Duty Hour Compliance: A Survey of U.S. Military Medical Interns and Residents.

Abstract

In 2011, the Accreditation Council for Graduate Medical Education (ACGME) modified its duty hour standards for interns and residents. This was done, in part, because of a belief that increased compliance with these standards was needed to positively impact resident fatigue, resident quality of life, and patient safety. However, several studies indicate that duty hour noncompliance and false reporting by interns and residents remains a significant concern for residency program directors. This study examined the compliance of interns and residents with ACGME duty hour standards at a large military graduate medical education (GME) training program. We conducted a survey of 535 trainees assigned to 24 GME programs within the National Capital Consortium (NCC). Statistical analysis for descriptive parameters used a standard error of measure on the basis of sample and target population sizes to calculate two-sided 95% confidence intervals (CIs). A χ2 analysis was performed to compare response differences for particular survey questions. A Cronbach α coefficient was calculated to compare the internal consistency of responses for questions in which individual responses were expected to correlate. This study was reviewed by the Offices of Research at the Walter Reed National Military Medical Center and the Uniformed Services University and adjudicated as "Not Research." Overall, 41.3% (N = 221) of those contacted completed all survey questions. From the available responses, 31.6% (95% CI, 26.9-36.2) reported at least one occurrence of implicit pressure to alter duty hour reporting, and 32.0% (95% CI, 27.3-36.7) reported at least one occurrence of altering reported duty hours. In addition, 37.2 (95% CI, 32.5-41.9) reported being unable to always follow duty hour limits and 58.1% (95% CI, 53.1-63.1) felt time working at home on residency requirements should be included in reported duty hours. Our results indicate that a significant portion of interns and residents within the NCC were unable to consistently follow ACGME duty hour standards and various systemic barriers within the GME training environment may have contributed. To remove or mitigate these barriers, we recommend using an approach similar to those of "high-reliability organizations" in which organizational processes are systematically investigated to improve safety, quality, and efficiency. Additional surveys or cognitive interviewing within the NCC and at other military GME training sites could be used to help refine these barriers, discover other barriers, determine the scope of these issues within the entire military GME training system, and to measure the outcome of correction actions.