Surgical residents' adherence to post-call duty hour limits: what are the challenges for education and patient care?
Surgical residents’ adherence to duty hour regulations is strongly encouraged by academic and hospital administrations. Yet, known challenges arise in implementing duty hour limits in surgical training programs. Previous research has indicated that a number of complex, interconnected cultural and structural factors influence residents’ decisions to adhere to duty hour policy, and varied perspectives exist among surgical trainees and faculty on the benefits of duty hour limits relating to education, resident wellness, and patient care.
In the Department of Surgery at the University of Toronto, surgical residents post-call duties are expected to end at noon on the day following in-house call. Senior residents are given allowance to choose to remain in the clinical environment beyond noon to participate in exceptional educational opportunities. In 2013, we conducted a pilot study to assess compliance with the post-call policy; numerous instances of noncompliance were identified.
This aim of this study is to gain an in-depth understanding of the influences on University of Toronto surgical residents’ decisions to leave or stay in the hospital following their call and how these relate to the educational exemption.
Participants described a number of closely linked structural and cultural processes that influence their decision to either stay or leave the hospital post-call. Some cultural factors are summarized here as: IMPRESSION MANAGEMENT; INTERPRETING SILENCE; AUTONOMY IN A HIERARCHY
Residents’ described their decisions to stay as part of an impression management strategy among faculty and peers.
Resident: “I think what really complicates matters is that there are many residents who refuse to leave, so if you’re the only one leaving while other people are staying then you look bad.”
Faculty recognized the potential for this perception to emerge when residents are given an option to stay for additional learning.
Faculty: “I think, all of them – both juniors and seniors – might perceive that if they’re leaving early and others haven’t left early then they’re lesser residents than those who have stayed.”
Without explicit faculty enforcement to leave post call, residents felt they had to interpret ambiguous faculty expectations where the default choice was always to stay.
Resident: “Sometimes, even though nothing is said overtly there’s an implicit or perceived disappointment on [faculty] part that you’re not going to be around, and sometimes having the anticipation of that will just make you stay and not deal with it.”
Faculty described a contrasting view on the meaning of silence, suggesting those who are not explicit about residents leaving do not care what residents do.
Faculty: “If residents are staying late no one’s asking a lot of questions about that. If no one’s asking questions then there’s a perception that we don’t really care if they stay late.”
Autonomy in a Hierarchy
Some residents perceived the need for permission from their faculty to leave post call, which led them to stay.
Resident: “I think it’s a lot easier for us to go home if they say, ‘You need to get out of here,’ versus if they just don’t say anything at all and make us feel like we have to decide what they want us to do.”
Faculty viewed residents as adult learners who could decide without faculty input whether to stay or leave.
Faculty: “I think that if we took a more active role in making people go home then maybe it would be better but, honestly, these people are adults and they need to take some responsibility for their own education. I never ask anyone to stay, never.”
When given allowance to remain in the hospital for more learning, surgical residents must negotiate choice within a complex web of evolving social and cultural expectations, embedded in a dynamic patient care and training environment. Data analysis for this study is ongoing.