B. J. Goudreau1, D. F. Grabski1, A. G. Ramirez1, J. Gillen1, W. M. Novicoff2, P. W. Smith1, B. Schirmer1, C. M. Friel1 1University Of Virginia,Department Of Surgery,Charlottesville, VA, USA 2University Of Virginia,Department Of Orthopaedic Surgery,Charlottesville, VA, USA
Introduction: The inception of work hour restrictions for resident physicians in 2003 created impactful and controversial change within surgery training programs. On a recent ACGME survey at our institution, we noted a discrepancy in low recorded duty hour violations and surgery residents' perception of poor duty hour compliance. We sought to identify factors that lead to duty hour violations and encourage accurate reporting among surgical trainees. We hypothesize that accurate reporting will permit program specific modifications that enhance educational and clinical opportunity while ensuring compliance with ACGME work hour limitations.
Methods: A3/Lean methodology, an industry derived systematic problem-solving approach, was used to investigate barriers to accurate duty hour reporting within the department of surgery at an academic institution. In close partnership with our Graduate Medical Education office, we encouraged a 6-month trial period where residents were asked to accurately record duty hours and provide descriptive explanations of violations without consequence to the invididual or program. Utilizing the A3/Lean session as the break point, we performed before and after analysis of duty hour violations. Quantitative analysis was used to elucidate trends in violations by post graduate year and rotation. Qualitative evaluation by thematic area revealed resident attitudes and opinions about duty hour violations.
Results:Through the A3/Lean process, residents reported fear of personal and programmatic punitive measures, desire to retain control of their surgical education, and frustration with the administrative burden following violations as deterrents to honest duty hour reporting. The intervention was successful in changing logging behavior,10 total violations prior vs.179 violations after (p = 0.003) the A3/Lean evaluation. The increase was largely derived from Short Break violations (4 vs. 134, p = 0.021). Analysis of violations revealed program-specific trends by post-graduate year (Table 1), rotation and weekend cross-coverage. Systematic issues were identified and programmatic interventions were implemented. Additional findings included lower than anticipated 80-hour work week violations despite high numbers of short break violations. The ability to participate in cases/procedures and a sense of professional responsibility emerged as themes among residents describing violations.
Conclusion:Systematic evaluation of duty hour reporting within a surgical training program can identify structural and cultural barriers to accurate duty hour reporting. Accurate reporting can identify program specific trends in duty hour violations that can be addressed through programmatic intervention.
