commentaries 7
would separate random from real
differences. With sample sizes of 66
or more at each PT-time in all 3
schools, comparisons may be
over-powered and may detect
statistically significant differences
for what constitutes very small dif-
ferences in school means. It then
becomes important to determine
what difference is a difference that
makes a difference?
Values should be tested for statistical
significance and consideration given to
the magnitude of difference to be consid-
ered of practical importance
The following conclusions can be
drawn:
Formula scoring has been impli-
cated in introducing construct-
irrelevant variance into scores as a
result of individual differences in
risk-taking propensity.
Use of Dscores for cumulative
trends, such as growth in medical
knowledge, dilutes later high-cur-
riculum-dose effects by early scores
with low doses and high levels of
random error variance. Eliminating
early low-curriculum-dose scores
Feeling pressure to stay late: socialisation and profes-
sional identity formation in graduate medical education
1
Department of Medical Education, University
of Michigan Medical School, MI, USA
2
Department of Surgery, University of Toronto,
Ontario, Canada
3
Department of Internal Medicine, University
of Michigan Medical School, MI, USA
Correspondence: Stanley J Hamstra PhD,
Department of Medical Education,
University of Michigan Medical School,
G1208 Towsley, SPC 5201, 1500 East Medical
Center Drive, Ann Arbor, Michigan 48109-
5201, USA. Tel: 00 1 734 763 1424;
Fax: 00 1 734 936 1641;
E-mail: shamstra@umich.edu
doi: 10.1111/j.1365-2923.2007.02958.x
ª Blackwell Publishing Ltd 2007. MEDICAL EDUCATION 2008; 42: 7–9
from averages and limiting the
averages to the most recent PT-times
might address the problem.
Benchmarking different schools by
PT results raises the stakes and
could lead to student study efforts
being driven by the PT, a practice
that some who developed PTs were
hoping to stop.
The use of either d-scores or
Dscores can magnify trivial differ-
ences. Values should be tested
for statistical significance and
consideration should be given to
the magnitude of difference to
be considered of practical
importance.
REFERENCES
1 Muijtjens AMM, Schuwirth LWT,
Cohen-Schotanus J, van der Vle-
uten CPM. Origin bias of test items
compromises the validity and fair-
ness of curriculum comparisons.
Med Educ 2007;41:1217–1223.
2 Cross LH, Frary RB. An empirical
test of LordÕs theoretical results
regarding formula scoring of mul-
tiple-choice tests. J Educ Meas
1977;14 (4):313–21.
Stanley J Hamstra,1 Sarah I Woodrow2 & Rajesh S Mangrulkar3
The impact of resident work hours
on patient care has been the sub-
ject 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.
3 Traub RE, Hambleton RK, Singh B.
Effects of promised reward and
threatened penalty on performance
of a multiple-choice vocabulary test.
Educ Psych Meas 1969;29:847–61.
4 Albanese MA. The correction for
guessing: a further analysis of Ang-
off and Schrader. J Educ Meas
1986;23 (3):225–35.
5 Kruger J, Dunning D. Unskilled
and unaware of it: how difficulties
in recognising oneÕs own incompe-
tence lead to inflated self-assess-
ments. J Pers and Soc Psychol 1999;77
(6):1121–34.
6 Albanese M, Dottl S, Mejicano G,
Zakowski L, Seibert C, Van Eyck S,
Prucha C. Distorted perceptions of
competence and incompetence are
more than regression effects. Adv
Health Sci Educ Theory Pract 2006;11
(3):267–78.
7 Burton RF. Misinformation, partial
knowledge and guessing in true ⁄
false tests. Med Educ 2002;36:805–
11.
8 Frary RB. Formula scoring of mul-
tiple-choice tests (correction for
guessing). Educ Meas Issues Pract
1988;7:33–38.
9 Blake JM, Norman GR, Keane DR,
Mueller CB, Cunnington J, Didyk
N. Introducing progress testing in
McMaster UniversityÕs problem-
based medical curriculum: psycho-
metric properties and effect on
learning. Acad Med 1996;71
(9):1002–7.
10 McHarg J, Bradley P, Chamberlain
S, Ricketts C, Searle J, McLachlan
JC. Assessment of progress tests.
Med Educ 2005;39:221–7.
An article in this issue of Medical
Education1 addresses this topic in a
unique way. The data were col-
lected 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
7
commentaries
on patient interaction the following
day. The authors found that resi-
dents 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 com-
pared 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 todayÕs environ-
ment 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 dele-
gating responsibility, or simply un-
clear guidelines about when to stop
working.2 It may simply be that some
people are inefficient workers.
Another argument that bears con-
sidering – 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 Ôprofessional
identity formationÕ. 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
8 ª Blackwell Publishing Ltd 2007. MEDICAL EDUCATION 2008; 42: 7–9
heard this referred to as an Ôimplicit
contractÕ – 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 restric-
tions, residents were able to do this
by taking ÔownershipÕ of patients,
whereby they attended to and per-
formed every aspect of care, includ-
ing writing orders, scheduling tests,
calling consultants, counselling
patients and family members,
and formulating diagnostic and
therapeutic plans.
One interesting aspect of the tar-
get 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 restric-
tions reflect concern over the
adoption of a shift mentality on
the part of residents and a per-
ceived 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 demon-
strated 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 stu-
dents. No doubt some medical
students or interns arrive on a
service with new notions of profes-
sionalism, 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 mar-
ginalised because they fail to inter-
pret 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 pro-
cess 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 hand-
ing 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 envi-
ronment (e.g. restoring the tradi-
tional 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
individualÕs 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 profes-
sional 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
Ôassaults on autonomyÕ described
in the target article served to
change the residentsÕ behaviour
towards an external group (in this
case, the patients). Even within
the medical profession, distinct
sub-cultures may exist. For exam-
ple, surgery residents perceive
themselves as being more resilient
to the effects of sleep deprivation
than their peers in internal med-
icine and psychiatry, despite evi-
dence to the contrary.5 This
misperception may result from a
surgical sub-culture in which stay-
ing late for the sake of patient
care is highly valued and rein-
forced.3 Broader cultural factors
may also influence this process of
socialisation. In Sweden, for
ª Blackwell Publishing Ltd 2007. MEDICAL EDUCATION 2008; 42: 7–9
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 work-
ing 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 iden-
tity 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.
REFERENCES
1 Liu C-C, Wissow LS. Residents who
stay late at hospital and how they
commentaries 9
perform the following day. Med
Educ 2008;42:74–81.
2 Van Eaton EG, Horvath KD,
Pellegrini CA. Professionalism and
the shift mentality: how to recon-
cile patient ownership with limited
work hours. Arch Surg 2005;140 (3):
230–5.
3 Kellogg KC, Breen E, Ferzoco SJ,
Zinner MJ, Ashley SW. Resistance
to change in surgical residency: an
ethnographic study of work hours
reform. J Am Coll Surg 2006;202
(4):630–6.
4 Park JP, Woodrow SI, Reznick RK,
Beales J, MacRae HM. Patient care
is a collective responsibility: per-
ceptions of professional responsi-
bility in surgery. Surgery 2007;142
(1):111–8.
5 Woodrow SI, Park J, Murray BJ,
Bernstein M, Reznick RK, Hamstra
SJ. Differences in the perceived
impact of sleep deprivation among
surgical and non-surgical residents.
Med Educ 2008; In press.
6 Ihse I, Haglund U. The Swedish
40-hour work week: how does it
affect patient care? Surgery
2003;134:17–8.
7 Morris-Stiff GJ, Sarasin S, Edwards
P, Lewis WG, Lewis MH. The
European Working Time Directive:
one for all and all for one? Surgery
2005;137 (3):293–7.
8 West D, Codispoti M, Graham T,
Specialty Advisory Board in Car-
diothoracic Surgery of the Royal
College of Surgeons of Edinburgh.
The European Working Time
Directive and training in cardio-
thoracic surgery in the United
Kingdom. Surgeon 2007;5 (2):81–5.
9 Greaves JD. Training time and
consultant practice. Br J Anaesth
2005;95 (5):581–3.
10 Woodrow SI, Segouin C, Armbrus-
ter J, Hamstra SJ, Hodges B. Duty
hours reforms in the United States,
France, and Canada: is it time to
refocus our attention on educa-
tion? Acad Med 2006;81 (12):1045–
51.
9