert  IFriedmann  PWilliams  WTACGME Work Group on Resident Duty Hours; Accreditation Council for Graduate Medical Education, New requirements for resident duty hours. JAMA 2002;288 (9) 1112- 1114
PubMed Link to Article
Landrigan  CPRothschild  JMCronin  JW  et al.  Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med 2004;351 (18) 1838- 1848
PubMed Link to Article
Whang  EEMello  MMAshley  SWZinner  MJ Implementing resident work hour limitations: lessons from the New York State experience. Ann Surg 2003;237 (4) 449- 455
PubMed
Landrigan  CPBarger  LKCade  BEAyas  NTCzeisler  CA Interns' compliance with Accreditation Council for Graduate Medical Education work-hour limits. JAMA 2006;296 (9) 1063- 1070
PubMed Link to Article
Niederee  MJKnudtson  JLByrnes  MCHelmer  SDSmith  RS A survey of residents and faculty regarding work hour limitations in surgical training programs. Arch Surg 2003;138 (6) 663- 671
PubMed Link to Article
Carlin  AMGasevic  EShepard  AD Effect of the 80-hour work week on resident operative experience in general surgery. Am J Surg 2007;193 (3) 326- 330
PubMed Link to Article

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