Journal Club

Multidimensional effects of the 80-hour work week at the University of Michigan Medical School. White et. al. Academic Medicine 2006; 81: 57-62.

Reviewed by Randy Rockney, Brown University

Three years ago, July 2003, ACGME regulations to restrict resident work schedules to 80 hours a week went into effect in U.S. residency programs. Residency work hour restrictions were implemented because of concerns for residents' personal lives, to create a more appropriate learning environment, and to promote patient safety. Concerns were raised that work hour restrictions might compromise both patient care and medical education. So far, not surprisingly, there is some evidence that the work hour restrictions have increased students' interest in surgery, but students have also expressed the concern that residents will be less available to teach them. The authors of this paper examined the effects of resident work hour restrictions on medical student education in four core clerkships at the University of Michigan.

The perceptions of students completing four core clerkships-Pediatrics, Internal Medicine, Surgery, and Obstetrics and Gynecology-measured in the year just preceding the implementation of the work hour restrictions (2002-2003) were compared to the perceptions of students completing those same core clerkships in the first year of implementation of the work hour limitations (2003-2004). Of note, the authors used clerkship evaluation data on question-naires to assess students' satisfaction with their core clerkships in use for over ten years. In other words, at the times the two groups responded, the authors had not planned or discussed their study on the effects of resident work hour restrictions on medical student education. The four clerkships were chosen because it was known that residents shared significant responsibility for medical student education on those clerkships.

The researchers found that there were significant decreases in student satisfaction with their clerkship experiences after implementation of the resident work hour restrictions in all the clerkships except pediatrics. These downward trends were most notable in the surgery-oriented clerkships, Surgery and Obstetrics and Gynecology, where students reported less access to faculty (OB and Surgery), less access to residents (OB), lower quality of house staff teaching (OB), lower quality of feedback (OB and Surgery), lower overall quality of clerkship (OB and Surgery), less observation of clinical skills (OB), reduced clarity of expectations (Surgery), less ability to manage patient problems (OB and Surgery), more time in unproductive activities, i.e., "scut," (Surgery), and less time in independent study (Surgery). Students in the Internal Medicine clerkship reported a significant decrease in the quality of the feedback they received and an increase in the amount of time spent in unproductive activities. Students in the Pediatric clerkship reported increased accessibility of faculty, increased quality of faculty teaching, and increased quality of feedback. A trend toward increased quality of the Pediatric clerkship did not reach significance.

Completion of the end of the clerkship evaluation questionnaires was voluntary and response rates varied by clerkship ranging from a high of 100% for Obstetrics and Gynecology in the 2003-2004 cohort to a low of less than 50% in the 2002-2003 cohort for surgery. Another study limitation was that, while there were no differences between the credentials of students (MCAT scores, GPAs) in each cohort, the qualifications of the residents, or the goals, objectives, and expectations of the clerkships, important changes had occurred in each clinical department from one clerkship year to the next. Physicians assistants had been hired by the Surgery department and hospitalists by both the Internal Medicine and Pediatrics departments. Differences in student perceptions may be attributable to the different roles assigned to those new hires: pediatric hospitalists focussed more on teaching while the internal medicine hospitalists and surgery physician assistants served more to take on overflow clinical responsibilities. Also, probably of most significance, the second cohort of students completed their clerkships in the first year of the resident work hour restriction regulations, a situation in which most departments would be expected to experience "growing pains" as necessary adjustments had to be made. From a personal perspective, problems experienced at my program during that first year improved dramatically in the subsequent two years. Indeed, the Obstetrics and Gynecology clerkship at the University of Michigan made changes designed to improve students' experiences including adoption of a night float system and the addition of "laborists" (labor and delivery hospitalists), that led to increases in positive perceptions by the students of their clerkship experiences.

The major implications of this study are that, obviously, significant changes like resident work hour restrictions are going to be felt by all stakeholders including the medical students. If residents are less available to teach the students and faculty are called upon to perform some of the patient care responsibilities formerly assigned to residents, something has to be added or changed to limit the negative impact of such changes on medical student education. Learning from experience and anticipating changes, programs can make adjustments to adapt to those changes and hopefully create improvements in education that go beyond mere adjustments or filling in the holes.

(Two things strike me: 1) it's really critical to have baseline measures in place if you plan a change. It's hard to learn from experience if you have not figured out where you are. 2) Consumer Reports always advises not to buy a car in its first model year. The third year's data will be critical. How did the clerkships adjust to the growing pains? - Bruce Morgenstern)