Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Saturday, December 8, 2007

The ACGME Resident Physician Work-hours Enforcement Policy: Why the Social Norms, Power Structures and Social Isolation of Academic Medicine Will Ensu

Physician trainees, or “residents,” have traditionally worked shockingly long hours, often in excess of 100 hours per week, including marathon “on-call” shifts in excess of 36 hours (1). There is mounting evidence that excessive work-hours lead to increased medical errors (2), reduced learning for the resident (3), and greater likelihood of the resident being in a car crash (4), among other negative outcomes. There is also evidence that after 24 hours of wakefulness, a person has the psychomotor performance of a person with a 0.10 blood alcohol level, which is a level high enough to warrant an arrest for drunk driving (5-7). To many, it would seem obvious that the system should be changed, for the sake of both doctor and patient.

In 2002, Congress began considering a bill that would regulate resident work hours (8); to avoid outside interference in the medical education system, medicine decided to regulate itself (9). Since 2003, new work-hours regulations dictate, among other limits, that a resident physician shall not work shifts of greater than 36 hours in total length, with a total of no more than 80 hours a week (10). These regulations were promulgated by the Accreditation Council for Graduate Medical Education (ACGME), the governing body that regulates all educational aspects of physician residency training programs.

The enforcement mechanism for these regulations is non-anonymous reporting by a resident physician to the ACGME; the ACGME will place a reported residency program on probation, possibly revoking its accreditation if the violations are not corrected (11,25,26). This is a powerful threat, and it would seem that under such threat, residency programs should fall into line. Yet teaching hospitals routinely violate the work-hours regulations, and residents fail to report them to the ACGME (12). How could that be?

The ACGME relies on a power-coercive model (13, p. 40) as the basis for its policy; it assumes by ordering residency programs to comply, imposing sanctions for violations, and by placing the onus on the residents to report any violations, it has solved the problem of excessive work-hours.

Yet residents face intense pressure every day, from both peers and superiors to accept the status quo. The social norms of residency do not encourage questioning traditional work-hours, nor do residency program directors, who hold immense power over residents’ careers. Additionally, residents are chronically sleep-deprived and under high levels of stress -- conditions that make it hard to stand up for oneself. In this paper I will explore why it is that our nation’s young physicians allow themselves to be worked to exhaustion, despite ample evidence that the work-hours system needs to change.

The Effect of Social Norms

Social Norms Theory states that much of people’s behavior is influenced by their perception of how other members of their social group behave, and that people tend to misperceive, i.e., exaggerate the negative health behavior of their peers. If people think a harmful behavior is typical, they are more likely to engage in that type of behavior (14).

At work, a young physician adopts the norms of their colleagues and superiors in an attempt to blend in and succeed professionally. Resident physicians are professionally socialized in a rigid and hierarchical system (15). Every year that a resident advances in their training gives them more authority, with first-year residents (or “interns”) already having authority and responsibility for training and supervising medical students, but still reporting to junior residents, who report to seniors, and so on up the line. At the top of the pyramid are chief residents and attending physicians, in turn supervised by residency program directors and department chairs, respectively.

Residents see more senior physicians as their role models, emulating both the positive and negative aspects of their professional behavior (16). Positive evaluations and praise from one’s attending physicians or senior resident is the key to success in medicine, and the key to being accepted by one’s peers. In residency, staying late, finishing all assigned work, and not complaining are seen as valuable attributes. Questioning whether those same attributes cause harm to physician or patient is not part of the norms of the medical profession. Being “tough” enough to work long hours – even if it means potentially putting oneself or one’s patients in a compromised position – is accepted and praised. Senior residents will look down on an intern who does not stay late to finish his or her work, and deem them to be “weak” (17).

And where does the senior resident pick up this attitude? When attending physicians – particularly prestigious chairs and program directors - say that 36-hour shifts are necessary to protect the “continuity of patient care” and ensure appropriate learning for the resident (18,19), then the resident accepts that (20) and communicates that norm down the hierarchical chain. Many attending physicians hold to the idea that increased hand-offs from shorter shifts are the real danger to patient care (21,22), without examining ways hand-offs or shift arrangements might be improved (23,24). These physicians insist that learning best happens during long, overnight shifts, so that residents can follow their patients’ progress, despite evidence that shows that learning becomes impeded with excessive fatigue (3).

The effect of medicine’s rigid hierarchy on a resident’s likelihood of reporting a work-hours violation cannot be overemphasized. In one surgery program, an attempted change to the work schedule was ineffective when interns were told to sign out to their senior residents; the interns ended up doing the work themselves rather than “insult” the seniors by giving them an intern’s work to do (17).

And what if a resident does report a work-hours violation? One resident reported his program to the ACGME, following an incident where he forgot to order an important blood test, after 34 hours awake and at work. The program was placed on probation, and his angry colleagues subsequently ostracized him to the point where he had to leave the program (25, 26). For someone who has spent his whole life working to become a doctor, the possibility of being professionally shunned is a powerful disincentive to report any violations.

The Effect of Social Power

Each residency program is run by a Program Director, a physician respected in her field, who holds enormous sway in recommending a resident for future employment. The Program Director can be instrumental in securing a spot in a prestigious cardiology fellowship, or a position with a lucrative ENT practice. Conversely, the Program Director can decide a resident doesn’t “measure up” for a good job following residency, and has control over whether a resident can sit for the board-certification or even become fully licensed to practice. Ultimately, a program director has the power to fire a resident who he deems unsatisfactory; a resident who has been fired has very little chance of finding a new residency spot. Under such conditions, it would take a brave – or foolhardy – resident to out her program’s hours violations to the ACGME.

Program directors (and other medical faculty) may hold all of the five bases of power over a resident, as defined by French and Raven in “The Bases of Social Power” (27). The more obvious forms of power that a program director holds over a resident are reward power and coercive power. Reward power refers to being able to promote or professionally reward the resident; coercive power refers to the program director’s ability to harm a resident’s professional career. Because of this power, maintaining good relations with supervisors comes even at the expense of quality care, and residents worry that even pointing out an error made by a superior could harm their careers (15).

The program director also holds legitimate power and expert power over housestaff. Expert power refers to the acceptance of the program director by the resident as an expert in their field, and aids the exercise of what residents see as legitimate power. The authors define legitimate power as power that stems from the resident’s internalized values. These values lead the resident to believe that the program director has a legitimate right to exert control over the resident and that the resident, in turn, has an obligation to accept this control. These values may include what the resident thinks constitutes quality patient care and medical education, as well as the resident’s acceptance of the medical hierarchy as a legitimate social structure.

Finally, a program director may hold what French and Rave term referent power. This is the power of the program director or other faculty to exert influence over the resident, because the resident wants to be like that person or is attracted to the prestige and professional success of the faculty member in question.

Power does not lie with the program director alone; coercive power over the residents, ironically, also lies with the ACGME; as stated above, the ACGME will place a program in violation of the work-hours regulations on probation. This leaves the program one step away from having its accreditation revoked, in which case the residents would need to find spots in other residency programs, or lose completely the opportunity to become a fully licensed physician.

Reporting violations to the ACGME thereby endangers the ability of every resident in the program to become a licensed physician. By the time a resident nears the end of their training, they have invested years of their lives and potentially hundreds of thousands of dollars in their education, and the thought of losing all they have worked for is a powerful disincentive to report violations. Indeed, such a strong disincentive raises the very serious question of whether the ACGME actually wants residents to report work-hours violations at all.

The Effect of Psychological Wellbeing

Studies have documented the link between sleep deprivation and depression (28) as well as variable nighttime shift work (29), so it is no surprise that some studies have shown an alarmingly high rate of depression among residents (30-32). Physicians in general are more likely than the general population to abuse drugs and alcohol, and to successfully attempt suicide (33). Residents may additionally be subject to systemic workplace mistreatment and abuse by superiors (34), stress from both job and family (35, 36) and high levels of professional burnout (37) – all potential causes or correlates of depression.

Symptoms of depression include (ironically) sleep disturbance, diminished interest in life activities, feelings of guilt or worthlessness, energy loss, concentration difficulties and indecisiveness (39). Depression amplifies negative messages residents receive about their performance, and can cause them to feel inferior. A depressed resident may feel like an “imposter,” like they are not as good a physician as others may think they are (40). In such circumstances, it would be easy for a resident to believe that they are in fact a “weak” resident, because they are not capable of attaining that mythical gold standard, being able to handle extended shifts without exhaustion.

Supportive social networks have been shown to mitigate a physician’s job-related stress. Likewise, discussing problems at work with a supportive professional network has been shown to increase psychological wellbeing. Unfortunately, physicians in general are neither likely to have extensive support networks outside of work, nor to discuss problems at work with colleagues; one study showed only 15% of physician participants discussed work-place stress with a colleague; only 33% discussed such problems with a supportive spouse, even though 88% of participants were married (41). Working long hours and oftentimes being far away from family make the forming of outside support networks difficult; those residents with families may find they become a source of stress, as loved ones vie with work for time and attention (42). Given the rigid power structure of medicine, a depressed, exhausted resident may well conclude that change is simply not possible or worth fighting for.

Implications

Extended work-hours have been proven to be harmful to both resident physicians and their patients, yet long hours persist. Clearly, the enforcement mechanism for the ACGME work-hours regulations is not working, and we need to look elsewhere for solutions.

It is tempting to replace one power-coercive approach with another, inflicting harsher penalties on hospitals, or having outside investigators take on the burden of checking up on residency work hours. However, it is not clear that this would work; residents, the main witnesses to work-hours abuse, will continue to remain silent witnesses, until the culture of medicine changes. One exception to this might be to make humane work hours a requirement for Joint Commission (JCAHO) accreditation, or to have work-hours reported publicly as a measure of health care quality, as these methods seem to spur hospitals to action (43).

Part of the problem is that this really isn’t a medical issue at all; it’s an economic one. Residents working 80-120 hours per week do the work of several employees, and any resident will tell you that much of the work they do in no way contributes to learning how to be a physician (1, p. 320). With funding earmarked to offset the loss of resident labor, hospitals might be more willing to consider change, especially as health care in this country faces an uncertain financial future.

The one source of true hope seems to come from forward-thinking program directors that see the need for change and work to engineer creative solutions. The addition of “day float” and “night float” shifts -- twelve-hour shifts, where a resident picks up coverage from others who need to go home – have been successfully implemented across the country (44,45). Changing the way teaching rounds are structured has been shown to help get residents out of work on time and maintain educational quality (24). One program has thrown out the call system entirely, and moved to a system of twelve-hour shifts (46).

The theory of social diffusion (47) informs us that one approach might be to spread good practices through early adopters. With enough funding and public accolades, leaders in their fields might suddenly find that new work-hours solutions become a priority. Headlines could proclaim, “Mass General improves quality and patient safety with well-rested docs!” Surely some of our nation’s best and brightest doctors can come up with a schedule that is both humane and provides excellent education.

By actively encouraging respected leaders in a variety of the medical fields to experiment, more program directors are sure to follow. Residency programs compete to get the best residents they can, and are therefore concerned with their prestige; some may change scheduling simply to prevent a loss of perceived status in the medical community. Instead of a punitive approach, the process could be one of professional competition, academic research and improved patient care.

Conclusion

With the stakes so high for young professionals, is it any wonder that most residents would never think to report their program for work-hours violations? The current work-hours regulations ignore the influence of workplace power, social norms and resident psychological health on America’s youngest physicians. By paying attention to the social factors that prevent residents from enforcing work-hours regulations on their own, teaching hospitals, the ACGME and our nation’s physicians could find a real solution to this public health disaster.

REFERENCES

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3 Comments:

  • At December 13, 2007 at 6:42 PM , Blogger Victoria said...

    I really liked your paper. I had never thought of this problem like this before. It's true that there is so much pressure when you are a young professional to do as many hours as you can; but in the case of medical residents it's really dangerous to not only the individual but the patients, as well. It makes me wonder if anyone will look at sleep deprivition/work overload for undergrads and graduate students!

     
  • At December 14, 2007 at 10:12 AM , Anonymous Deinera said...

    Though I had heard about this intervention before, I had never thought of it as a public health intervention, per se. However, I think your arguments are well-thought out and extremely convincing, and highlight how residency hours do become a threat to the public health. I think you have looked at this intervention from a unique perspective...really enjoyable paper!

     
  • At December 14, 2007 at 11:51 AM , Blogger Read said...

    So how would the medical community react to this paper? Your comments on the appropriate way to address the problem are right on. It sounds like a major part of the solution is getting the buy-in of the hospital admin.

     

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