Perspective: creating an ethical workplace: reverberations of resident work hours reform.

Institute for Health Policy, Massachusetts General Hospital, Boston, Massachusetts 02114, USA.
Academic medicine: journal of the Association of American Medical Colleges (Impact Factor: 2.34). 04/2009; 84(3):315-9. DOI: 10.1097/ACM.0b013e3181971ee1
Source: PubMed

ABSTRACT Medical professionals are a community of highly educated individuals with a commitment to a core set of ideals and principles. This community provides both technical and ethical socialization. The development of ethical physicians is highly linked to experiences in the training period. Moral traits are situation-sensitive psychological and behavioral dispositions. The consequence of long duty hours on the moral development of physicians is less understood. The clinical environment of medical training programs can be so intense as to lead to conditions that may actually deprofessionalize trainees. The dynamic relationship between individual character traits and the situational dependence of their expression suggests that a systems approach will help promote and nurture moral development. Ethical behavior can be supported by systems that make it more difficult to veer from the ideal. Work hours limits are a structural change that will help preserve public safety by preventing physicians from taking the moral shortcuts that can occur with increasing work and time pressures. Work hours rules are beneficial but insufficient to optimize an ethical work and training environment. Additional measures need to be put in place to ensure that ethical tensions are not created between the patient's well-being and the resident's adherence to work hours rules. The ethical ideals of physician autonomy, selflessness, and accountability to the patient must be protected through the judicious and flexible use of work hours limits, physician extenders, census caps, nonteaching services, and high-quality handoffs.

  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Residents learn and participate in care within hospital cultures that 5 tolerate unprofessional conduct and cynical attitudes, labeled the "hidden curriculum." We hypothesized that this hidden curriculum 5 have deleterious effects on residents' professional development and investigated whether witnessing unprofessional behavior during residency was associated with burnout and cynicism. We surveyed internal medicine residents at 2 academic centers for 3 years (2008-2010). Hidden curriculum items assessed exposure to unprofessional conduct. We used regression analyses to examine if hidden curriculum scores were associated with cynicism and the Maslach Burnout Inventory depersonalization and emotional exhaustion domain scores. The response rate was 48% (337 of 708). In the 284 surveys analyzed, 45% of respondents met burnout criteria and had significantly higher hidden curriculum scores (26 versus 19, P < .001) than those not meeting criteria. In cross-sectional analyses, the hidden curriculum score was significantly associated with residents' depersonalization, emotional exhaustion, and cynicism scores. Cynicism scores were also associated with burnout. Exposure to unprofessional conduct was associated with higher burnout and cynicism scores among internal medicine residents. We also found that cynicism and burnout were significantly associated and 5 be measures of similar but not necessarily identical responses to the challenges posed by residency. Measuring the hidden curriculum and cynicism 5 provide direction for educators attempting to reform hospital culture and improve resident well-being.
    12/2011; 3(4):503-10. DOI:10.4300/JGME-D-11-00044.1
  • [Show abstract] [Hide abstract]
    ABSTRACT: PURPOSE: A new internal medicine call structure was implemented at two teaching hospitals at the University of Toronto, Canada, in 2009, motivated by patient safety concerns, new duty hours regulations, and dissatisfaction among attending physicians. This study aimed to determine attendings', residents', and students' experiences with the new structure and to look carefully for unintended consequences. METHOD: Between June and August 2009, the authors conducted an in-depth qualitative study using level-specific focus groups of attending physicians, residents, and medical students (n = 28) with experience of both the old and new call systems. Discussions were analyzed using grounded theory. RESULTS: Analysis revealed six themes (physician, manager, learner, teacher, workload, and "teamness") as well as the overarching theme of accountability. Although participants perceived the new system as better for patient care, there were several trade-offs. For example, workload was more predictable and equitable but less flexible, and senior residents reported less personal continuity for patients but increased continuity of care on the team level. Teaching and learning were negatively affected. Despite the negative effects, participants perceived that overall accountability improved on many levels, and participants felt the trade-offs were worth the perceived benefits. CONCLUSIONS: Residents were flexible and altruistic, accepting trade-offs in their own experiences in favor of patient care. Education was negatively affected. This study highlights the importance of carefully studying changes to look for anticipated and unanticipated consequences.
    Academic medicine: journal of the Association of American Medical Colleges 08/2012; 87(10):1421-1427. DOI:10.1097/ACM.0b013e31826768d4 · 2.34 Impact Factor