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The Impact of Resident Duty Hours Reform on the Internal Medicine Core Clerkship: Results from the Clerkship Directors in Internal Medicine Survey

Kogan, Jennifer R. MD; Pinto-Powell, Roshini MD; Brown, Lin A. MD; Hemmer, Paul MD, MPH; Bellini, Lisa M. MD; Peltier, Deborah MD

doi: 10.1097/01.ACM.0000246873.04942.a8
Duty Hours
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Purpose In July 2003, resident duty hours regulations were implemented. The impact of these regulations on medical student education has received minimal attention. The objective of this study was to evaluate the perceptions of internal medicine clerkship directors about the impact of resident physician duty hours reform on medical student teaching, assessment, and clerkship structure.

Method A survey was sent to 114 institutional members of Clerkship Directors in Internal Medicine in May 2004. The survey included 17 attitude items rated on a 5-point Likert scale, five items related to clerkship structure, and four open-ended questions. Descriptive statistics were performed on the responses.

Results Ninety-six surveys were returned (84%). The majority of respondents did not believe duty hours reform had a positive impact on clerkship students' educational experiences, whereas 48.3% agreed or strongly agreed that residents had more difficulty evaluating students' clinical skills. There was not a significant change in inpatient clerkship structure after duty hours implementation. Time for teaching students, concerns about a shift-work mentality, and student continuity with their teams were major challenges. Impact on ambulatory internal medicine rotations was minimal.

Conclusions Internal medicine clerkship directors are concerned about the impact of resident duty hours reform on student education. Additional studies of this educational impact are needed.

Dr. Kogan is assistant professor of medicine and director of undergraduate medical education, Department of Medicine, University of Pennsylvania Health System, Philadelphia, Pennsylvania.

Dr. Pinto-Powell is assistant professor of medicine and co-director of the internal medicine clerkship, Dartmouth Medical School, Lebanon, New Hampshire.

Dr. Brown is associate professor of medicine and co-director of the inpatient medicine clerkship, Dartmouth Medical School, Lebanon, New Hampshire.

Dr. Hemmer is associate professor of medicine and director of the internal medicine clerkship, Uniformed Services University of the Health Sciences, Bethesda, Maryland.

Dr. Bellini is associate professor of medicine and vice dean of graduate medical education, University of Pennsylvania Heath System, Philadelphia, Pennsylvania.

Dr. Peltier is associate professor of medicine, geriatrics and ambulatory medicine clerkship director, Dartmouth Medical School, Lebanon, New Hampshire.

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

Correspondence should be addressed to Dr. Kogan, 3701 Market Street, Suite 640, Philadelphia, Pennsylvania 19104; telephone: (215) 615-3944; fax: (215) 615-3997; e-mail: (jennifer.kogan@uphs.upenn.edu).

Editor's Note: A Commentary on this Research Report appears on page 1017.

Undergraduate medical education is intimately linked with graduate medical education. Because the inpatient internal medicine clerkship is a core component of undergraduate medical education and depends on experiences with resident and attending physicians,1 any substantive change in resident training should be evaluated for its impact on medical students and clinical clerkships.

In July 2003, the Accreditation Council for Graduate Medical Education (ACGME) mandated new duty hours regulations for all residents in United States training programs. These regulations require that residents work fewer than 80 hours per week, with have one of every seven days free from clinical activities when averaged over four weeks; work fewer than 24 continuous hours with an additional 6 hours permitted for transition of care and educational activities; and have 10 hours of rest between duty periods.2 Resident duty hours reform has sparked considerable debate regarding its effect on resident education and patient care. Advocates cite the positive impact of duty hours by decreasing resident fatigue, depression, and burnout and by increasing patient and resident safety.3–5 Opponents have voiced concern about the impact on continuity of patient care and professional identity.6

In contrast to the extensive debate concerning the impact of resident duty hours on resident education and patient safety, little public debate has occurred regarding the effect of resident duty hours reform on medical students.7,8 Many residency programs have instituted significant change in their inpatient structures to ensure compliance with duty hours reform, which typically has meant creating “shift work” for residents (e.g., night floats, day floats). Students have voiced concern that resident duty hours reform might thus decrease resident time for teaching, decrease patient-related teaching as patient care responsibilities are delegated to physician assistants or nurse practitioners, and decrease the continuity of education.9 If resident workloads are shifted to faculty, there might also be less time for faculty to teach students. Together, these changes could affect medical students' academic and professional development because exposure to good teachers during the clerkship is associated with improved student learning.9

The purpose of this study was to seek the observations and perceptions of internal medicine clerkship directors about the impact of resident duty hours reform on resident and attending teaching, on student feedback and evaluation, and on clerkship structure.

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Method

The Clerkship Directors in Internal Medicine (CDIM), the national organization of individuals responsible for teaching internal medicine to medical students, conducts an annual, confidential survey of its membership. The first section of the survey is devoted to gathering demographic information: age, gender, academic rank, clinical promotion track, tenure status, number of years in the role of clerkship director, and outpatient and inpatient clinical responsibilities (Table 1). Each year, the CDIM membership can submit questions to be included in the annual survey. The 2004 CDIM survey included a section of questions, developed by us and revised by the CDIM Publication Committee for clarity and content, concerning the impact of resident duty hours reform on the internal medicine clerkship. We designed the questions to gain insight into the positive or negative impact that resident duty hours reform was having on resident and attending teaching, feedback and evaluation, patient care, and student attitudes in the internal medicine core clerkship (Table 2). Attitudes were rated on a 5-point Likert scale (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, and 5 = strongly agree). Respondents could answer “do not know” to any of the items; for purposes of analysis, a “do not know” response was coded as missing. We asked clerkship directors whether their state had legislated duty hours restrictions before July 2003 and whether changes had been made to clerkship structure since July 2003. We included four open-ended questions asking respondents to describe (1) the impact of duty hours reform on the ambulatory internal medicine core clerkship, (2) the impact of duty hours reform on the inpatient clerkship, (3) the greatest challenge resident duty hours reform had posed in the clerkship, and (4) the positive effects of duty hours reform on student education.

Table 1

Table 1

Table 2

Table 2

In May 2004, 114 U.S. and Canadian institutional members of CDIM received the online annual CDIM survey (not all medical schools have a representative to CDIM). Institutional members of CDIM are typically the medical school's internal medicine clerkship director. Survey nonresponders were contacted once by e-mail or telephone.

We performed descriptive statistics (frequencies, means, medians, standard deviations, range) and determined mean attitude ratings for each attitude statement. We used within-person t-tests to compare characteristics of clerkship structure before and after duty hours reform. Using a chi-square test, we compared differences in attitudes between clerkship directors living in states where duty hours had been legislated before 2003 and clerkship directors living in states where duty hours had been implemented after 2003. We also used a chi-square test to determine the impact of demographic variables on clerkship directors' attitudes. Given the multiple analyses performed, we used the more conservative cutoff of P < .001 to determine statistical significance. Data were analyzed using SAS 9.1 (SAS Institute Inc., Cary NC). Three of the authors (R P-P, LAB, JRK) analyzed the narrative responses to the open-ended questions for emerging themes and subsequently categorized comments according to these themes.

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Results

Ninety-six surveys from institutional members were returned, for a response rate of 84%. The demographics of survey respondents are shown in Table 1. Respondents identified themselves as clerkship directors (n = 95; 99%) and introductory clinical medicine course directors (n = 1; 1%). The mean length of time spent as a clerkship director was 6.2 years (range 0.5–33 years; SD = 5.9). The vast majority (85%) of respondents (n = 78) indicated that before July 2003, their state had not legislated duty hours restrictions for their residents.

Overall, 69.7% of respondents disagreed or strongly disagreed with the statement that resident duty hours reform had had a positive impact on the educational experience of their core clerkship students, whereas only 2.2 agreed or strongly agreed. The remainder (28.3%) were neutral. Clerkship directors were almost equally split in their belief of whether clerkship students should have the same duty hours restrictions as residents, with 41.2% disagreeing or strongly disagreeing, and 44.4% agreeing or strongly agreeing (the remaining 14.4% were neutral).

Respondents' more specific attitudes regarding resident duty hours are summarized in Table 2. The Cronbach alpha coefficient for the items was 0.84. With respect to resident and attending teaching, only 1.1% of respondents felt that residents had more time to teach, and only 6.3% believed residents had better attitudes towards teaching. Responses regarding attending teaching and attitudes towards teaching were similar. Sixty-seven percent of respondents disagreed or strongly disagreed with the statement that there had been more bedside teaching since duty hours implementation. Perceptions regarding the difficulty of scheduling clerkship didactics varied among respondents, with 23.4% believing that scheduling didactics had become more difficult, and 36.8% disagreeing or strongly disagreeing with this statement. Whereas almost half of clerkship directors said they believed that students had been spending fewer hours in the hospital (52.7%), others said they did not believe this was the case (21.6%).

With respect to feedback and evaluation, more respondents (48.3%) agreed or strongly agreed that residents had more difficulty evaluating students' clinical skills. Similarly, more respondents (57.0%) disagreed or strongly disagreed with the statement that students were receiving more feedback from residents. Respondents were less impressed with the impact of resident duty hours on attending evaluation and feedback to students, with the majority (51.1%) neutral as to whether students were receiving more feedback from attending physicians.

Although approximately two thirds of respondents disagreed with the statement that students had more continuity with their team, the majority of respondents did not feel that students' opportunity to follow a patient through their hospitalization had been compromised, and very few (12.1%) believed that students were doing more cross coverage (i.e., evaluating acutely ill hospitalized patients who belonged to another inpatient ward team/service). Importantly, 62.9% of respondents agreed or strongly agreed that students were learning that the number of hours worked takes precedence over patient care. Almost 70% believed that students now expect to spend less time in the hospital.

There were no significant differences in any of the aforementioned attitudes based on respondents' age, sex, academic rank, months spent as ward attending, or working in a state in which duty hours had been legislated before July 2003.

Table 3 summarizes structural characteristics of the medicine clerkship before and after duty hours implementation. The percentage of clerkships requiring overnight call decreased after duty hours implementation; however, there was no significant impact on the percentage of conferences taught by residents, student days off per month, or use of teaching attending faculty for student education (defined as faculty without primary clinical responsibilities who meet with clerkship students for teaching).

Table 3

Table 3

With respect to the open-ended questions, the results of the thematic analysis are summarized in Table 4. Not all respondents answered each question. Sixty-two (65%) respondents addressed the impact of duty hours reform on ambulatory teaching. A minority of the 96 respondents (n = 8; 8%) had no ambulatory component to their clerkship. Forty-three respondents (66%) stated that resident duty hours had “no impact” or “minimal impact” on their ambulatory clerkship. When a reason was cited for why duty hours had no impact on the ambulatory clerkship (n = 11), 64% indicated that the most common reason was that students did not work with residents during the ambulatory rotation. For those clerkships in which duty hours did affect the ambulatory clerkship (n = 9), the most common themes were decreased interactions between residents and students (n = 5; often because of postcall clinic cancellations) and decreased student–faculty interactions (n = 3) because of faculty productivity demands and increased workload covering the inpatient ward service.

Table 4

Table 4

Eighty respondents answered the question addressing the impact of duty hours on the inpatient clerkship, and 82 answered the question regarding the greatest challenge of the duty hours restrictions. Ninety respondents answered at least one of the two questions. Because the impact on the inpatient clerkship was also considered to be the clerkship directors' greatest challenge, we considered these responses together. The themes that emerged included the impact on time, the shift-work mentality, and the impact on continuity. The dominant theme was time, with the term “time” cited by 38 (42%) of the 90 respondents. Respondents discussed lack of time for teaching students (n = 31); scheduling team teaching and conferences (n = 11) and providing feedback and evaluating students (n = 9) were also noted. Illustrative comments include:

  • Residents are now way too busy during the day to teach. They are forced to cram their patient care duties into fewer hours, so they got rid of teaching.
  • It's difficult for attending [physicians] to spend as much time directly observing or teaching when we are often in the position of filling in for whichever resident is off.
  • Post call rounds are now all work to get the residents out, with little postcall teaching and subsequent shortening/curtailing of the lengthy student presentations postcall and less questioning of the student from the attending.
  • Teaching time on rounds is frequently constrained due to the need to get the resident out on time. Also, teaching conferences in ward team setting are less due to periodic absences of a resident on a day off.
  • Conducting evaluation sessions is more difficult and is scheduled on two separate days rather than on one day to accommodate resident schedules.

Reference to shift-work mentality was noted by 34 (38%) of the 90 respondents, with comments linking this to professionalism and quality of patient care. Illustrative comments include:

  • Maintaining and instilling professionalism in students [is challenging] so that they realize that patient care is important—not just number of hours worked.
  • Impressing both residents and students with the concept of ownership of patients—taking full responsibility rather than beginning every response with, “well, I didn't admit this patient.”

Disruption of “continuity” was the biggest impact and was the greatest challenge of resident work hours according to 32 (36%) of the 90 respondents. This included student's continuity with their team (n = 13) and the student's or team's continuity with their patients (n = 15). Comments representative of this theme include:

  • The team is significantly less cohesive due to resident days off during the week, and it is substantially more difficult to carry out teaching activities as a team.
  • There is less continuity for patients and, therefore, for students, with more emphasis on getting out of the hospital. There is less sense of ownership of patients you admitted and less continuity for the students.
  • The degradation of the “team” concept has caused the inpatient aspect of the clerkship to lose one of its strongest benefits . . . the opportunity to work with and learn from others of varying levels of training.

The positive impact of resident duty hours reform on the medicine clerkship was cited by 68 respondents (71%). Seventeen (25%) felt that there had been no positive effects or opportunities created by resident duty hours reform. The benefit of better-rested residents and students was cited by 15 (22%), with some respondents suggesting that this, in turn, could improve residents' well-being (n = 5) and teaching (n = 4). Controlled resident hours and improved lifestyle were felt be beneficial effects that might attract students to internal medicine (n = 9). Illustrative comments include:

  • If residents are better rested, they might stay in better moods and be more amenable to teaching.
  • Students can see that resident training is controlled and that residents are protected from excessive work-hour requirements. Students may have more opportunity for self-directed learning.
  • Internal medicine perhaps will be made a bit more attractive in terms of time commitment during residency.
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Discussion

In this study, we sought the opinions and perspectives of internal medicine clerkship directors from across the United States in an effort to understand the impact of residency reforms on the education of medical students. Residents contribute substantially to medical student education,10 and residents' ability and willingness to teach has been shown to influence students' subsequent career choices, clerkship performances, and professional growth.11–13 As such, clerkship directors and the educational programs they oversee stand to be influenced, positively or negatively, by residency reform. Our results reveal concerns about teaching, continuity of care, and professionalism.

There is concern that the pressure for residents to work within specific time limits might decrease the amount of time available for them to teach students. There is also concern that attitudes towards teaching have not significantly improved after work-hour reform. The actual impact on resident teaching remains uncertain, with some recent studies suggesting that residents are teaching the same amount or more than they had been before duty hours reform,14,15 and others suggesting that time constraints result in fewer opportunities for residents to teach medical students.16 In a recent survey of students in six different clerkships at a single medical school, the students reported that limitation of resident hours had not affected their learning or residents' interest and skill in teaching.17 Although these single-institution studies provide some reassurance that medical student education may not be adversely affected by duty hours reform, our study of clerkship directors from across the United States uncovered a common concern that teaching was suffering. Given these conflicting findings, we recognize that more research is needed to understand the impact of duty hours on residents' teaching of medical students, particularly focusing on both resident and student performance.

Our study raises another concern: that the overall educational environment now may be more fragmented for students. Most survey respondents believed that there was less continuity between students and their team and that students were receiving less feedback, particularly from their residents. Because feedback is essential to learning and already occurs infrequently, this does raise concerns about the effect on medical student education. A recent study suggests a significant decrease in the quality of feedback received by students on their internal medicine clerkship after implementation of duty hours reform.18 This impact on feedback needs further study.

In contrast to the structural changes that have occurred in many residency programs to comply with duty hours limitations, our study shows that there have been relatively few changes in the structure of the internal medicine core clerkships, other than a reduction in the frequency of overnight call for medical students. This corroborates research showing minimal changes in clerkship structure since duty hours implementation.7,17 The relative stability of the clerkship structure may underlie the perception by the majority of clerkship directors that students' continuity with their patients, as opposed to their team, had not been compromised. This seems reassuring, because longitudinal care of patients has been the focus of many inpatient medicine clerkships. However, a significant minority of respondents believe that student and resident continuity with their patients has been compromised. Identification of clerkship structures or team structures that maintains trainees' continuity with their patients would be valuable.

It has been proposed that “lifestyle” factors dissuade medical students from pursuing careers in internal medicine,19 and in certain specialties, work-hour restriction improves students' perceptions about that field.20 Several respondents suggested that resident duty hours reform might make internal medicine more attractive to medical students as a “lifestyle-friendly” career choice. However, it is also possible that limited duty hours might decrease student interest in internal medicine, as “the previously conducive learning environment of the ward is increasingly buffeted by an ever shortening length of stay and a reduced time available for teaching.”1

We acknowledge limitations to this study. First, although the survey response rate (84%) is adequate for analysis, there may be some nonresponder bias; clerkship directors who did not believe duty hours had had an impact on the clerkship might have been less likely to respond. Although the respondents to the survey cited more concerns than benefits from residency duty hours reform, we tried to provide a balance of survey questions that sought opinions on both negative and positive effects of duty hours (e.g., “residency duty hours reform has had a positive impact on the educational experience of my core clerkship medical students”) and free-response items. Additionally, the views expressed are those of internal medicine clerkship directors, and it is not known whether clerkship directors in other disciplines would have similar opinions. Although the opinion of experienced educators is valuable, it is uncertain whether students' experiences have been affected more than or less than clerkship directors believe. Additionally, because this survey focused on attitudes, it is unknown whether clerkship directors' views are a response to the mere presence of change rather than to the actual change itself. However, the consistency of the responses from a majority of clerkship directors at U.S. medical schools suggests that the stresses and the changes are real. Nevertheless, exploring longitudinal changes in clerkship directors' attitudes regarding the impact of duty hours reform on medical students will be important, as will be other multi-institutional studies addressing teaching, feedback, and student opinion.

Our study points to several important additional areas for future investigation. Beyond what we have mentioned, it will be important to focus on outcomes such as the quality of descriptive evaluation of student performance by residents and faculty, student examination performance, career selection, and postgraduate training performance. Multi-institutional perspectives and analysis are needed to examine how different types of programmatic changes (i.e., night floats, day floats, use of nurse practitioners/physician assistants and hospitalists) affect students. Unfortunately, in some respects, it will be difficult to prospectively assess the impact of duty hours reform on student experience because current students and residents have only trained under the new regulations. Another important focus of future research will be assessment of the programmatic changes that have been initiated in internal medicine clerkships to increase the efficacy and efficiency of education, similar to those studies done in resident education.21

Duty hours reform is here to stay, with stricter limitations certainly possible.22 Additionally, closer attention to student hours is part of the revised Liaison Committee for Medical Education requirements.23 As such changes continue to unfold, understanding the impact of duty hours on students will be important because altering one part of the continuum of medical education affects many stakeholders, including learners, patients, health care organizations, clinician teachers, and the health profession's educational organizations.

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Acknowledgments

The authors wish to thank Judy A. Shea, PhD, and Pam Frazier for their assistance with this manuscript and the CDIM Publications Committee for their thoughtful review of the study questionnaire.

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Disclaimer

The survey data presented in this paper are the property of the Clerkship Directors in Internal Medicine and are used with permission. The views expressed in this paper are solely those of the authors and do not represent the views of the United States Air Force, the Department of Defense, or other federal agencies.

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References

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