Carpenter Robert O, Spooner John, Arbogast Patrick G, Tarpley John L, Griffin Marie R, Lomis Kimberly D
Department of General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee 37232-2730, USA.
Curr Surg. 2006 Nov-Dec;63(6):448-55. doi: 10.1016/j.cursur.2006.06.003.
The Accreditation Council for Graduate Medical Education (ACGME) implemented requirements regarding allowable duty hours for resident training in the United States in July 2003. In a previous pilot study at Vanderbilt University Medical Center, a significant number of residents reported violation of requirements. In addition, almost half of those individuals admitted under-reporting their hours worked. The authors' goal was to further delineate the type and frequency of violations and under-reporting.
A survey tool was designed to assess specific types of violations as well as factors that influence the number of hours residents worked and reported. Approval was obtained from the Vanderbilt Institutional Review Board and Office of Graduate Medical Education before enrollment of subjects. The program directors of Pediatrics, Internal Medicine, Medicine-Pediatrics, and General Surgery supported the participation of their residents. A voluntary anonymous survey of these residents was conducted 1 year after the pilot study.
Of 263 eligible residents, 175 were surveyed. Of 175 residents, 125 (71%) residents responded. Eighty-five percent of residents reported violation of duty-hour requirements within the preceding 3 months. Residents reported violation of specific requirements as follows: 1 day off in 7, 28%; 80-hour weekly average, 65%; and "24+6" consecutive hours, 85%. Residents were asked to estimate the number of hours by which they exceeded requirements. Hours over the 80-hour weekly requirement were reported as follows: 1 hour, 12%; 2 hours, 15%; 3 hours, 21%; 4 hours, 5%; 5 hours, 14%; and 6 or more hours, 33%. Hours over the "24+6" requirement were reported as follows: 1 hour, 30%; 2 hours, 42%; 3 hours, 18%; 4 hours, 7%; 5 hours, 1%; and 6 or more hours, 2%. Forty-eight percent of respondents admitted under-reporting violations to their program director.
Eighty-five percent of residents reported at least 1 violation, and 48% admitted under-reporting violations. These results support the previous findings of 80% and 49%, respectively. Of the various requirements, the "24+6" rule was most frequently violated. Of those in violation of the "24+6" requirement, the majority (90%) exceeded limits by no more than 3 hours. Of those in violation of the 80-hour weekly average requirement, the majority (57%) exceeded limits by no more than 5 hours. Per the ACGME website, "an RRC may grant exceptions for up to 10% of the 80-hour limit, to individual programs based on a sound educational rationale." Although the overall percent of residents reporting violation remains high, the number of excess hours worked is small relative to established standards (within 10%). The authors propose that systems adaptations could be developed to improve compliance. Special attention is warranted to investigate the activities of residents in the post-call period.
毕业后医学教育认证委员会（ACGME）于2003年7月在美国实施了住院医师培训允许工作时长的相关要求。在范德堡大学医学中心此前的一项试点研究中，大量住院医师报告称存在违反要求的情况。此外，几乎一半的受访者承认少报了工作时长。作者的目标是进一步明确违规及少报情况的类型和频率。
设计了一种调查工具，用于评估特定类型的违规行为以及影响住院医师工作和上报时长的因素。在招募受试者之前，已获得范德堡大学机构审查委员会和毕业后医学教育办公室的批准。儿科学、内科学、医学 - 儿科学和普通外科的项目主任支持其住院医师参与调查。在试点研究1年后，对这些住院医师进行了一次自愿匿名调查。
在263名符合条件的住院医师中，175人接受了调查。在175名住院医师中，125人（71%）进行了回复。85%的住院医师报告在过去3个月内违反了工作时长要求。住院医师报告的具体违规情况如下：连续7天休息1天，占28%；每周平均80小时，占65%；“24 + 6”连续小时数，占85%。要求住院医师估计超出要求的时长。超出每周80小时要求的时长报告如下：1小时，占12%；2小时，占15%；3小时，占21%；4小时，占5%；5小时，占14%；6小时及以上，占33%。超出“24 + 6”要求的时长报告如下：1小时，占30%；2小时，占42%；3小时，占18%；4小时，占7%；5小时，占1%；6小时及以上，占2%。48%的受访者承认向项目主任少报了违规情况。
85%的住院医师报告至少有1次违规，48%的人承认少报了违规情况。这些结果分别支持了之前80%和49%的研究结果。在各项要求中，“24 + 6”规则被违反的频率最高。在违反“24 + 6”要求的人中，大多数（90%）超出限制不超过3小时。在违反每周平均80小时要求的人中，大多数（57%）超出限制不超过5小时。根据ACGME网站的规定，“基于合理的教育理由，地区评审委员会（RRC）可为个别项目批准最多不超过80小时限制的10%的例外情况。”尽管报告违规的住院医师总体比例仍然很高，但相对于既定标准（在10%以内），超出的工作时长数量较少。作者建议可以开发系统适应性措施以提高合规性。特别需要关注调查住院医师下班后的活动。
