Abstract
For most workers, a policy that capped work hours to 80 per week would not be controversial. But surgeons are not most workers; and when the Accreditation Council for Graduate Medical Education adopted a policy that restricted work hours of residents, it was met with a great deal of resistance. Why Surgeons Struggle with Work-Hour Reforms, by James E. Coverdill and John D. Mellinger, contextualizes resistance to work-hour reforms within the localized culture of surgery and the social organization of medical work. The authors argue that the policy was inconsistent with core defining features of surgical work, including understandings of fatigue, commitments to continuity in care, an ethic of “no dumping,” definitions of professionalism, and established work practices and training expectations. Because of these inconsistencies, the policy was not widely supported by those it was meant to protect or those who trained them.
The authors are a great team, combining the strengths of an in-depth and thorough sociological analysis (Coverdill) with the firsthand, lived experience of a surgeon and surgical educator (Mellinger). Combined, their perspectives provide a nuanced and unresolved account of how attempts to improve the work conditions of medical professionals may backfire. I use “unresolved” here in the best way possible in order to emphasize that this debate is ongoing. The authors admit that they do not have clear-cut answers for how to move forward. This gives the reader an opportunity to fully engage with the ethical and practical questions at hand.
One indicator of the strength of their account is that as a reader, my perspective on the policy was changed several times as I considered the data and analysis in this text. For instance, the first empirical chapter describes how surgeons think about fatigue. In particular, working through fatigue is a job requirement and a skill that residents must learn: fatigue may slow work, but it does not negatively affect care quality; and the body is trained to do the work, even when fatigued. Initially, I could not imagine thinking that long hours with little to no sleep would be an important component of medical education. After reading this chapter, I was more ambivalent. Throughout the text, I found myself reconsidering many of my starting assumptions. This quality makes Why Surgeons Struggle with Work-Hour Reforms an ideal text for teaching, especially in a Medical Sociology or Sociology of Work course. Given the detail of the data, analysis, and discussion of medical education, it would also likely be a good text for students in the health sciences, health professions, or bioethics.
Another strength of the book is the extensive and diverse data presented. Throughout each chapter, the authors use ethnographic, interview, and survey data to provide a well-rounded account of the experiences and perspectives of surgeons. The data are integrated, such that the ethnographic observations helped to shape the interview and survey questions. The authors then leverage the interview findings to better explain survey findings. At the end of each chapter, Mellinger provides autobiographical reflections to articulate continued tensions and questions.
I found the reflection at the end of Chapter Five (“Less for You, More for Me?”) to be especially effective. This chapter described how restrictions on resident work hours generated a labor shortage that was often filled with longer work hours for the attendings and the use of advanced practice providers. The authors show that these organizational solutions were not all bad, but that they did seem to reduce how much responsibility residents felt toward “their patients.” Throughout the text, the authors argue that a sense of ownership over patients is important for ensuring care quality, continuity through the whole process, and problem solving. They ask: if residents were not taking on the ownership aspect of surgical culture, how might that negatively affect patients and the institution of medicine moving forward?
The concluding reflection then tells a touching story of Mellinger’s care for Danny, a patient who suffered a great deal. When he died, Mellinger felt unsure of what he should have learned from the situation. His chairman later told him that it was a meaningful story for him to share with residents because it showed his “continued commitment to my patient, doing my best to care for him, even when it meant facing my failure, day after day” (p. 149). The authors conclude by reiterating that commitment should be to the patient, not to the hours on a clock. Organizations can fix the labor shortage and cover all hours on the clock, but can they fix a lack of commitment?
Overall, I found this book to be quite compelling and the richness of the various forms of data to be helpful for generating new explanations of resistance. However, one disadvantage of this approach is that some data points may require a deeper analysis. This primarily came up in reference to a secondary argument that women and men residents did not seem to have differing perspectives on the work-hour reform efforts. Earlier sociological research in this area showed that women were more supportive of reform, so the authors sought to show that there were very few gender differences in their survey responses, and that women were often just as critical of the policies as were the men.
While this is true of the data they present, a deeper gender analysis may have shown something else. In the survey responses where there were gender differences, women were almost always more adherent to the surgical culture they describe. For instance, Chapter Three (“Stay-or-Go Decisions by Residents”) describes how the culture of work makes it difficult for residents to leave at the end of a shift. One survey asked residents how often they stayed over and for what reasons. There were 13 possible reasons for staying over and six showed statistically significant differences between women and men. In all six, women were more likely to say they stayed. Women training in medicine know that they face sexism and gendered expectations, especially in the most physically and time pressured specialties, such as surgery. Given this, they likely felt a need to overcompensate and overconform to the norms of the profession. This comes out in several other survey items as well.
Ultimately, the authors conclude the text by leaving it to the reader to decide what should be next for work-hour reforms. Their analysis makes it clear that for any reform to be successful, it needs to take into consideration the culture of surgery and the social organization of this type of work. Not only does it provide a helpful lens through which to view the current debate, but the concepts and arguments could be applied to a host of other health care policy questions or organizational functioning issues as well.