Multi-Institutional Survey Suggests Duty Hour Violations and UnderReporting by Surgical Interns

Background: Surgical residents may be perceived as silent violators of duty hours as they try to balance patient care and regulatory compliance. Methods: In order to examine the perspective of general surgery interns on their reporting of work hours, a survey questionnaire was distributed between May 6 and June 3, 2019 to first year surgical trainees at four major academic institutions near the end of their internship year. Results: A total of 25 of 59 interns participated in our survey (42.4% response rate). Work-life balance was consistently rated as the most significant challenge facing surgical interns. All (100%) interns had at one time under-reported work hours, while 28% did so “often”, and 32% “occasionally”. Interestingly, one in five surgical interns reported receiving external pressure from their residency program to under-report working hours. Conclusion: Surgical interns have difficulties adequately balancing their life with the rigorous work of a surgical resident, and that nearly all surgical interns both violate and under-report their work hours. Understanding the reasons why surgical trainees decide to under-report duty hours would help surgical educators develop innovative, non-punitive methods to improve work hour compliance.


Introduction
In 1984, the death of Libby Zion, a young female patient in the care of overworked residents, introduced a conversation of work hour limitations [1]. The lessons learned in her case spread quickly across New York State and in 1987 led to the development of NY State Department of Health Code 405 initiating work hour limitations [2]. The initiation of work hour limitations was ultimately adopted across the country by the Accreditation Council for Graduate Medical Education (ACGME) in 1988 and has undergone two major revisions, most recently in 2017 [3]. Since the death of Libby Zion, the lessons learned continue to resonate in the medical community. As such, work hour limitations have remained a highly debated topic, often highlighting generational disparities between attending physicians and house officers. This is particularly true in surgical training when considering the trade-off between shorter work weeks and preparation for independent surgical practice. We hypothesized that surgical residents may often be perceived as silent violators of imposed work hour limitations. It is well documented that among surgical residents, surgical interns are the most frequent violators of work hour restrictions [4][5][6]. Consequently, our aim was to explore the perception of general surgery interns on their reporting of work hours while adapting to new clinical demands as a first-year surgical trainee.

Methods
Interviews and focus group discussions with surgical interns were used to generate and validate our survey content. We pilot-tested the questionnaire in a group of 10 surgical interns to ensure clarity, relevance, and comprehensiveness.
The survey consisted of 30 questions structured as multiplechoice items or as statements with a 5-point Likert response scale (Supplement) [7]. The anonymous survey was distributed using a web-based tool (Survey Monkey.com Corporation), near the end of the internship year (between May 6 and June 3, 2019) to all surgical interns at four major academic medical centers in Boston, MA. Two automated reminders were sent two and four weeks after the distribution of the survey.
Participation was voluntary and responses were confidential. No incentives were offered for participating.
All the data were collected in accordance with the requirements of our Institutional Review Board. All data collected are anonymous and participants cannot be identified by residency program.

Results
Over a collection period of one month, a response rate of 42.4% (25/59 surgical interns) was achieved. Over half (52%) of the respondents were categorical general surgery residents while the remainder were designated preliminary (28%) or non-designated preliminary (20%). Other characteristics of our survey participants are displayed in table 1 [7].
The vast majority (76%; 19/25) of residents described their transition from medical school to residency as "good" or "very good".
When anonymously surveyed about under-reporting of work hours during their surgical intern year, 100% of the interns had at one time under-reported work hours. Over a quarter of them (28%; 7/25) "often" under-reported work hours, while 32% did so "occasionally".
Interestingly, one in five surgical interns (20%) reported receiving external pressure from their residency program to under-report working hours in order to comply with the 80-hour work week rule ( Figure 3).
Although most surveyed interns reported feeling overworked and exceeding work hour limitations, 70% of respondents reported that intern year "strengthened their determination to become a surgeon" with only 10% of them considering switching to a non-surgical career.
The results were similar across both genders (females and males) and internship tracks (categorical and preliminary).

Discussion
After the death of Libby Zion in 1984, there has been a rising discussion of work hour restrictions [1,6,[8][9][10][11]. The ACGME highlights four key factors driving current work-hour requirements: a team-based approach, physician well-being, education, and safety [3,12]. The burden of balancing these factors lay upon each surgical training program to effectively balance the trade-offs encountered when trying to maximize educational opportunities with both physical and mental wellbeing of their surgical trainees, all while maintaining an environment of patient safety.
Our results show that surgical interns have support from program leadership and most of them found their intern year experience to be a positive one in preparing them for the subsequent years of surgical training. However, nearly all surgical interns violated duty hour requirements during their intern year.
The rigors of surgical internship are starkly different from those of the preceding years in medical school. We have previously shown that surgical interns struggle finding a balance between work and personal demands such as maintaining pre-existing relationships outside of work [7]. The FIRST Trial demonstrated that surgical interns are the most frequent violators of the duty hour requirements and the 80hour work week [4]. Consistent with current literature we found that nearly all surgical interns had violated hours, and despite ACGME regulations, they had all falsified their hours worked at least once during their internship. Furthermore, the vast majority of interns misrepresented their duty hours on a regular basis. This is troublesome given that programs seek to recruit hard working and honest residents to their training programs.
Motivating factors for under-reporting work hours are likely multifactorial. Szymczak JE,et al. [13] found that common reasons for violating duty hours were to complete patient care tasks or continue providing care for a critically ill patient with whom they were familiar. Occasionally violating hour regulations for these instances could be seen as a demonstration of ownership of patients as well as a sign of maturity and professionalism by young surgical trainees and should be encouraged by program leadership. On the other hand, regular duty hour violations raise concerns for possible under-staffing that should be addressed by administration.
An additional explanation for under-reporting may be that surgical interns worry honesty in reporting duty hours may lead others to perceive them as inefficient. Surgical residency has long valued a "stay until the work is done" mentality. Duty hour restrictions may be perceived as forcing residents to succumb to a "shift work" mentality. Residents may feel guilty and looked down upon should they leave unfinished tasks for incoming coverage to complete. Of course, there are occasions when residents must care for critically ill individuals and immediate transfer of care would be deleterious to the patient's health and would itself be considered a violation of ACGME guidelines [3,12,13]. One might say that such behavior is unprofessional and an undesirable quality of a surgical trainee. It is possible that junior house officers have difficulty distinguishing between critical moments in which departure should be delayed and times when handoff of incomplete tasks is appropriate.    Third, the anonymous nature of our survey prevented us from tracking the results back to individual residency programs to perform useful comparisons of reported duty hours among different programs, and identification of factors that might have contributed to the feeling of overwork among the surgical interns.

Sci Forschen
Despite these important limitations, we hope that our study will improve our understanding of the workload challenges encountered by surgical interns. Our findings should stimulate further discussions to improve duty hours implementation and compliance in surgical training.

Conclusions
In this study we demonstrate that a large proportion of surgical interns have difficulties adequately balancing their life with the rigorous work of a surgical resident, and that nearly all surgical interns both violate and under-report their work hours. Duty hour regulations are important for helping surgical trainees maintain a healthy worklife balance, but their success depends on effective implementation and compliance. Understanding the reasons why many hardworking surgical trainees decide to under-report duty hours would help surgical educators develop innovative, non-punitive methods to improve work hour compliance. In the age of increasing awareness of surgeon burnout, residency programs should be proactive in fostering a culture that encourages honest reporting of hours worked and promotes an environment that both supports and stimulates productivity and wellness.  Interestingly, one in five residents reported external pressure from their program to misrepresent their duty hours. This is in contrast to the high level of support interns perceive from their program leadership. We suggest that the culture within the respective surgical training program should encourage honest reporting of hours without penalizing or stigmatizing residents. Furthermore, surgical residents should be encouraged to report true working hours to highlight potential staffing or coverage gaps that may not already be apparent to program administrators, in an attempt to mitigate future violations. It is reassuring that despite the rigorous demands and schedules encountered by surgical interns, nearly all surgical interns had a positive year of training and look forward to the remainder of surgical training.
It is well demonstrated that anonymous reporting of work hours promotes honest reporting by internal medicine and general surgery residents [6]. Therefore, surgical residency programs could consider anonymous or blinded reporting of duty hours. Unfortunately, despite these possible interventions, self-reported duty hours remain at risk of selection and recall biases.
Like all survey studies, this study is prone to various limitations. First, the sample size in our study is small. Although the number of our survey participants is similar to other studies on education of surgical residents, a larger study at a national level would be important for improving the generalizability of our findings.
Second, with only 25 of 59 interns participating in our survey (42.4% response rate) we cannot account for the perspectives of the surgical interns who did not participate in our survey. Although we believe that the responses collected are representative of all surgical interns that received the survey, we cannot exclude significant differences between respondents and non-respondents.