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Professionalism in the Twilight Zone: A Multicenter, Mixed-Methods Study of Shift Transition Dynamics in Surgical
James E Coverdill1, Adnan Alseidi, David C Borgstrom
1J.E. Coverdill is associate professor, Department of Sociology, University of Georgia, Athens, Georgia. A. Alseidi is associate director, General Surgery Residency Program, and director, HPB Fellowship, HPB and Endocrine Surgery, Virginia Mason Medical Center, Seattle, Washington. D.C. Borgstrom is associate professor, Department of Surgery, West Virginia University, Morgantown, West Virginia. D.L. Dent is professor of surgery, Division of Trauma and Emergency Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas. R.D. Dumire is general surgery residency program director and medical director of trauma services, Conemaugh Memorial Medical Center, Johnstown, Pennsylvania. J. Fryer is professor of surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois. T.H. Hartranft is clinical professor of surgery, Ohio University, and general surgery residency program director, Mount Carmel Health System, Columbus, Ohio. S.B. Holsten is associate professor and general surgery residency program director, Department of Surgery, Medical College of Georgia, Augusta University, Augusta, Georgia. T. Nelson is chief of general surgery and executive physician, Health System Surgical Services, University of New Mexico, Albuquerque, New Mexico. M. Shabahang is director, Department of General Surgery, and general surgery residency program director, Geisinger Medical Center, Danville, Pennsylvania. S. Sherman is associate clinical professor and associate director, General Surgery Residency Program, Michigan State University / Grand Rapids Medical Education Partners, Wyoming, Michigan. P.M. Termuhlen is regional campus dean, University of Minnesota Medical School, Duluth, Minnesota. R.J. Woods is associate professor and general surgery residency program director, Wright State University Boonshoft School of Medicine, Dayton, Ohio. J.D. Mellinger is professor, chair of general surgery, and general surgery residency program director, Southern Illinois University School of Medicine, Springfield, Illinois.
Purpose:
Duty hours rules sparked debates about professionalism. This study explores whether and why general surgery residents delay departures at the end of a day shift in ways consistent with shift work, traditional professionalism, or a new professionalism.
Method:
Questionnaires were administered to categorical residents in 13 general surgery programs in 2014 and 2015. The response rate was 76% (N = 291). The 18 items focused on end-of-shift behaviors and the frequency and source of delayed departures. Follow-up interviews (N = 39) examined motives for delayed departures. The results include means, percentages, and representative quotations from the interviews.
Results:
A minority (33%) agreed that it is routine and acceptable to pass work to night teams, whereas a strong majority (81%) believed that residents exceed work hours in the name of professionalism. Delayed departures were ubiquitous: Only 2 of 291 residents were not delayed for any of 13 reasons during a typical week. The single most common source of delay involved a desire to avoid the appearance of dumping work on fellow residents. In the interviews, residents expressed a strong reluctance to pass work to an on-call resident or night team because of sparse night staffing, patient ownership, an aversion to dumping, and the fear of being seen as inefficient.
Conclusions:
Resident behavior is shaped by organizational and cultural contexts that require attention and reform. The evidence points to the stunted development of a new professionalism, little role for shift-work mentalities, and uneven expression of traditional professionalism in resident behavior.
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