Coverdill, James E.; Carbonell, Alfredo M.; Fryer, Jonathan; Fuhrman, George M.; Harold, Kristi L.; Hiatt, Jonathan R.; Jarman, Benjamin T.; Moore, Richard A.; Nakayama, Don K.; Nelson, M. Timothy; Schlatter, Marc; Sidwell, Richard A.; Tarpley, John L.; Termuhlen, Paula M.; Wohltmann, Christopher; Mellinger, John D.
The duty hours restrictions for resident physicians enacted by the Accreditation Council for Graduate Medical Education (ACGME) in 2003 came at a time of renewed interest in medical professionalism. Editorials foretold passionately of the “death of professionalism” in surgery and other disciplines.1,2 Research fanned flames by pointing to the emergence of “shift mentalities” and widespread concern about drop-offs in patient care.3 In the midst of this maelstrom, some argued that the ACGME duty hours restrictions had simply set the stage for the emergence of a “new professionalism.”
Exemplified by the eloquent statement of Van Eaton et al,4 proponents of a new professionalism suggested that traditional conceptions and enactments of “patient ownership” by residents could and should be replaced by new understandings and practices based on the principles of teamwork. Individual patient ownership, founded on residents knowing everything about their patients and doing everything for them, would give way to team ownership. The new professionalism would be nurtured though clear guidelines as to what residents would be expected to know and do for their patients and those they cross-cover along with instruction in how to conduct sign-outs and hence safely transfer care across shifts. Van Eaton et al4(p234) described these changes as radically transforming the “ethos of residency.”
In this study, we explore the extent to which a new professionalism has taken root, focusing on general surgery residents, a group for whom professionalism was traditionally coupled to long work hours. We employ a multiinstitutional design and explore a hypothesis advanced by the Institute of Medicine (IOM): “Training programs, regardless of specialty, that have just a few residents will have a harder time adapting to reduced duty hours than those with more residents.”5(p3:7) Other research, however, suggests that smaller programs may rely less on residents for procedures and patient care, factors that may foster a new professionalism.6
The study includes residents from 15 programs in general surgery located in 11 states and all four mainland U.S. time zones. On-site coordinators at six university-based and nine non-university-based programs secured local institutional review board approval, administered the questionnaire during the summer of 2009 to categorical residents, and gathered materials enclosed in envelopes. We achieved an 82% response rate (N = 306). The data provide statistical power of nearly 0.90 to detect relatively small differences (an effect size of w = 0.20) between residents in small (N = 73), medium (N = 79), and large (N = 154) residency programs, defined here as fewer than 20, 20 to 29, and 30 or more residents.
Ten questionnaire items probe old and new forms of professionalism. Items were derived from statements about the two professionalisms made by Van Eaton et al.4 Because there has been little research on these issues, there were no validated questions to draw on. We checked items for face validity and clarity by conferring with residents and faculty at the last author's institution and with the director of the Survey Research Center at the lead author's university. Responses were formatted as five-point scales ranging from “strongly disagree” to “strongly agree,” with a neutral middle category. Results, obtained in STATA (11, College Station, TX),7 include means, percentage who “agree or strongly agree” (for interpretive ease), and Pearson chi-square tests for the analysis of program size differences.
A final questionnaire item requested participation in a follow-up interview. Volunteers provided contact information separately to maintain the anonymity of questionnaire responses. The semistructured interviews allowed us to better understand beliefs and behaviors regarding professionalism. Although we asked direct questions about professionalism, we gained substantial traction on a key aspect of the new professionalism—stay-or-go decision making at the end of a shift—by posing three scenarios. In each, a resident had worked a day shift and was about ready to sign out to a night resident or team when he or she was presented with (1) an urgent need on the part of one of his or her patients for a chest tube, (2) a desire on the part of a patient and his or her family for a conference, and (3) newly arrived consultant recommendations that meant one of the resident's patients would need to have work done in the evening (e.g., studies and labs) or care would be delayed the following day. For each scenario, residents were asked about the reasoning that would guide their behavior and what responses would be likely and desirable. Each scenario parallels one developed by Van Eaton et al4(p233) to illustrate new and old professionalism. Residents readily recognized these issues, addressing them at length and with passion.
The lead author conducted interviews with 52 residents chosen randomly from the 40% (N = 123) who volunteered. Interviews averaged 28 minutes in length; most were conducted by telephone and all were recorded (with permission). Analysis involved thematic coding of the 416 transcript pages after four readings and subsequent use of MAXQDA (Marburg, Germany), software designed to facilitate open and axial coding and the rigorous analysis of textual evidence. Given the sensitivity of responses regarding professionalism and stay-or-go decisions during shift changes, residents were assured of strict confidentiality. That promise meant that our qualitative analysis was conducted by the lead author, an external investigator, and focuses on dominant themes only, not those which would require consensus-generating coding discussions. A member check with 10 residents affirmed that the results resonate with their experiences.
The overall means and percentages (first column of numerical values) in Table 1 point to a mixture of old and new professionalism. As for the old professionalism, the vast majority (84% or 257/306) believe that some residents work longer-than-permitted hours in the name of professionalism. Few believe that they are taught how to do sign-outs (16% or 49/306), are given clear guidance as to what to do if patient conditions change at the end of their duty periods (32% or 98/306), or believe that it is now routine and acceptable for residents to pass work off to night teams (37% or 113/306). This suggests the continued salience of a long-hour, do-your-own-work culture, hallmarks of the old professionalism. Other items point to the partial emergence of a new professionalism. For example, residents see patient care more as a team than an individual responsibility (76% or 233/306) and do not agree that cross-covering residents lack a sense of patient ownership or responsibility (37% or 113/306). Most (68% or 208/306) agree that residents are provided with clear expectations as to what they are to know and do for their patients and those they cross-cover. Relatively few (27% or 83/306) maintain that inefficient work practices are the main reason work is passed to night teams.
Only two items differ significantly by program size (P < .05, items 5 and 9), a pattern that runs counter to the IOM hypothesis that smaller programs may have more difficulties adapting to reduced duty hours.5(p3:7) The two issues that differ may also be subject to interpretational ambiguities, as no small programs in our study had a dedicated team of residents on “night float,” a fact that may alter the meaning and salience of the expressions “cross-covering residents” in item 5 and “night teams” in item 9. What prevail are general patterns, not substantial or sustained differences across programs.
The interview evidence suggested that residents rely on discretion, not clear guidelines, when they face stay-or-go decisions at the end of shift. Only one resident denied the essential role of discretion, saying that “if we are going to have the rules, people have to go home” (ID#1:PGY1). Others saw the need for a flexible interpretation of the duty hours restrictions: “I think we have two different, sometimes conflicting, rules in play. One is you put your patient's well-being above your own. The other is to follow the work hour rules. There are going to be times when those two rules are in conflict. When that happens, putting the patient's well-being above the rules takes precedence” (ID#2:PGY5). Residents described how the hour rules “are meant to be an average, not an absolute” (ID#3:PGY3) and that “there is some fudge room—I might work more this particular week because I have a patient whose family needs a conference, but it's 80 hours averaged over the four weeks” (ID#4:PGY4). The expression “it's situational” was invoked to describe how residents would, and ideally should, handle stay-or-go decisions. While details vary across scenarios, two considerations were paramount: deep concerns about night staffing, and perceived professional obligations.
Day and night staffing are not equivalent. Residents described how small night teams covered all floor patients as well as consults, traumas, and urgent and emergent procedures. Capable and conscientious night teams might get tied up or have to prioritize activities; it was thus impossible to bank on night teams getting to passed-off issues immediately, if at all. One resident's comments are typical: “Night float is fewer people taking care of the same number of patients, so if everybody checks out something little it becomes big—plus there are all the emergencies that come in” (ID#5:PGY2). Even well-conducted sign-outs were understood as providing only rudimentary information: “There's really no way to check out the entire situation to somebody” (ID#6:PGY2). Exacerbating that situation was the distinct possibility of an experience mismatch, whereby care or a family conference might end up in the hands of a less experienced night resident. These patterns combined to leave nearly all residents concerned that night teams might not be available or able to complete passed-off work. One resident summed up the prevailing reluctance to sign out much to night float this way: “We like to get everything done ourselves so that we don't have to check something out” (ID#7:PGY4).
Those concerns appear to magnify perceived professional obligations on the part of day residents during shift transitions. Residents were quick to stress that daytime residents are aware of the fluid plans and discussions within the team and with patients and families that only rarely become documented in patient records, prompting the sentiment that “for patient care purposes, it's always better if the day team takes care of things” (ID#8:PGY1). Familiarity and trust, they argued, “aren't generic—they require a relationship and experience” (ID#3:PGY3). Timely care can in some cases be more easily and efficiently provided by the day resident; many spoke of how it takes longer to track down a night team resident and sign out the placement of a chest tube—let alone a family conference—than it does to simply do them. For many residents, there is also a strong sense of old-fashioned patient ownership, evident in comments like “it's my patient and my work and I wouldn't want to ask someone else to manage that” (ID#9:PGY2), and pride in that ownership, evident in statements like “if it's something that needs to be done, at our institution we take care of it ourselves” (ID#10:PGY4).
The results bear on the state of a new professionalism and the role of system factors in shaping professionalism. Two keys to the new professionalism are the ability and desire to pass work across shifts by residents who embrace the team ownership of patients. Although the questionnaire suggests some glimmers of a new professionalism, it also indicates the continued salience of a traditional professionalism in a reluctance to pass work from day to night teams, unclear guidance regarding stay-or-go decisions during shift transitions, little educational emphasis on sign-outs, and the practice of long hours in the name of professionalism. The interviews refined that portrait by highlighting the role of discretion, concerns about night staffing, and perceived professional obligations. Six years after the introduction of the duty hours restrictions, a new professionalism represents a stalled revolution among general surgery residents in programs large and small. Strikingly, the challenges and concerns expressed by interns in a 1993 study dovetail with those found here.7
The results imply a need to consider carefully and realistically how systems issues may impede cultural shifts like those entailed in the new professionalism. As described by Leape,8 systems issues are failures in the design of work tasks, training, and the conditions of work. Even if residents were completely sold on the virtues of a new professionalism, it is hard to see how those ideals could routinely translate into action, given the prevailing workloads and staffing of residencies. Staffing at night is simply not the same as in the day. As one resident put it, night teams “put a finger in the dike until the morning” (ID#11:PGY4), hardly a characterization of equal status with day teams. The dramatic disjunction between day and night staffing leads residents to conclude that passing off work to night teams can be, in at least some situations, tantamount to shirking professional obligations to patients and families, risking inferior or delayed care, and “dumping” on fellow residents. Given those concerns, to require residents to pass off work in a strict, clock-driven way would challenge their ability to exercise discretion and discharge what they view as key professional obligations.
It is also unrealistic to expect that improved sign-out practices and protocols can do much to improve shift transitions without additional attention to staffing issues and workloads. Few surgical programs teach residents how to conduct sign-outs, a pattern that may indicate resistance on the part of faculty or a hidden curriculum opposed to a new professionalism. However, absolutely perfect sign-outs to night teams overburdened with too many patients and other obligations are likely to represent only a marginal improvement. Likewise, the IOM's5(p1:11) proposition that sign-outs can be an opportunity to reassess patient care and catch previous errors is terrific in theory, but it assumes relatively equal teams across the day-night transition, not the finger-in-the-dike reality described by residents. The IOM's emphasis on resident workloads needs to be expanded to include cross-shift workloads.
Abstract notions of professionalism guide action within particular social contexts, and those contexts help or hinder their realization. Schein,9(p8) a giant in the field of organizational culture, argues that whether or not a culture is functionally effective “depends not on the culture alone, but on the relationship of the culture to the environment in which it exists.” Hafferty and Castellani10(p294) similarly emphasize that professionalism “does not take place in a vacuum.” To be fully realized, the cultural transformation represented by the team-based new professionalism must be supported by other system factors, namely team staffing and workloads. Culture is but one part of an interdependent system.
The authors are grateful to the Department of Surgery at the Medical College of Georgia for its support and to the faculty and residents who gave generously of their time to participate in the questionnaire and interview prongs of the project.
The Department of Surgery at the Medical College of Georgia (Augusta, Georgia) provided funding for this research.
This study was reviewed and approved by Institutional Review Boards at each data-collection site and at the lead author's university.