Association for Surgical Education Work-hour restrictions as an ethical dilemma for residents Robert O. Carpenter, M.D. a,b, *, Mary T. Austin, M.D. a , John L. Tarpley, M.D. a , Marie R. Griffin, M.D., M.P.H. b , Kimberly D. Lomis, M.D. a a Department of General Surgery, Vanderbilt University Medical Center, D-4311, Medical Center North, 1161 21st Avenue South, Nashville, TN 37232-2730, USA b Department of Preventive Medicine, Vanderbilt University Medical Center, Nashville, TN, USA Manuscript received April 12, 2005; revised manuscript January 5, 2006 Presented at the 2005 Surgical Education Week, New York, NY, March 29 –April 2, 2005 Abstract Background: We propose that the standardized work-hour limitations have created an ethical dilemma for residents. Methods: A survey tool was designed to assess factors that influence the number of hours residents work and report. The program directors of pediatrics, internal medicine, and general surgery at our institution supported their residents’ participation. A voluntary, anonymous survey of these residents was performed. Results: One hundred seventy of 265 eligible residents were surveyed. Eighty-one percent of residents surveyed responded. Eighty percent of respondents reported exceeding work-hour restrictions at least once within the past 6 months. The factor of greatest influence measured was concern for patient care (80%). Forty-nine percent of respondents admitted underreporting their work hours. Conclusions: The Accreditation Council for Graduate Medical Education work-hour restrictions have created an ethical dilemma for residents. Our data show that a significant number of residents feel compelled to exceed work-hour regulations and report those hours falsely. © 2006 Excerpta Medica Inc. All rights reserved. Keywords: Resident training; Education; Ethical dilemma; Underreporting; Work hours; Regulations; Patient safety In 1989, the State of New York began enforcing a series of regulations limiting the number of hours residents in train- ing could work. These regulations have become known as “Code 405” [1]. The subsequent implementation of national standardized work-hour restrictions resulted in many diffi- cult issues with which program directors and their residents must now contend. The disparate and complex concerns that led to nationwide internal regulation of resident labor in July 2003 have been well documented [2–11]. We believe that the resulting paradigm shift presents one of the greatest challenges to graduate medical education in the past 3 decades. The work-hour regulations are significantly more com- plex than the “80-hour work week” familiar to the lay public (Fig. 1). Furthermore, their impact on the culture and prac- tice of academic medicine remains to be fully appreciated. An underlying assumption of these limitations is that resi- dents desire to work fewer hours. This may be true in principle yet may be perceived by residents as impractical given the day-to-day high-volume and rapid rate of work among teaching-hospital care teams [12,13]. Informal discussions with residents at our institution in the months after implementation revealed a troubling pattern of angst and internal conflict regarding the act of reporting hours worked. These discussions and subsequent unstructured focus groups led us to hypothesize that resi- dents are now confronted by significant ethical dilemmas resulting from the very regulations intended to protect them. Mapping out the breakpoints of this hypothetical conflict begins with a defined volume of work assigned to a resident and/or care team. This workload must be divided between members of the team with time appropriated per task from the overall pool of workable hours. The time required for completing the assigned tasks will place a hypothetical resident into either a state of compliance or violation. Those Supported in part by a grant from the Agency for Healthcare Research and Quality (T32 HS 13833) through the Vanderbilt Department of Pre- ventive Medicine. * Corresponding author. Tel.: +1-615-343-9486; fax: +1-615-343-9485. E-mail address: robert.carpenter@vanderbilt.edu The American Journal of Surgery 191 (2006) 527–532 0002-9610/06/$ – see front matter © 2006 Excerpta Medica Inc. All rights reserved. doi:10.1016/j.amjsurg.2006.01.002