Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA.
Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA; Office of Graduate Medical Education, University of Virginia School of Medicine, Charlottesville, VA.
Surgery. 2020 Feb;167(2):302-307. doi: 10.1016/j.surg.2019.05.029. Epub 2019 Jul 8.
The inception of work hour restrictions for resident physicians in 2003 created controversial changes within surgery training programs. On a recent Accreditation Council for Graduate Medical Education survey at our institution, we noted a discrepancy between low recorded violations of the duty hour restrictions and the surgery resident's perception of poor duty hour compliance. We sought to identify factors that lead to duty hour violations and to encourage accurate reporting among surgery trainees.
The A3/Lean methodology, an industry-derived, systematic, problem-solving approach, was used to investigate barriers to accurate reporting of duty hours by residents within the Department of Surgery at our academic institution. In partnership with our office of Graduate Medical Education, we encouraged a 6-month period where residents were asked to record duty hour accurately and to provide honest, descriptive explanations of violations without punitive effects on residents or the program. We performed a 6-month before-and-after analysis of duty hours violations after the A3/Lean implementation. Quantitative analysis was used to elucidate trends in violations by post graduate year and rotation. Qualitative evaluation by key thematic areas revealed resident attitudes and opinions about duty hour violations.
Residents reported concern for personal and programmatic, punitive measures, desire to retain control of their education, and frustration with the administrative burden after violations as deterrents to honest duty hour reporting. The intervention was successful in changing logging behavior with 10 total violations prior to A3 meeting and 179 violations afterward (P = .003). This change was driven largely from an increase in short break violations (4 vs 134, P = .021). Analysis of violations revealed trends by post-graduate year, rotation, and weekend cross-coverage. Key findings including less than anticipated violations of the 80-hour work week despite high rates of short break violations. The ability to participate in procedures voluntarily and a sense of professional responsibility emerged as the prevailing themes among surgery residents describing violations.
Systematic evaluation of duty hour reporting within a surgery training program can identify structural and cultural barriers to accurate reporting of duty hours. Accurate reporting can identify program-specific trends in duty hour violations that can be addressed though programmatic intervention.
2003 年，住院医师工作时间限制的出台，给外科培训项目带来了颇具争议的变化。在我们机构最近的一项美国毕业后医学教育认证委员会调查中，我们注意到记录的违规行为与外科住院医师对工作时间合规性的较差感知之间存在差异。我们试图确定导致工作时间违规的因素，并鼓励外科受训人员准确报告工作时间。
我们使用 A3/精益方法（一种源自工业界的系统的、解决问题的方法）来调查我们学术机构外科部门住院医师准确报告工作时间的障碍。我们与研究生医学教育办公室合作，鼓励住院医师在 6 个月内准确记录工作时间，并对违规行为提供诚实、描述性的解释，而不对住院医师或项目产生惩罚性影响。在实施 A3/精益方法后，我们对工作时间违规行为进行了 6 个月的前后分析。通过对毕业后年份和轮转的定量分析，阐明了违规趋势。通过关键主题领域的定性评估，揭示了住院医师对工作时间违规的态度和看法。
住院医师报告了对个人和项目的惩罚措施、保留教育控制权的愿望以及违规后的行政负担的担忧，这些都是对诚实工作时间报告的阻碍。干预措施成功地改变了记录行为，在 A3 会议之前有 10 次总违规，之后有 179 次违规（P=0.003）。这一变化主要是由于短休息违规行为的增加（4 次对 134 次，P=0.021）。违规行为的分析揭示了毕业后年份、轮转和周末交叉覆盖的趋势。关键发现包括，尽管短休息违规率很高，但违反 80 小时工作周的违规率低于预期。自愿参与手术的能力和专业责任感成为外科住院医师描述违规行为的主要主题。
对外科培训项目工作时间报告进行系统评估，可以确定准确报告工作时间的结构性和文化障碍。准确报告可以识别出特定项目的工作时间违规趋势，可以通过项目干预措施来解决这些问题。
