Blitz Jason B, Rogers Amy E, Polmear Michael M, Owings Alfred J
Navy Environmental and Preventive Medicine Unit Six, 385 South Avenue, Pearl Harbor, HI 96860.
Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814.
Mil Med. 2017 Nov;182(11):e1997-e2004. doi: 10.7205/MILMED-D-17-00105.
In 2011, the Accreditation Council for Graduate Medical Education (ACGME) modified its duty hour standards for interns and residents. This was done, in part, because of a belief that increased compliance with these standards was needed to positively impact resident fatigue, resident quality of life, and patient safety. However, several studies indicate that duty hour noncompliance and false reporting by interns and residents remains a significant concern for residency program directors. This study examined the compliance of interns and residents with ACGME duty hour standards at a large military graduate medical education (GME) training program.
We conducted a survey of 535 trainees assigned to 24 GME programs within the National Capital Consortium (NCC). Statistical analysis for descriptive parameters used a standard error of measure on the basis of sample and target population sizes to calculate two-sided 95% confidence intervals (CIs). A χ analysis was performed to compare response differences for particular survey questions. A Cronbach α coefficient was calculated to compare the internal consistency of responses for questions in which individual responses were expected to correlate. This study was reviewed by the Offices of Research at the Walter Reed National Military Medical Center and the Uniformed Services University and adjudicated as "Not Research."
Overall, 41.3% (N = 221) of those contacted completed all survey questions. From the available responses, 31.6% (95% CI, 26.9-36.2) reported at least one occurrence of implicit pressure to alter duty hour reporting, and 32.0% (95% CI, 27.3-36.7) reported at least one occurrence of altering reported duty hours. In addition, 37.2 (95% CI, 32.5-41.9) reported being unable to always follow duty hour limits and 58.1% (95% CI, 53.1-63.1) felt time working at home on residency requirements should be included in reported duty hours.
Our results indicate that a significant portion of interns and residents within the NCC were unable to consistently follow ACGME duty hour standards and various systemic barriers within the GME training environment may have contributed. To remove or mitigate these barriers, we recommend using an approach similar to those of "high-reliability organizations" in which organizational processes are systematically investigated to improve safety, quality, and efficiency. Additional surveys or cognitive interviewing within the NCC and at other military GME training sites could be used to help refine these barriers, discover other barriers, determine the scope of these issues within the entire military GME training system, and to measure the outcome of correction actions.
2011年，研究生医学教育认证委员会（ACGME）修订了实习医生和住院医生的工作时间标准。这样做的部分原因是，人们认为需要提高对这些标准的遵守程度，以对住院医生的疲劳、生活质量和患者安全产生积极影响。然而，多项研究表明，实习医生和住院医生不遵守工作时间规定以及虚假报告的问题，仍然是住院医师培训项目主任的重大担忧。本研究调查了一个大型军事研究生医学教育（GME）培训项目中实习医生和住院医生对ACGME工作时间标准的遵守情况。
我们对分配到国家首都联盟（NCC）内24个GME项目的535名学员进行了调查。描述性参数的统计分析使用基于样本和目标人群规模的测量标准误差来计算双侧95%置信区间（CI）。进行χ分析以比较特定调查问题的回答差异。计算Cronbach α系数以比较预期个体回答具有相关性的问题的回答内部一致性。本研究经过沃尔特里德国家军事医疗中心和军事卫生大学研究办公室审查，并裁定为“非研究”。
总体而言，41.3%（N = 221）的被联系者完成了所有调查问题。从可得的回答中，31.6%（95% CI，26.9 - 36.2）报告至少有一次受到改变工作时间报告的隐性压力，32.0%（95% CI，27.3 - 36.7）报告至少有一次改变报告的工作时间。此外，37.2%（（95% CI，32.5 - 41.9）报告无法始终遵守工作时间限制，58.1%（95% CI，53.1 - 63.1）认为根据住院医师培训要求在家工作的时间应计入报告的工作时间。
我们的结果表明，NCC内相当一部分实习医生和住院医生无法始终遵守ACGME工作时间标准，GME培训环境中的各种系统性障碍可能起到了一定作用。为消除或减轻这些障碍，我们建议采用类似于“高可靠性组织”的方法，即系统地调查组织流程以提高安全性、质量和效率。在NCC和其他军事GME培训地点进行额外的调查或认知访谈，可用于帮助细化这些障碍、发现其他障碍、确定这些问题在整个军事GME培训系统中的范围，并衡量纠正措施的效果。
