A resident gets up in the middle of a required lecture about fatigue and sleep deprivation to answer a page about a patient she admitted the night before when she was on call from home. She has been called in from home three times during the past week in the middle of the night and has gotten no more than four hours of sleep each night. She has an infant at home who wakes up during the night to be fed, and each time, the pager goes off.
When she returns to the lecture, the speaker, an expert on sleep, presents her with a form to sign that acknowledges that she understands the risks of sleep deprivation, which include medical errors and car crashes on the way home from the hospital. The resident throws the form on the floor and mutters, “What BS!” The lecturer files a complaint with the program director about the resident’s attitude and unprofessional behavior. When the resident meets with the program director she mentions that she and others in the program have all been falsifying their duty hours forms because they are usually in violation, and if they report honestly, they will be criticized for being inefficient and hurting the program’s accreditation. The program director counsels the resident and documents in her portfolio the complaint of unprofessional behavior for the incident with the speaker and also notes the dishonesty in duty hours documentation.
I pondered this incident, related to me by a colleague, as I was considering my editorial about professionalism for this month’s issue of Academic Medicine. Professionalism has been among the topics most frequently published by our journal, and we recently presented on our website the second e-book collection of journal articles on professionalism that were published from 2011 to 2016.1 Hafferty2 has provided an introduction to that collection and a review of the first collection,3 also an e-book, in an article in this issue that summarizes professionalism scholarship published in this journal from 1994 to 2016 and the historical context of that scholarship. While the literature encompasses many topics, including definitions, approaches to training, and professionalism within the broader health care context, much of the literature involves unprofessional behavior of students or residents, such as lack of integrity.4 Recognition of professionalism lapses by students is important because Papadakis et al5 have shown that students who were noted to have problems with professionalism in medical school had a higher likelihood of future discipline for professionalism lapses than those who did not have such problems. Was the incident I related earlier an example of the type of behavior that would presage future professionalism problems for the resident involved? What changes in the conditions of residents’ training could have prevented that kind of behavior?
The concept of the hidden curriculum can help us explore professionalism issues related to duty hours regulations in graduate medical education. Gofton and Regehr6 assert that in many cases the unprofessional behaviors and attitudes that students and residents exhibit are not learned during the formal or informal educational program but come from exposure to the hidden curriculum, which includes informal rules, attitudes, and beliefs that are assimilated through the socialization process that occurs during education. In this issue, Lawrence et al7 have provided a scoping review of the hidden curriculum in medical education, and Hafferty and Martimianakis8 have written an Invited Commentary on their review. Lawrence et al note that the hidden curriculum is generally portrayed as having a negative influence on medical students, leading to “the erosion of idealism, and the increase in cynicism and bias that occur during medical school,” although there is no consensus about what constitutes the hidden curriculum. They further note that the most common suggestion to combat the ill effects of the hidden curriculum is that “schools make the hidden curriculum explicit to both faculty and students.”
The idea of the hidden curriculum also can help us understand the long history of residents’ resistance to duty hours rules. Fargen and Rosen9 and Carpenter et al10 have documented that residents often falsify their hours. Carpenter et al note that as many as 85% of the residents surveyed admitted to falsification of duty hours over the previous three months. Falsification has been deemed unprofessional behavior by many program directors and graduate medical education deans. Why would residents do something that their supervisors believe to be unprofessional?
Szymczak et al11 conducted an ethnographic study of internal medicine and general surgery residents in 2008 to assess the effects of the duty hours regulations on professional morality after concerns were raised about
residents who are concerned primarily with their own needs, are eager to sign out when they have reached their eighty hours, and feel little or no ownership of or responsibility for their patients. In essence, under duty hour regulations residents would cease to be professionals but would become shift workers regulating their work hours according to the clock instead of their patients’ needs. Even if residents do not adopt this shift work mentality they will still have to behave in an unprofessional way: lying about the number of hours they worked.
What Szymczak et al found was a more nuanced situation, where residents violated duty hours when a need for patient care required it, and were concerned that accurately reporting duty hours violations would imply that they were inefficient and could even harm their program. Issues of truthfulness conflicted with autonomous responsibility to patients, loyalty to the residency, and the reputations of the residents and the program. As a consequence, the residents would often adopt a default position of claiming to not remember exactly how many hours they worked rather than admitting to overtly lying. Aspects of motivation for adult learning identified in self-determination theory12 that included the desire for competence, connectedness, and autonomy came into conflict with regulatory and institutional codes of honor.
West and Shanafelt13 describe the impact of the work environment, including long hours and physical and mental stress, upon student professionalism. They identify how difficult it is for physicians, residents, and students to put the needs of the patient first when their own physical and mental resources are depleted. They note that at the heart of the debate about duty hours and its effect on professionalism “are attitudes concerning the role of physicians’ personal health and well-being in professional development and quality of patient care.” Hafferty and Tilburt14 add the element of fear among residents as a negative motivator that can affect professional behavior.
Taken together, these environmental and structural forces may create conditions in which residents are faced with choosing to disregard their need for sleep, abuse their health, violate duty hours, and lie about their hours, or provide inadequate patient care that will leave them feeling guilty and inadequate. Program directors and hospital administrators who are responsible for protecting the well-being of residents and enforcing work regulations may be either unaware of such dilemmas or unable or uninterested in finding solutions—or may tacitly agree with the subterfuge of the residents. In fact, faculty who are the role models, team leaders, teachers, and assessors of the residents—and who have no restrictions on their own work hours—often remind the residents how much easier current life for residents is than it was in their day. What are residents, who function as part of a social network led by these faculty, to make of these contradictions?
This conundrum is well suited for inclusion in the hidden curriculum, where conflicts between rules and actual expectations set in motion an elaborate dance in the dark. Residents and students learn the steps of this dance, which involves following the rules when they can, ignoring them when they must, and accepting the dishonesty that they practice as the lesser of two evils.
To eliminate this hidden curriculum requires first exposing it and admitting the truth of what is happening and why, followed by creating an ethical and fair alternative. How might this be done?
First, we medical educators should temporarily eliminate any consequences for residents who violate duty hours restrictions so that we can accurately define the extent of the problem. Resident work hours are made up of scheduled hours and time that extends beyond the schedule because of administrative responsibilities, continuity of patient care, unplanned emergencies, and other unscheduled activities. Both work schedules and other unscheduled activities need to be analyzed and addressed. There is great variability in work schedules and work hours among programs and institutions, and we need to focus on those that seem to be potentially most harmful. We should also stop labeling the falsification of duty hours as a failure of professionalism, because residents are usually aware that such an act has consequences but feel they have no alternative. Stopping such labeling would allow us to gather more accurate data, define the extent of the problem, and not add to the stress of the residents. We should also utilize ways to measure resident work hours without requiring the residents to personally enter their hours. There are other methods to do this, utilizing technology, that do not put residents in the impossible position of perhaps harming themselves, their patients, and their programs, or lying.
Second, once we understand the extent of the problem—which would likely vary by specialty and institution—we would need to decide how to create better resident work schedules, starting with the programs with the most challenging schedules and making certain that the schedules are realistic and build in time for unscheduled activities. We would want to base the schedules on adult learning theories, placing learning experience first and foremost and recognizing that learners are in vulnerable positions and should be protected. The term duty hours should disappear from the lexicon of medical education because duty implies an obligation, whereas learning depends on the motivation to learn, which rarely is linked to duty. An educational experience should give learners the opportunity to reflect and to develop relationships with patients and colleagues from which they create their professional identities and deepen their knowledge and skills.
The work that must be done to support the patient care activities of hospitals and clinics should primarily be the responsibility of the health system and its trained health professionals and staff. Entrustment concepts for professional activities provide a framework for sharing responsibilities between learners and fully trained professionals. While educational principles can improve the care delivery system, the experience of learners should not be driven by the patient care needs of the health system. Instead, the curriculum and the time allotted to educational experiences should be driven by such goals as better patient health, better health care, lower cost, and wellness of health providers. If program directors had control over many of the resources currently flowing through hospitals for education, they could likely allocate them in a way that would provide a better learning environment than currently exists. Because residents are apparently able to become well educated in other countries in far less than the 80 hours a week mandated as a maximum in the United States,15 it is likely that the current number of work hours would decrease. The current trend of changing our time-based training system to one that is competency based and time flexible, described by ten Cate et al16 in their article in last month’s special supplement to Academic Medicine, may provide some valuable ideas about how to reform current schedules and to make them more flexible and responsive to individual needs and opportunities.
Third, we need to recognize the need for additional support for residents with new children. The unpredictable sleep needs of infants do not end after a six-week maternity leave. New parents who are already sleep deprived from their 80-hour workweeks may not be in a position to assume a full work schedule after the typical leave period. It was predictable that the resident in the anecdote at the beginning of this editorial would be near the breaking point when she was coping with an infant and a challenging night call schedule. We should adjust resident schedules and reduce work hours for months after return to residency to allow for the loss of control over sleep that an infant will create. Similarly, an illness or injury may demand a gradual and prolonged scheduling modification as residents return to patient care activities. Eighty hours, even under the best of circumstances, imposes a huge physical and mental stress. After an illness or childbirth, it can become untenable. Changes in our approach to these special circumstances need to be made in conjunction with the certifying boards and Centers for Medicare and Medicaid Services, who pay for most graduate medical education. Medical professionalism is embodied in the relationship of the profession to its learners as well as in the relationship between the learners and their patients, and our training regulations should reflect both relationships.
Finally, it is time to broaden our professionalism discussion to include empowerment of our residents, students, and faculty who currently feel vulnerable and powerless to effect change. Empowerment means a leveling of hierarchies and sharing of the mechanisms to effect changes in our learning environment and patient care settings with everyone who would be affected by the changes, including learners, staff, and patients. While empowerment can occur through a conscious organizational effort to promote equity, it can also occur through the daily interactions and conversations that take place in our health care institutions. Dwyer and Faber-Langendoen17 in this issue describe, as part of an ethical action exercise, an example of how to encourage students to speak up when they observe unprofessional conduct or unsafe care of patients.
I have chosen to discuss the issue of professionalism and duty hours because it is an example of the hypocrisy that creates the hidden curriculum. Rather than using professionalism as a weapon to punish our students and residents, it is time for us to look into the mirror. How much do we really care about our residents who are up all night and then go home to a newborn who will not allow them to sleep? How much do we care about the resident with a knee injury who is hobbling down the hallway trying to keep up with the care team while recovering from surgery? How much do we care about the resident who should be going home to rest after 14 hours in the hospital but is instead filling out paperwork for patients who need to go to a nursing home because the hospital has refused to pay for a social worker who could have performed this task? While I am sure we would all say that we do care, I am not sure that we care enough to confront current power structures or our own advantages within the current system that would need to change to make a difference. If we do not care enough, our residents will continue to suffer the consequences of overwork, and resiliency training will not be enough to overcome the depression, burnout, and suicidal ideation that will take hold of them.
We must move from our discussions about professionalism to the reality of abusive health professions learning environments and the culture that supports them so that we can create a culture of empowerment. Empowerment requires an honest reckoning of the hidden curriculum, a willingness to make a fresh start with our residency schedules and work hours, and a recognition of the potential within our learners and ourselves to create something better than what we were given. Empowerment will require trust between residents and faculty and a commitment to the health and education of our learners, who will know better than outside regulators how to allocate their time to the best benefit of their learning and the needs of their patients. An empowered group of learners and faculty will make the hidden curriculum visible to all and align professionalism with equitable and effective health care education and delivery.
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