Professional values, value conflicts, and assessments of the duty-hour restrictions after six years: a multi-institutional study of surgical faculty and residents

doi:10.1016/j.amjsurg.2010.06.015

The American Journal of Surgery

Volume 201, Issue 1, January 2011, Pages 16-23

https://doi.org/10.1016/j.amjsurg.2010.06.015 Get rights and content

Abstract

Background

The aim of this study was to explore professional values, value conflicts, and assessments of the Accreditation Council for Graduate Medical Education's duty-hour restrictions.

Methods

Questionnaires distributed at 15 general surgery programs yielded a response rate of 82% (286 faculty members and 306 residents). Eighteen items were examined via mean differences, percentages in agreement, and significance tests. Follow-up interviews with 110 participants were explored for main themes.

Results

Residents and faculty members differed slightly with respect to core values but substantially as to whether the restrictions conflict with core values or compromise care. The average resident–faculty member gap for those 13 items was 35 percentage points. Interview evidence indicates consensus over professional values, a gulf between individualistic and team orientations, frequent moral dilemmas, and concerns about the assumption of responsibility by residents and “real-world” training.

Conclusions

The divide between residents and faculty members over conflicts between the restrictions, core values, and patient care poses a significant issue and represents a challenge in educating the next generation of surgeons.

Section snippets

Methods

This study included faculty members and residents from 15 residency programs in general surgery located in 11 states and all 4 time zones (Table 1). Onsite coordinators secured approval by their local institutional review boards, administered the questionnaire during the summer of 2009, gathered completed forms (enclosed in envelopes to assure confidentiality and anonymity), and returned materials to the lead author. Categorical residents and clinically active faculty members were eligible to

Results

Table 1 provides basic sample information. Table 2 presents exact question wording along with overall results and those for faculty members and residents. Panel A in Table 2 presents 3 traditional professional values for surgeons phrased in a positive fashion (items 1–3) and 2 that suggest value flexibility (items 4 and 5). Overall, there was strong, nearly universal support for traditional values and only weak support for value flexibility. Panels B and C focus on potential conflicts between

Discussion

The results suggest 3 notable themes. The first involves strong support for classic professional values. Although residents' support for professional values on the questionnaire was in fact somewhat lower than that voiced by faculty members, differences tended to be relatively small, showing no evidence of a substantial “generation gap” in abstract professional values. The second theme is that the translation of values into action, and the evaluation of that translation for key outcomes like

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Public Perceptions of General Surgery Residency Training
2021, Journal of Surgical Education
Citation Excerpt :
Fifty articles were excluded as they did not address perceptions of general surgery residency training. The majority of the published literature regarding perceptions of general surgery training pertained to those perceptions of medical students, residents, fellows, and faculty (e.g., Table 18-89). Only 7 manuscripts met the inclusion criteria, meaning that articles assessing the public's perception of general surgery training constitute 3% of the published literature90-96 (Table 2).
Patients are integral to surgical training. Understanding our patients’ perceptions of surgical training, resident involvement and autonomy is crucial to optimizing surgical education and thus patient care. In the modern, connected world many factors extrinsic to a patient's experience of healthcare may influence their opinion of our training systems (i.e., social media, television shows, and internet searches). The purpose of this article is to contextualize the literature investigating public perceptions of general surgery training to allow us to effect patient education initiatives to optimize both surgical training and patient safety.
This is a perspective including a literature review summarizing the current knowledge of public perceptions of general surgery training.
Little is published regarding patient and public perceptions of general surgery residency training and the role of residents within this. Current literature demonstrates that the majority of patients are willing to have residents participate in their care. Patients' attitude toward resident involvement in their operation is improved by utilizing educational materials and by ensuring a supervising attending is present within the operating room. These observations, coupled with future work to delve deeper into factors affecting public perceptions of surgical training and resident involvement within this, can guide strategies to improve surgical education.
Assessing the 16 hour intern shift limit: Results of a multi-center, mixed-methods study of residents and faculty in general surgery
2018, American Journal of Surgery
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The National Academy of Medicine report that recommended 16-h shifts for all residents also affirmed that residency training must “reinforce professionalism and its obligations”.1, p.126 The cap amplified concerns about how duty-hour restrictions, more generally, challenge the development and enactment of professionalism among residents.21 The questionnaire documents wide gaps among residents, where assessments of the cap become more negative with increasing seniority, a pattern also found in another recent study.22
The study explores how residents and faculty assess the ACGME's 16-h limit on intern shifts.
Questionnaire response rates were 76% for residents (N = 291) and 71% for faculty (N = 279) in 13 general surgery residency programs. Results include means, percentage in agreement, and statistical tests for 15 questionnaire items. Semi-structured interviews conducted with 39 residents and 43 faculty were analyzed for main themes.
Few view the intern shift limit as a positive change. Views differ (P < 0.01) for residents and faculty on 12 of 15 item means and across PGY levels on all 15 items. Interviews indicate concerns about losses with respect to education and professional development, difficulties when interns transition to their second year, and how intern shifts may be more fatiguing than expected.
The 16-h limit on intern shifts has remained a source of concern and an educational challenge for residents and faculty.
Implications of current resident work-hour guidelines on the future practice of surgery in Canada
2012, Journal of Surgical Education
Citation Excerpt :
Conversely, postgraduate clinical educators are concerned, however, about the decline in resident duty hours citing possible negative effects on resident education, including less clinical exposure and less continuity of care.2 To date, the studies examining the effects of work-hour restriction guidelines on surgical education have been limited to examining the immediate implications, such as numbers of cases, technical ability of finishing residents, and faculty opinions regarding these guidelines.2-4 These analyses have served to outline what remains a contentious issue.
Work-hour restrictions have had a profound impact on surgical training. However, little is known of how work-hour restrictions may affect the future practice patterns of current surgical residents. The purpose of this study is to compare the anticipated career practice patterns of surgical residents who are training within an environment of work-hour restrictions with the current practice of faculty surgeons.
An electronic survey was sent to all surgery residents and faculty at 2 Canadian university-affiliated medical centers. The survey consisted of questions regarding expected (residents) or current (faculty) practice patterns.
A total of 149 residents and 125 faculty members completed the survey (50.3% and 52.3% response rates, respectively). A greater proportion of males were in the faculty cohort than in the resident group (77.6% vs 62.4%, p = 0.0003). More faculty than residents believed that work-hour restrictions have a negative impact on both residency education (40.8% vs 20.8%, p = 0.008) and preparation for a surgical career (56.8% vs 19.5%, p < 0.0001). Compared with current faculty, residents plan to take less call (p < 0.0003), work fewer days of the week (p < 0.0001), are more likely to limit their duty hours on postcall days (p = 0.009), and take parental leave (p = 0.02) once in practice. Male and female residents differed somewhat in their responses in that more female residents plan to limit their postcall duty hours (55.4% vs 36.5%, p = 0.009) and to take a parental leave (51.8% vs 16.1%, p < 0.0001) compared with their male resident colleagues.
Current surgical residents expect to adopt components of resident work-hour guidelines into their surgical practices after completing their residency. These practice patterns will have surgical workforce implications and might require larger surgical groups and reconsideration of resource allocation.
Association of Program Directors in Vascular Surgery (APDVS) survey of program selection, knowledge acquisition, and education provided as viewed by vascular trainees from two different training paradigms
2012, Journal of Vascular Surgery
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This dichotomy of opinion on the work-hours issue has been noted in the past. Upper-level resident responses came closer to attending opinions, in line with what is noted in this survey.23 Although all level of residents believe that continuity of care and the surgeon's responsibility are standards (core professionalism) that need to be maintained, a team approach to this care was more embraced by the lower-level residents in one study.
Methods of learning may differ between generations and even the level of training or the training paradigm, or both. To optimize education, it is important to optimize training designs, and the perspective of those being trained can aid in this quest. The Association of Program Directors in Vascular Surgery leadership sent a survey to all vascular surgical trainees (integrated [0/5], independent current and new graduates [5 + 2]) addressing various aspects of the educational experience. Of 412 surveys sent, 163 (∼40%) responded: 46 integrated, 96 fellows, and 21 graduates. The survey was completed by 52% of the integrated residents, 59% of the independent residents, and 20% of the graduates. When choosing a program for training, the integrated residents are most concerned with program atmosphere and the independent residents with total clinical volume. Concerns after training were thoracic and thoracoabdominal aneurysm procedures and business aspects: 40% to 50% integrated, and 60% fellows/graduates. Integrated trainees found periprocedural discussion the best feedback (79%), with 9% favoring written test review. Surgical training and vascular laboratory and venous training were judged “just right” by 87% and ∼71%, whereas business aspects needed more emphasis (65%-70%). Regarding the 80-hour workweek, 82% felt it prevented fatigue, and 24% thought it was detrimental to patient care. Independent program trainees also found periprocedural discussion the best feedback (71%), with 12% favoring written test review. Surgical training and vascular laboratory/venous training were “just right” by 87% and 60% to 70%, respectively, whereas business aspects needed more emphasis (∼65%-70%). Regarding the 80-hour workweek, 62% felt it was detrimental to patient care, and 42% felt it prevented fatigue. A supportive environment and adequate clinical volume will attract trainees to a program. For “an urgent need to know,” the integrated trainees are especially turning to online texts rather than traditional textbooks, which suggests an opportunity for a shift in educational focus. Point-of-care is the best time for education and feedback, suggesting a continued need for dedicated faculty. The business side of training is underserved and should be addressed.
Interest in and perceived barriers to flexible-track residencies in general surgery: A national survey of residents and program directors
2011, Journal of Surgical Education
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This result might reflect the process of younger surgeons becoming acculturated into traditional surgical norms. Our findings echo the results of another recent duty hours survey by Coverdill et al.,24 suggesting that the views of senior residents tend to align more closely with the views of faculty than with those of junior residents. Not surprisingly, research was the most popular motivating factor for participating in flexible tracks, as most of our survey respondents worked in academic medical centers, where research typically is encouraged.
The American Board of Surgery now permits general surgery residents to complete their clinical training over a 6-year period. Despite this new policy, the level of interest in flexible scheduling remains undefined. We sought to determine why residents and program directors (PDs) are interested in flexible tracks and to understand implementation barriers.
National survey.
All United States general surgery residency programs that participate in the Association of Program Directors in Surgery listserv.
PDs and categorical general surgery residents in the United States.
Attitudes about flexible tracks in surgery training. A flexible track was defined as a schedule that allows residents to pursue nonclinical time during residency with resulting delay in residency completion.
Of the 748 residents and 81 PDs who responded, 505 residents and 45 PDs were supportive of flexible tracks (68% vs 56%, p = 0.03). Residents and PDs both were interested in flexible tracks to pursue research (86% vs 82%, p = 0.47) and child bearing (69% vs 58%, p = 0.13), but residents were more interested in pursuing international work (74% vs 53%, p = 0.004) and child rearing (63% vs 44%, p = 0.02). Although 71% of residents believe that flexible-track residents would not be respected as the equal of other residents, only 17% of PDs indicated they would not respect flexible-track residents (p < 0.001).
Most residents and PDs support flexible tracks, although they differ in their motivation and perceived barriers. This finding lends support to the new policy of the American Board of Surgery.
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The Association for Surgical EducationProfessional values, value conflicts, and assessments of the duty-hour restrictions after six years: a multi-institutional study of surgical faculty and residents

Abstract

Background

Methods

Results

Conclusions

Section snippets

Methods

Results

Discussion

J Surg Educ

Curr Surg

Am J Surg

Resident duty hours: enhancing sleep, supervision, and safety

Effects of work hour reduction on residents' lives: a systematic review

JAMA

Cumulative operative experience is decreasing during general surgery residency: a worrisome trend for surgical trainees?

J Am Coll Surg

The Association for Surgical Education
Professional values, value conflicts, and assessments of the duty-hour restrictions after six years: a multi-institutional study of surgical faculty and residents