The Key Literature In Medical Education podcast this week looks at some interim program evaluation data of the resident duty hour restriction program. While the methods are subject to hindsight bias and the subjectivity of self-response data, the findings of a survey of all American internal medicine program directors is fascinating. There are some positive outcomes, but as expected, some unintended consequences. Is it worth the $1.6 billion cost of the program?
As always check out the podcast for a more in-depth review; while you’re there give us a 5 star rating on iTunes.
For a different take on resident duty hour restrictions, check out the International Conference on Residency Education debate hosted by the national Canadian public broadcaster on the same topic. “They snooze, you lose; they don’t snooze, you still lose.”
KeyLIME Session 76 – Article under review:
View/download the abstract here.
Garg M, Drolet BC, Tammaro D, Fischer SA. Resident duty hours: a survey of internal medicine program directors, Journal of General Internal Medicine, Oct 2014, 29 (10): 1349-54.
Reviewer: Linda Snell (@)
The 2011 ACGME Common Program Requirements regulated duty hours of resident physicians, with three goals: improved patient safety, quality of resident education and quality of life for trainees. However there have been concerns about whether restricting duty hours might also have negative impacts on learning.
To assess Internal Medicine program director (PD) perceptions of the results of implementation of these duty hour requirements (DHR) one year following implementation of the new standards in July 2012.
Type of paper
Research: observational study design with cross-sectional survey data collected from residency program directors of all ACGME-accredited US IM training programs.
Key Points on the Methods
A good effort to search and reach all 381 PDs by e-mail, 3 reminders; 32 question survey included demographics, general questions about ‘approval’ and impression of DHR (scale -disapprove, neutral, approve), specific questions about changes in patient care and medical education resulting from DHR (scale – worse, unchanged, improved). Appropriate uni- /multi-variate stats done.
Approval of DHR:
• about half overall ‘approved’ of changes;
• >70% approved of Direct supervision of PGY1, 80-h work week , 1 day off in 7, 8 h off between shifts, Night shift frequency (< 7 consecutive days)
• 65% disapproved of 16-h PGY1 shifts,
• < half approved of 24+4 h senior resident shifts
• YET 61 % of IMPDs stated that there should be fewer duty hour regulations and 20% thought length of training should be increased
• no differences between academic and community sites
Perceived impact of DHR
• Improved: Resident quality of life
• Unchanged: Resident board/in-service scores, Education vs service balance, Supervision of residents
• Worse: Continuity of care, Resident education, Resident ownership of patients, Resident preparation for more senior role, Frequency of hand-offs/sign-out, Program director workload. A minority report that quality (8 %) or safety (11 %) of patient care has improved.
• No clear consensus: Patient safety, Quality of patient care, Number of patient’s seen, Resident fatigue, Increased physician extender (NP, PA) coverage
The authors conclude that not all disciplines will have same response to DHR (EM vs surgical vs medical) because of different cultures. They question whether cost of implementation (~$1.6 billion) will be offset by decrease in adverse events caused by fatigue. Despite finding overall approval of the DHR, individual components are still perceived negatively, especially the 16-hour PGY-1 limitation. Few PDs reported that DHR have resulted in better outcomes for patients or education for residents. In addition, while resident quality of life may be improved, the workload for program directors seems to have increased.
Spare Keys – other take home points for clinician educators
Interesting but somewhat predictable results, with all the problems that surveys have when asking for perceptions without hard outcomes. However this study will probably be widely cited as participants were from some of the largest programs, with specific requirements for experiential work-based learning.
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