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Does Simulator-Based Clinical Performance Correlate With Actual Hospital Behavior? The Effect of Extended Work Hours on Patient Care Provided by Medical Interns

Gordon, James A. MD, MPA; Alexander, Erik K. MD; Lockley, Steven W. PhD; Flynn-Evans, Erin RPSGT; Venkatan, Suresh K. MBBS; Landrigan, Christopher P. MD, MPH; Czeisler, Charles A. PhD, MD; for the Harvard Work Hours, Health, and Safety Group (Boston, Massachusetts)

doi: 10.1097/ACM.0b013e3181f073f0
Virtual Patients/Simulation

Purpose: The correlation between simulator-based medical performance and real-world behavior remains unclear. This study explored whether the effects of extended work hours on clinical performance, as reported in prior hospital-based studies, could be observed in a simulator-based testing environment.

Method: Intern volunteers reported to the simulator laboratory in a rested state and again in a sleep-deprived state (after a traditional 24- to 30-hour overnight shift [n=17]). A subset also presented after a shortened overnight shift (16 scheduled hours [n=8]). During each laboratory visit, participants managed two critically ill patients. An on-site physician scored each case, as did a blinded rater later watching videotapes of the performances (score=1 [worst] to 8 [best]; average of both cases=session score).

Results: Among all participants, the average simulator session score was 6.0 (95% CI: 5.6–6.4) in the rested state and declined to 5.0 (95% CI: 4.6–5.4) after the traditional overnight shift (P<.001). Among those who completed the shortened overnight shift, the average postshift simulator session score was 5.8 (95% CI: 5.0–6.6) compared with 4.3 (95% CI: 3.8–4.9) after a traditional extended shift (P<.001).

Conclusions: In a clinical simulation test, medical interns performed significantly better after working a shortened overnight shift compared with a traditional extended shift. These findings are consistent with real-time hospital studies using the same shift schedule. Such an independent correlation not only confirms the detrimental impact of extended work hours on medical performance but also supports the validity of simulation as a clinical performance assessment tool.

Dr. Gordon is director, Gilbert Program in Medical Simulation, associate professor of medicine, Harvard Medical School, and chief, Division of Medical Simulation, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts.

Dr. Alexander is assistant professor of medicine, Harvard Medical School, and director of medical student education, Brigham and Women's Hospital, Boston, Massachusetts.

Dr. Lockley is assistant professor of medicine, Division of Sleep Medicine, Department of Medicine, Harvard Medical School, and associate neuroscientist, Division of Sleep Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.

Ms. Flynn-Evans is research associate, Division of Sleep Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.

Dr. Venkatan is a teaching associate in surgery, Harvard Medical School, and simulation specialist, Division of Medical Simulation, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts.

Dr. Landrigan is assistant professor of pediatrics and medicine, Harvard Medical School, director, Sleep and Patient Safety Program, Division of Sleep Medicine, Department of Medicine, Brigham and Women's Hospital, and research director (inpatient service), Division of General Pediatrics, Department of Medicine, Children's Hospital, Boston, Massachusetts.

Dr. Czeisler is director, Division of Sleep Medicine, Baldino Professor of Medicine, Harvard Medical School, and chief, Division of Sleep Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.

Please see the end of this article for information about the authors.

Correspondence should be addressed to Dr. Gordon, Division of Medical Simulation, Department of Emergency Medicine, Massachusetts General Hospital, Zero Emerson Place, Suite 3B, Boston, MA 02114; telephone: (617) 726-7622; fax: (617) 724-0917; e-mail: jgordon3@partners.org.

© 2010 Association of American Medical Colleges