Different Views about Work-Hour Limitations in Medicine: A Qualitative Content Analysis of Surgeons', Lawyers', and Pilots' Positive and Negative Arguments

Background Whereas work-hour regulations have been taken for granted since 1940 in other occupational settings, such as commercial aviation, they have been implemented only recently in medical professions, where they lead to a lively debate. The aim of the present study was to evaluate arguments in favour of and against work-hour limitations in medicine given by Swiss surgeons, lawyers, and pilots. Methods An electronic questionnaire survey with four free-response items addressing the question of what arguments speak in favour of or against work-hour limitations in general and in medicine was sent to a random sample of board-certified surgeons, lawyers in labour law, and pilots from SWISS International Airlines Ltd. Results In all, 279/497 (56%) of the respondents answered the survey: 67/117 surgeons, 92/226 lawyers, and 120/154 pilots. Support for work-hour limitations in general and in medicine was present and higher among lawyers and pilots than it was in surgeons (p<0.001). The latter agreed more with work-hour limitations in general than in medicine (p<0.001). The most often cited arguments in favour of work-hour limitations were “quality and patient safety,” “health and fitness,” and “leisure and work-family balance,” whereas the lack of “flexibility” was the most important argument against. Surgeons expected more often that their “education” and the “quality of their work” would be threatened (p<0.001). Conclusions Work-hour limitations should be supported in medicine also, but a way must be found to reduce problems resulting from discontinuity in patient care and to minimise the work in medicine, which has no education value.

Conclusions: Work-hour limitations should be supported in medicine also, but a way must be found to reduce problems resulting from discontinuity in patient care and to minimise the work in medicine, which has no education value.

Background
The circumstances that led to the tragic death of Libby Zion in a New York teaching hospital in 1984 opened a debate about patient safety in medicine [1]. It has been recognised that relatively moderate levels of fatigue impair performance in a way quite similar to that of alcohol intoxication [2], which could be a safety risk for patients. Extended work shifts were found to be linked with more serious medical errors and impaired performance in simulated surgical tasks [3][4][5]. As a result of a subsequent broad political discussion, regulations of doctors' work hours in Western countries followed. What had been taken for granted since 1940 in other occupational settings, such as commercial aviation, namely strict workhour regulations and rest periods [6], was completely new for medical professions. Regulations to limit pilot flight time and rest times were strict and above all initiated to eliminate midair pilot fatigue caused by long working hours, which could put the plane and its passengers at great risk [7]. Regarding medical professions, the number of work hours was limited differently in diverse industrialised countries, without any evidence regarding an ideal. Whereas the US Accreditation Council for Graduate Medical Education implemented nationwide duty-hours standards beginning July 1, 2003, with work hours limited to 80 hours per week for junior doctors [8], work-hour limitations for all residency programs in Switzerland were set on January 1, 2005, by the Swiss government [9]. They include a 50-hour weekly limit with a maximum overtime of 2 hours per day and 140 hours per year, respectively, and at least 11 hours of rest between duty periods. Overtime per day may exceed 2 hours during work-free business days or in emergency cases. Daily rest time may be reduced to 9 hours several times per week, as long as the average resting time over a two-week period amounts to 12 hours daily.
The implementation of work-hour limitations developed into a lively debate with, on the one side, the positive effects of ameliorating residents' quality of life and giving them more time to maintain a social network [10,11] and on the other side, the threat to the Halsted paradigm of unconditional dedication to training with negative impacts on surgical education owing to reduced caseloads [11][12][13]. However, because work hours are frequently underreported by residents [14], they did not decrease uniformly with the implementation of work-hour limitations. Furthermore, the effect on patients' safety is contradictory as well, with little evidence of improvement from restricting residents' work hours [15][16][17][18].
With regard to ongoing policy debates about work-hour limitations in medicine, the aim of this study was to evaluate arguments given by Swiss surgeons in favour of and against work-hour limitations in medicine. For comparison, the same questions were posed to pilots-with their decades of strict work-hour regulations-and to labour law lawyers, so that they could consider the issue from their model guidelines and standards in daily business and experience in legal matters, respectively. The current argumentary in studies is solely lead by physicians.

Methods
We used an electronic questionnaire survey with four free-response items addressing the question of what arguments speak in favour of or against workhour limitations for general employees on the one hand to get arguments independent of a certain profession and for physicians working in hospitals on the other hand. The free-response items read as follows: ''In your opinion, what arguments are in favour of or against work-hour limitations in general?'' and ''what arguments are in favour of or against work-hour limitations in medicine?''. In addition, participants were asked to grade their agreement with work-hour limitations in general and in medicine (Likert scale of 1 to 5: 15completely disagree, 25rather disagree, 35neither agree nor disagree, 45rather agree, 55completely agree). We gathered additional information including sociodemographic characteristics (age, sex, marital status), work characteristics (hours worked, work experience, part-time work), and hierarchy. The survey was pretested for acceptability and clarity in an interdisciplinary focus group consisting of surgeons, pilots and lawyers, respectively.
An outline of this study was evaluated by the Cantonal Ethical Committee of Graubunden, Switzerland. The ethical committee did not provide a specific waiver for the present study. Completion of the survey comprised written informed consent to participate in the study. The Swiss Surgical Society database and the Swiss Bar Association were freely accessible to everyone during the time of our study. We obtained anonymous data from Heiner Hoffmann from the SWISS International Airlines Ltd database because these data were not freely accessible to us. To ensure the participants' anonymity, data from participant questionnaires were entered into an anonymous database. Participants had the option to provide us their e-mail addresses if they wished discuss the issue further.

Participants
A random sample of 15% of board-certified surgeons and labour law lawyers registered in the database of the Swiss Surgical Society (n5783 ordinary members) and with the Swiss Bar Association (n51507 members), respectively, were invited to participate in an electronic qualitative survey during 2011/2012 [19,20]. Additionally, a random sample of 15% of SWISS International Airlines Ltd. Pilots who were members of the Swiss Air Line Pilots Association (SwissALPA) Aeropers, Kloten, Switzerland (n51029 members) was contacted.

Qualitative analysis
An experienced sociologist with particular expert knowledge in qualitative data analysis performed all statistical computations. The arguments in favour of and against work-hour limitations in general and in medicine were evaluated using Mayring's content analysis by first transcribing the respondents' free-response arguments into an Excel file and then defining the level of abstraction to inductively form categories and generate a code manual [21]. In an additional step, the texts were encoded and assigned to the content categories. A formative check of reliability and, finally, a summative check of reliability were performed. Dichotomous variables were analysed by Chi 2 -test.
To explore the impact of age on the arguments in favour of or against workhour limitations, the participants were split into two groups based on their median age. A split into 5 groups (1-5, 6-10, 11-20, 21-30 and 31-50 years in profession) was performed to analyze the influence of work experience.  (Table 1).

Agreement with work-hour limitations in general and in medicine
The agreement with work-hour limitations in general, ranked on a 5-point Likert scale anchored by 15completely disagree and 55completely agree, differed among the groups: 3.89¡0.99 for surgeons, 3.99¡1.03 for lawyers and 4.66¡0.65 for pilots; p,0.001. The agreement with work-hour limitations in medicine differed as well: 3.39¡1.28 for surgeons, 4.10¡1.02 for lawyers, and 4.75¡0.57 for pilots; p,0.001. Whereas no difference was found for lawyers and pilots, surgeons agreed more with work-hour limitations in general than with limitations in medicine (p,0.001).

Comparison of arguments among surgeons, lawyers, and pilots
A comparison among surgeons, lawyers, and pilots regarding the number of arguments in the different categories in favour of and against work-hour limitations is shown in Tables 4 and 5. For all occupation groups combined, there was no difference in the number of arguments for or against work-hour limitations in different categories in terms of relationship status (living with a partner vs. no partner) or hierarchical status (low vs. medium vs. high). Regarding  Even if it is not only the quality, the treatment might be impaired.
Patients have different contact persons.

Organisability
In general 43 (11.9) Need for a good organisation.
Lack of enforceability (in certain professions, the failure to comply with work-hour limitations is accepted common practice).
Certain inflexibility in shift scheduling.
In medicine 35 (25.7) Planning services is more complicated.
There are patients in need at any time.
Duty rosters are difficult to prepare, especially with regard to limiting the number of days.

Performance
In general 13 (3.6) Less performance per employee.
Risk of increased pressure on employees leading to their ignoring the work-hour limitations and claiming the wrong effective work hours.
Work-hour limitations are seen as an ''optimum'' by employers, although they should be considered a ''maximum''.
In medicine 1 (0.7) Increased number of physicians working at the same place. Comparing the participants who agreed with work-time regulations with the remainder, no difference was found in the number of arguments in favour of or against work-time regulations, respectively.

Discussion
The results of the present report show that the agreement with work-hour limitations in general and in medicine is present and higher for lawyers and pilots than that in surgeons. The latter agreed more with work-hour limitations in general than in medicine. The most often named arguments in favor of work-hour limitations were ''quality and patient safety'', ''health and fitness'', and ''leisure and work-family balance'', whereas the ''lack of flexibility'' was the most important argument against.
Surgeons, lawyers, and pilots agreed with work-hour limitations in general and medicine. The agreement was higher for lawyers and pilots. It is evident that pilots support work-hour limitations, as they have been accustomed to them for decades to prevent fatigue and to maintain adequate levels of alertness at all times to prevent adverse events [7]. In contrast to lawyers and pilots, surgeons did agree more with work-hour limitations in general than in the medical profession. This corresponds with the publication of Fischer, describing the general surgeon as the last ''compleat physician'', who should take care for his patient 24 hours a day, seven days a week [22]. According to Fischer, an 80-hour work-week would be too short a time for surgery residents to provide excellent care [22]. However, this finding also shows that lawyers and pilots did not judge work-hour limitations differently in medicine than in any other work discipline. Life-style and career orientation have changed: Many physicians are no longer willing to pay a high price for their career at the expense of their lifestyle [23][24][25]. Similarly, we found as principal argument for work-hour limitations by surgeons ''leisure and work-family balance'', independent of the marital status. The general opinion among the population is that sleep deprivation results in reduced alertness and jeopardized safety [26,27]. This is supported by the view of lawyers and pilots as specialists from a legal point of view and experienced executor of work-hour limitations. Furthermore, they named ''health and fitness'' as main argument for work-hour limitations. It is known that work-hour limitations lead to more time for resting, family, and responsibilities apart from work [28]. In contrast to the view of lawyers and pilots regarding the improved ''quality and patient safety'', several studies showed no evidence of reduced morbidity and mortality by reduced work hours [16,18]. Benefits of a decrease in residents' fatigue might have been reduced due to additional changes of the treating physician [17,29]. Traditionally, surgical skills are acquired during extended work shifts by observing and by assisting [26]. Not surprisingly, surgeons therefore mainly name their personal ''education'' and ''quality of work'' as arguments against work-hour limitations. A previous survey among Swiss surgical residents and attending physicians similarly showed a subjectively clear negative effect on surgical training and on patient care [10]. The reason behind the latter are concerns about loss of continuity in patient care [11,22,30].
Lawyers and pilots throw light on the issue from an external point of view, also as a patient, who would like a ''flexible'' surgeon, who is taking the time for the patient whenever necessary. The lawyers' and pilots' concerns about excessive ''costs'' incurred due to work-hour limitations is supported by a study of Payette et al., showing that the application of aviation duty-hour restrictions to the health care system would be prohibitively costly [7].
Similar to a survey among senior residents, participants over 46 years and with high work experience, respectively, saw more often an impaired ''education'' due to work-hour regulations [31]. In contrast to this estimation stand two US studies which showed that a change in work hours is not unconditionally linked with reduced operative caseloads, but may lead to increased operative experience by higher case volumes of senior residents [32,33].
One of the limitations of this study is its design as an observational study, as it cannot be used to determine a causal relationship between variables. No statement can be made regarding the surgeons, lawyers, and pilots who did not participate in the study and a non-responder bias cannot be excluded. However, compared to other studies in the surgical field, our response rate was high with 56% [34]. To limit the high number of answers resulting from the qualitative pattern of the present study, a random sample of 15% of board-certified surgeons, lawyers and pilots was selected. As a bias regarding the demography cannot be excluded, a comparison of arguments for participants of different age and gender has been performed.
The main strength of this study is that it was conducted with a random sample of surgeons in a variety of working arrangements, covering all of the surgical specializations in the Swiss Surgical Society, of lawyers with the practice area ''Labor Law'', and of pilots from all cultural regions in Switzerland.
To our knowledge, this is the first study exploring work-hour limitations in medicine from various professional groups in and outside of surgery: The affected employees, the experts in Labor Law, and persons experienced in dealing with duty-hour restrictions. According to lawyers and pilots, work-hour limitations should lead to better rested physicians with enhanced ''quality and patient safety'' and improved ''health and fitness''. Compared to surgeons, they agreed more often with work-hour limitations, mainly because surgeons expect a threat to their ''education'' and the ''quality of their work''. Surgeons in general agree with workhour limitations, as they mainly see concurrently an improvement in ''leisure and work-family balance'', but they agree less in terms of work-hour limitations in medicine.
It is hard to find rational reasons for lawyers and pilots finding that work-hour limitations in particular should not take place in medicine due to the improvements in safety and well-being shown for other professions. However, to cope with the different opinions, work-hour limitations should be supported, also in medicine, but a way must be found to reduce problems resulting from a discontinuity in patient care and to minimize the work in medicine, which has no education value, without generating excessive ''costs''.