M. J. Erlendson1, L. S. Lehmann4, F. G. Javier1, K. A. Davis2, M. R. Mercurio3, C. Thiessen2 1Yale University School Of Medicine,New Haven, CT, USA 2Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA 3Yale University School Of Medicine,Department Of Pediatrics,New Haven, CT, USA 4Brigham And Women’s Hospital,Department Of Medicine,Boston, MA, USA
Introduction: The impact of work hour regulations on curtailing residents’ duty hours remains unclear. Previous single-institution studies suggest that residents under-record their hours. To our knowledge, this is the first multi-center study to qualitatively evaluate resident accuracy in the self-reporting of duty hours.
Methods: This multicenter qualitative study utilized semi-structured half-hour interviews of randomly selected general surgery interns and chief residents at 13 US institutions. Phone interviews were recorded, transcribed, and de-identified. Qualitative analysis was conducted using standard major and minor coding protocol with Dedoose.
Results: Eight interns and 6 chief residents participated in this study; 6 were women and 8 were men. Thirteen house officers reported under-recording work hours; half began under-recording in the first month of internship. A majority reported under-recording an average of 5-10 hours weekly. Concern about jeopardizing program accreditation was the most commonly expressed reason for under-recording work hours (7/14). The importance of educational experience (5/14), not dumping work onto other residents (5/14), and patient care (5/14) were frequently described. Residents justified under-reporting by appealing to their autonomous decision to take on more work. For example, “I was taking care of a critically ill patient and I didn’t think that the team could handle it without me but I made that choice, so I take those hours off.” Other residents described expectations: “I see all my seniors working as hard as I do so I don’t feel comfortable asking for extra time off,” “We have a culture here…when you’re…on overnight you stay all the way through rounds in the morning.” Seven residents reported under-recording to fly below the radar: “I don’t need to bring any attention to myself on that front.” A few feared attendings’ responses to recorded violations: “We all take the same shortcuts in order to decrease retribution or attending or program director anger.” “[Publicly identifying residents who violated duty hour rules] degenerated into a venue for public shaming… to have everybody know that you’re the one who’s causing a problem and putting the program in jeopardy and you’re the one who’s gonna get yelled at.” Two residents reported that they were explicitly told to lie. “I think there’s a lot in surgery about being honest and telling the truth otherwise you’re an ineffective resident, you’re an ineffective doctor, and so I refused to lie until I was told to. So I told him if he wants me to lie, he has to tell me to lie, so he did.”
Conclusion: Most under-recording resulted from self-censorship mediated by internalization of professional norms and a desire to maximize educational opportunities; a minority feared external consequences. Understanding factors that influence resident recording will inform the development of policies that address the conflict inherent in resident self-reporting of hours.