Journal Club

Kogan, J.R., Pinto-Powell R., Brown, L.A., Hemmer, P., Bellini, L.M., Peltier, D.

The Impact of Resident Duty Hours Reform on the Internal Medicine Core Clerkship: Results from the Clerkship Directors in Internal Medicine Survey. Academic Medicine 2006 81(12):1038-44.

Reviewed by Judith L. Rowen, University of Texas Galveston

1. What is the problem and what is known about it so far? Residents serve as important role models and teachers for students on core clerkships. With ACGME mandated work hour restrictions, it is conceivable that residents may cut back on the amount of teaching they offer to students. The impact of duty hours on the residents themselves has been studied, with mixed results. Little data are available concerning the impact of duty hours on the teaching offered by the residents to students.

2. Why did the researchers do this particular study? To add to the body of knowledge concerning the impact of duty hours restrictions on medical student education, specifically with a focus on the impact on student clerkships from the perspective of clerkship directors.

3. Who was studied? Clerkship directors in Internal Medicine

4. How was the study done? The Clerkship Directors in Internal Medicine (CDIM) circulates an annual questionnaire to its membership; investigators are invited to submit potential topics/questions to be surveyed with the annual instrument in addition to standard demographic questions. The 2004 survey addressed the issue of the impact of resident duty hours reform on teaching, feedback and evaluation, patient care and student attitudes during the IM clerkship, using 5-point Likert scale items and 4 open-ended items. The survey was distributed to 114 members.

5. What did the researchers find? The response rate on the survey was 84%. Overall, 69.7% of the queried clerkship directors disagreed or strongly disagreed that duty hours reform had a positive impact on the educational experience of clerkship students. This general attitude was reflected in the responses to individual questions concerning resident time and attitudes for teaching, feedback and evaluation of students, and the impact on the patient care experiences for students. Responses to the Likert-scale items and open ended questions revealed special concern that students were learning "shift-work mentality" with subsequent erosion of professionalism, and that students' continuity with the team or patients was being compromised. When asked to name the most positive effect of duty hours reform on student education, 25% said there was no positive effect, with others noting that having more rested residents might improve the students' experience. The survey also asked whether changes had been made in the clerkship in response to resident duty hours restrictions, and other than some decrease in the requirement for overnight call, few programs made substantive changes.

6. What were the limitations of the study? This survey provides the perspective of clerkship directors, not the actual students or residents involved in the teaching interaction being studied. Although the opinions of clerkship directors are obviously important and may provide a broader perspective over time, this may not tell the whole story. Whether these data apply to other types of clerkships besides Internal Medicine is unknown.

7. What were the implications of the study? Yet one more study that points out that resident duty hours restrictions may have unintended consequences. We need to keep looking at this issue, especially as new staffing models are implemented. We also need to plan ahead for the likely institution of such duty hours restrictions for the students - we should have "before and after" studies ready to go and learn from what has gone on during the institution of restrictions for residents. Some prophylactic attempts to shore up altruism and the other components of professionalism against the onslaught of "shift work mentality" should be designed.

(Editorial comment: It is not altogether surprising that Clerkship Directors in IM are pessimistic about the effect of resident duty hours on medical student teaching. It is intriguing that the Directors felt that modeling "shift-work" was one of the major issues rather than say time for feedback or direct observation. Regardless, whether in the inpatient or outpatient setting, there are enormous pressures on teaching time and clerkships and educators will need to explore different models of teaching. Bill Raszka)