Why Surgeons Struggle with Work-Hour Reforms

John D. Mellinger, James E. Coverdill

Description

On July 1, 2003, work-hour reforms were enacted nationally for the roughly 129,000 resident physicians in the United States. The reforms limit weekly work hours (a maximum of eighty per week) and in-hospital call (no more than once every three nights), mandate days free of clinical and educational obligations (one day in seven), and regulate other aspects of resident work life.

Why Surgeons Struggle with Work-Hour Reforms focuses on general surgeons, a historically long-hour specialty, who fiercely opposed the reforms and are among the least compliant. Why do surgeons struggle with the reforms? Why do they continue to work long hours and view the act of doing so as reasonable if not quintessentially professional? Although the analysis is situated in the growing scientific literature on the consequences of fatigue, the authors do not adjudicate between the claims of surgeons and reform advocates about the effects of long work hours on patient or provider safety. Rather, the aim is to explore and explain how aspects of the occupational culture of surgeons and the social organization of surgical training and practice interlock to impede the reforms.

Acknowledgments
Introduction.  Explaining the Struggle: Culture, Social Organization, and Work-Hour Reforms      
Chapter 1. Fatigue as Impairment or Practical and Educational Necessity?                                  
Chapter 2. Patient Handoffs:  Can't Colleagues Assume Care Capably?                                       
Chapter 3. Stay or Go Decisions by Residents:  Why Not Leave When a Day Shift is Overor Hour Limits are Reached?
Chapter 4.  Professionalism, Old and New:  Time and Morality in Surgical Trainingand Practice
Chapter 5.  Less for You, More for Me?  Changing Workloads for Attendings andAdvanced Practice Providers
Chapter 6.  Revisions Imposed and Rescinded:  The Sixteen Hour Shift Limit for Interns       
Conclusion.  Policy to Practice:  Muddling Through Work-Hour Reforms                               
References                                                                                                                                   
 

Sujets

• Health Issues
• Social Science
• Sociologie, société et politique
• Disease
• Health

Informations

• Publié par: Vanderbilt University Press
• Date de parution: 15 janvier 2021
• Nombre de lectures: 0
• EAN13: 9780826501073
• Langue: English

Extrait

Why Surgeons Struggle with Work-Hour Reforms
Why Surgeons Struggle with Work-Hour Reforms
JAMES E. COVERDILL AND JOHN D. MELLINGER
VANDERBILT UNIVERSITY PRESS
Nashville, Tennessee
Copyright 2021 Vanderbilt University Press
All rights reserved
First printing 2021
Library of Congress Cataloging-in-Publication Data
Names: Coverdill, James E., author. | Mellinger, John D., 1958– author.
Title: Why surgeons struggle with work-hour reforms / James E. Coverdill and John D. Mellinger.
Description: Nashville : Vanderbilt University Press, 2020. | Includes bibliographical references and index.
Identifiers: LCCN 2020034115 (print) | LCCN 2020034116 (ebook) | ISBN 9780826501059 (paperback) | ISBN 9780826501066 (hardcover) | ISBN 9780826501073 (epub) | ISBN 9780826501080 (pdf)
Subjects: MESH: General Surgery—organization & administration | Surgeons | Workload | Policy Making | United States
Classification: LCC RD110 (print) | LCC RD110 (ebook) | NLM WO 21 | DDC 617.0068—dc23
LC record available at https://lccn.loc.gov/2020034115
LC ebook record available at https://lccn.loc.gov/2020034116
To Patrick, my amazing ten-year-old son, and Nathalie, my equally amazing but slightly older wife, for love, laughter, and epic Nerf-gun battles (from Jim)
To Elaine, whose love and support has brought richness to my life, and to Heather, Jordan, Caleb, and Courtney, who have amplified that yet more (from John)
Contents
Acknowledgments
INTRODUCTION. Explaining the Struggle: Culture, Social Organization, and Work-Hour Reforms
1. Fatigue as Impairment or Practical and Educational Necessity?
2. Patient Handoffs: Can’t Colleagues Assume Care Capably?
3. Stay-or-Go Decisions by Residents: Why Not Leave When a Shift is Over or Hour Limits Are Reached?
4. Professionalism, Old and New: Time and Morality in Surgical Training and Practice
5. Less for You, More for Me? Changing Workloads for Attendings and Advanced Practice Providers
6. Revisions Imposed and Rescinded: The Sixteen-Hour Shift Limit for Interns
CONCLUSION. Policy to Practice: Muddling through Work-Hour Reforms
References
Index
Acknowledgments
One of the great joys of conducting social research is the opportunity to routinely encounter profound expressions of generosity. To conduct our research, we needed to enlist the help of many people, from those who staff the offices of the many institutional review boards from which we needed approvals to those who kindly offered to complete surveys, participate in interviews, or be observed as part of the field observation component of the project. All told, 1,421 surgeons completed a survey for us, 258 offered an interview, and countless medical students, residents, attendings, nurses, and hospital staff accommodated and engaged Coverdill during his field observations in a general surgery residency program. What was especially remarkable about the generosity that we encountered is the context: virtually everyone we asked to participate in a survey or interview was already giving so much of their time and talents to others as they learned, practiced, and taught the craft of surgery. People, in short, made time, often texting about availability during a lull between cases or a slow time during a night shift. To all who gave of themselves in this way, and who must remain unnamed per the conventions of social research, we were, and remain, grateful.
We also benefitted from tangible support in the form of release time and support funds. The Franklin College of Arts and Sciences at the University of Georgia offered a few course releases, which made the early portion of the field observations possible, and support for research expenses. Likewise, the project was generously supported by funds from the J. Roland Folse Endowed Chair in Surgery at Southern Illinois University School of Medicine.
We also wish to thank a large network of surgeons who became collaborators due to their interest in, and support for, our research. We thank Gina L. Adrales, Adnan Alseidi, Kimberly D. Anderson, James. G. Bittner IV, Bruce W. Bonnell, David C. Borgstrom, Alfredo M. Carbonell, Joseph B. Cofer, Thomas H. Cogbill, Daniel L. Dent, Douglas B. Dorner, Russell D. Dumire, Jonathan Fryer, George M. Fuhrman, Carl Haisch, Kristi L. Harold, Thomas H. Hartranft, Jonathan R. Hiatt, Steven B. Holsten, Benjamin T. Jarman, Richard A. Moore, Don K. Nakayama, M. Timothy Nelson, Mary Anne Park, Walter L. Pipkin, Marc Schlatter, Mohsen Shabahang, Stanley Sherman, Richard A. Sidwell, John L. Tarpley, Paula M. Termuhlen, Alexandra L. B. Webb, Christopher Wohltmann, and Randy J. Woods. We offer special thanks to Paula M. Termuhlen for her steadfast and substantial support for us and for our research. For both of us, as the three waves of the research progressed, those listed above became not just collaborators, but also friends, mentors, and ultimately a “community of learning” that has made our professional and personal livers fuller, deeper, and richer in multiple ways. In that vein, Mellinger would also like to credit surgical leaders and educators including Bill Passinault, Jeff Ponsky, Tom Gadacz, Bruce MacFadyen, and Gary Dunnington as chairs and mentors who encouraged and supported the educational career focus that ultimately led to this work.
We are eager to thank the staff at Vanderbilt University Press and Shearwater Indexing for their deft handling of the manuscript. Zachary S. Gresham is a superb acquisitions editor. From our first contact with the press, Zack has been quick to respond with thoughtful, encouraging, informative, and also downright delightful commentary. For example, after sharing news late one afternoon that the editorial committee had approved the manuscript for publication, he followed up the next morning with the lead-off quip, “I hope you woke up smiling this morning.” Likewise, when we moved to the formal contract portion of the process, he began a note in a way that made us smile once more: “[off camera] ‘Cue the boilerplate!’ ” The dynamic Joell Smith-Borne was our managing production editor and thus oversaw the editing of the book’s interior. Drohan DiSanto created a stunning cover for the book, based on a suggestion offered by John Mellinger. The talented Jenna Phillips spearheaded marketing and publicity for the book. Betsy Phillips, Cynthia Yeager, and Brittany Johnson also played important roles in moving the process along. Andrea Baron and Bob Schwarz of Shearwater Indexing did fine work with the index and were a pleasure to work with as well. We express our appreciation and gratitude to the entire team at Vanderbilt University Press and Shearwater Indexing.
And finally, Coverdill’s career-long sociological colleague and collaborator William Finlay was a source of inspiration, unflagging support, and sage advice as the project emerged, developed, and came to fruition. He was a formal collaborator early on, but dropped off as his formidable administrative obligations mounted. The questionnaires and interview schedules for the third wave of the study benefited from thoughtful comments from the Surgical Education and Performance Group at Southern Illinois University. We also thank Sarah Ellen Williams, once a cherished undergraduate and now a promising medical student, for help entering and proofing the survey data. Jill Horn provided skillful assistance preparing portions of the manuscript and abundant cheer. To all, our heartfelt gratitude.
INTRODUCTION
Explaining the Struggle
Culture, Social Organization, and Work-Hour Reforms
I don’t think the debate is about whether being really tired makes you worse at your job. I think that’s very clear. The issue is whether it’s better to introduce all the unintended effects of limiting work hours. Is that a more optimal solution than the tired person continuing to care for a patient? That part, to me, is unclear.
A THIRD-YEAR MALE RESIDENT IN GENERAL SURGERY
For more than a hundred years, the process of learning to practice medicine in the United States has involved an extraordinary investment of time. In a residency program, medical-school graduates work under the supervision of faculty to care for patients, experience that is required to achieve board certification in a specific specialty area. Traditionally, hours of work and daily schedules were not only long, but also largely unregulated, subject only to cultural traditions and the whims of the most senior learners, the chief residents, and the practitioners and professors who provided, structured, and oversaw medical training. A veritable raft of memoirs by those who have gone through the process offer vivid if not visceral portraits of time demands. Suzanne Poirier’s (2009, 88) analysis of fifty memoirs published between 1965 and 2005 suggests that the greatest hardship of medical training is a lack of sleep, and that the “most extreme descriptions of exhaustion” stem from the demands of residencies. Miller’s (2008, vii) description of his surgery residency is typical: “It has been said that if medical training is like military service, then surgical residency is Marine Corps boot camp. Postgraduate training in surgery is longer than that of any other medical specialty, five years at least and frequently longer. Tortuous on-call schedules often demand exceedingly long work hours almost unimaginable in any other profession, 100-hour work weeks being the norm for a surgery resident” (emphasis in original). His recollections highlight a form of collective suffering that is a prominent and consistent theme in the memoirs.
Autobiographical reflections align with recent reviews and statistical evidence. Despite reductions in call schedules and increases in vacation time since the 1960s,