Feeling pressure to stay late: socialisation and professional identity formation in graduate medical education

The impact of resident work hours on patient care has been the subject of intense scrutiny, at least since the Libby Zion case appeared in the headlines in the USA in 1984. Ever since, a great many opinion pieces and very few well designed empirical studies have been published. Almost everyone would agree that more are needed. An article in this issue of Medical Education1 addresses this topic in a unique way. The data were collected in 1990 – fully 13 years prior to the implementation of the Accreditation Council for Graduate Medical Education (ACGME) 80-hour working week mandate – in an attempt to understand the causes for staying late and the implications on patient interaction the following day. The authors found that residents who had stayed late at the hospital the previous day – but who had not been on call – exhibited more dominance and less patient-centredness in their interactions when in clinic the next day compared with residents who had been on call and residents who had gone home on time. Residents who had stayed late also felt generally less competent and fulfilled than those who had gone home on time. An argument that bears considering is related to the socialisation processes involved in becoming a doctor, or ‘professional identity formation’. This study raises some interesting questions. For example, are these results relevant in today’s environment of mandated duty hour restrictions? We would argue that they are, because they shed light on the pressures to stay, which brings up issues of socialisation and the development of professional identity. The authors of the target article conclude that caring for critically ill patients while not on call made residents stay late. However, there are many other possible reasons, including uncertainty about delegating responsibility, or simply unclear guidelines about when to stop working.2 It may simply be that some people are inefficient workers. Another argument that bears considering – and to which the authors allude in their conclusions – is related to the socialisation processes involved in becoming a doctor, or what has been termed ‘professional identity formation’. As part of this process, residents may have stayed late to develop their reputation and increase future opportunities for education. In our interactions with residents over the years, we have heard this referred to as an ‘implicit contract’– residents work hard to win the opportunity for access to choice clinical material for learning, as well as increased interactions with the best clinician teachers. Before the imposition of duty hour restrictions, residents were able to do this by taking ‘ownership’ of patients, whereby they attended to and performed every aspect of care, including writing orders, scheduling tests, calling consultants, counselling patients and family members, and formulating diagnostic and therapeutic plans. One interesting aspect of the target article is that it allows for reflection on how this process of socialisation has changed with the implementation of the 80-hour working week. Indeed, some of the criticisms of the duty hour restrictions reflect concern over the adoption of a shift mentality on the part of residents and a perceived erosion in the concept of individual responsibility to the patient and hence continuity of care. This leaves residents with fewer opportunities to impress their supervising attending doctors and, in the process, develop their professional identity. Demonstrated individual dedication to patient care that was previously held sacred is not possible under the new mandate. The new environment calls for a new definition of what it means to be a professional – a definition that involves teamwork.2 The demonstrated individual dedication to patient care that was previously held sacred is not possible under the new mandate. This transition to new values can be confusing to all, including supervising attending doctors, residents and medical students. No doubt some medical students or interns arrive on a service with new notions of professionalism, only to be abruptly put into place by senior residents or attending doctors who are clinging to old values. Alternatively, if a culture of strict adherence to duty hour restrictions has been firmly established, those who violate the rules may well feel alienated. Are there any otherwise excellent and motivated students who are marginalised because they fail to interpret accurately the mixed messages that fly around? If they fail to identify local political and cultural issues, they place themselves in great danger of being passed over. Residency can be thought of as a socialisation where members learn how to behave as a part of a culture. In a unique ethnographic study, Kellogg et al.3 examined the process of imposing working hour restrictions in a surgical residency. Beginning 15 months prior to the ACGME mandate, the authors noted deep-seated cultural forces, including expectations that residents should demonstrate their toughness by resisting handing over patients to anyone. To do otherwise was seen as evidence of a lack of commitment to their patients. In introducing the duty hour restrictions, the authors found that practical solutions (e.g. implementing a night float system) were not enough. Despite the opportunity to hand over patients, residents resisted. Success was ultimately achieved by also addressing political and cultural issues involving the new team environment (e.g. restoring the traditional hierarchy of handing cases from a senior resident to a junior resident or intern). Only then did the pressure for residents to stay late subside. It seems that old notions about an individual’s responsibility to his or her patients are being supplanted by the principle of having in place an effective and trustworthy team. This new attitude towards professional responsibility is beginning to be accepted by clinician educators on the front line.4 This has parallels in aviation, where the importance of crew communications is recognised and valued. Old notions about an individual's responsibility to patients are being supplanted by having in place an effective and trustworthy team. Residency can be thought of as a process of socialisation whereby members learn how to behave as part of a culture. Identification with a group is reinforced by establishing common boundaries of behaviour and expectations. For example, the perception of ‘assaults on autonomy’ described in the target article served to change the residents’ behaviour towards an external group (in this case, the patients). Even within the medical profession, distinct sub-cultures may exist. For example, surgery residents perceive themselves as being more resilient to the effects of sleep deprivation than their peers in internal medicine and psychiatry, despite evidence to the contrary.5 This misperception may result from a surgical sub-culture in which staying late for the sake of patient care is highly valued and reinforced.3 Broader cultural factors may also influence this process of socialisation. In Sweden, for example, a 40-hour working week has been widely accepted in medical training for more than 30 years.6 In the UK, however, acceptance of the European Working Time Directive has not been entirely smooth7 and strong concerns have been expressed regarding the reduction in cases during training.8, 9 Although working hour restrictions are now in effect in most western countries, they vary considerably, as do the health care systems in which they exist.10 What is needed now is an explicit recognition of leadership and teamwork in the curriculum. The pressures to stay late may have changed since the imposition of duty hour restrictions in training programmes, but the process of professional identity formation remains. Amidst all the conflicting messages, residents who put in the extra mile may continue to feel less fulfilled, run the risk of burning out, and, consequently, become less engaged with their patients. In response to changes in the process of professional identity formation that have come about from managed care and duty hour restrictions, what is needed now is an explicit recognition of leadership and teamwork in the curriculum.

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