Table 3.

Innovation case study in surgery

Maine Medical Center (affiliate of Tufts School of Medicine), Portland, ME.
Program Director – James F. Whiting, MD (whitij@mmc.org).
637 Bed Hospital
Resident Physicians:	20
July 2008:	270 work hour violations (in one month) as I assumed program director position. Non-compliance in every area; data inaccurate or nonexistent; no one knew the rules and attendings didn’t feel there was a problem.
Phase 1 – Figure out the problem:	Established administrative compliance policy; all violations looked into; sessions with resident physicians; attending retreat.
Phase 1 – Results:	Good compliance with work hour recording; learned certain services habitual offenders; systemic violations.
Phase 2:	Continuation of oversight and monitoring; tweaks to schedule to eliminate systemic violations; one large service split in two as service was too big to round efficiently. Mock ACGME survey was conducted and mandatory recovery day instituted (if resident physician looks like they would be tracking too many hours they’d go home). Attendings pay more attention to hours (Note: On-call surgical attendings are encouraged not to schedule elective surgery on post-call day).
Phase 3 – Culture change:	“Despite a failure to demonstrate any significant detrimental impact of the work hour rules through data, it has recently become fashionable to blame work hour rules for eroding the surgical culture of accountability and ownership. According to this line of thought, work hour rules come with significant unintended consequences: surgical residents are acquiring the mentality of shift workers, no longer assuming the same ownership that we attained through working 100 hour plus weeks. This is not something that can be measured, but we know it is happening nevertheless…. “This kind of thing would be much easier to ignore if it was not so corrosive to the morale of surgical residents and if it did not fly in the face of what I see in the role of surgical program director every day. What is the major number of hours that one must work to learn the lessons of responsibility and accountability anyway?... The ‘average’ surgeon in the United States works 60 to 70 hours a week, but somehow understands this noble quality of patient ownership whereas today’s residents are ‘shift workers?’….Responsibility and ownership will never go out of style, but how those values are manifested is changing. Our residents know that accountability and collaboration are not mutually exclusive. “I believe that the current generation of surgical residents are better than we were, and work hour restrictions are part of the reason. They are a technologically savvy, cooperative, balanced generation. They are more efficient than we were, more open to new ideas, and just as committed to their patients. They understand the public’s uneasiness with our infatuation with endurance as a stand-in for excellence….It is time to grow up and stop whining. The dinosaurs went extinct and our surgical heritage deserves to evolve.”
	James F. Whiting Of Puppies and Dinosaurs: Why the 80-Hour Work Week is the Best Thing That Ever Happened in American Surgery Archives of Surgery, Vol. 145 (No. 4), April 2010