Synergy Medical Education Alliance, Saginaw, MI 48602, USA.
J Surg Educ. 2009 Nov-Dec;66(6):374-8. doi: 10.1016/j.jsurg.2009.05.002.
All residency programs must comply with the Accreditation Council for Graduate Medical Education (ACGME) work-hour guidelines, but compliance requires accurate interpretation of the rules. We previously surveyed the residents and program directors of general surgery residency programs and found significant discordance between what program directors and residents considered violations. Our current study expands our research to include family medicine and emergency medicine residents and program directors. This study aims to identify discrepancies of work-hour guideline interpretation within and between the specialties.
We created 10 scenarios related to work-hour issues. The ACGME reviewed them and judged whether a violation occurred in each scenario. From these scenarios, an Internet-based survey was generated and distributed electronically to every family medicine and emergency medicine residency in the United States. (Surgery programs were previously surveyed from March 1 through May 21, 2007 with the same scenarios.) Responses were collected anonymously via our Internet-based survey database from March 1 through May 17, 2008. All respondents were asked to identify themselves as either a program director or a resident. After reading each scenario, participants were asked to answer either "yes," "no," or "maybe/not sure." The option of "maybe/not sure" was in place to discourage guessing; those responses were not included in our analysis. After the data were collected, we calculated the percent of respondents that answered "yes" or "no" for each of the 10 scenarios related to work-hour issues. The results from within specialties (program directors vs residents) and between specialties (general surgery, family medicine, emergency medicine) were compared.
There were a total of 883 respondents (334 general surgery, 374 family medicine, and 175 emergency medicine). Respondents identified themselves as program directors (97), assistant program directors (21), or residents (765). Statistically significant differences were identified in the responses of program directors and residents within and between specialties.
Based on the scenarios we presented, there was a difference in interpretation between residents and program directors. There was even disagreement among program directors of different specialties on the interpretation of some of the scenarios. This finding reveals an ambiguity in the work-hour restrictions. We conclude that the ACGME-mandated work-hour guidelines are confusing and not universally understood. This problem is compounded by the cross-training with "off-service" residents from other specialties such as family medicine and emergency medicine. Hence, enforcement of the work-hour restrictions may be problematic, despite the best intentions and sincere effort of directors and residents to interpret the rules.
所有住院医师培训计划都必须遵守研究生医学教育认证委员会 (ACGME) 的工作时间指南，但遵守规定需要对规则进行准确解读。我们之前对普通外科住院医师培训计划的住院医师和培训计划主管进行了调查，发现培训计划主管和住院医师对违规行为的看法存在显著差异。我们目前的研究将研究范围扩大到包括家庭医学和急诊医学住院医师和培训计划主管。本研究旨在确定各专业内部和之间在工作时间指南解读方面的差异。
我们创建了 10 个与工作时间问题相关的场景。ACGME 对这些场景进行了审查，并判断在每个场景中是否发生了违规行为。根据这些场景，我们生成了一个基于互联网的调查，并分发给美国的每个家庭医学和急诊医学住院医师培训计划。（外科培训计划已于 2007 年 3 月 1 日至 5 月 21 日进行了调查，使用了相同的场景。）从 2008 年 3 月 1 日至 5 月 17 日，通过我们的基于互联网的调查数据库匿名收集了回复。所有回复者均被要求将自己标识为培训计划主管或住院医师。在阅读完每个场景后，参与者被要求回答“是”、“否”或“可能/不确定”。设置“可能/不确定”选项是为了防止猜测；这些回复未包含在我们的分析中。收集完数据后，我们计算了对与工作时间问题相关的 10 个场景中的每个场景回答“是”或“否”的回复者的百分比。比较了各专业内部（培训计划主管与住院医师）和各专业之间（普通外科、家庭医学、急诊医学）的结果。
共有 883 名回复者（334 名普通外科、374 名家庭医学和 175 名急诊医学）。回复者将自己标识为培训计划主管（97 人）、助理培训计划主管（21 人）或住院医师（765 人）。在各专业内部和各专业之间，培训计划主管和住院医师的回复存在统计学差异。
根据我们提出的场景，住院医师和培训计划主管对这些场景的解读存在差异。不同专业的培训计划主管对某些场景的解读甚至存在分歧。这一发现揭示了工作时间限制中的模糊性。我们的结论是，ACGME 规定的工作时间指南令人困惑，并且未被普遍理解。这种情况因与家庭医学和急诊医学等其他专业的“非本专业”住院医师交叉培训而更加复杂。因此，尽管培训计划主管和住院医师都有遵守规定的良好意愿和真诚努力，但工作时间限制的执行可能存在问题。
