The Effect of Reducing Maximum Shift Lengths to 16 Hours on Internal Medicine Interns’ Educational Opportunities
| Autor: | John Sergent, Joshua C. Denny, Eduard E. Vasilevskis, Cecelia Theobald, Neeraja B. Peterson, Jennifer Green, Sunil Kripalani, Jacob Hathaway, Nancy J. Brown, Kelly C. Sponsler, Daniel G. Stover, Neesha N. Choma |
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| Jazyk: | angličtina |
| Rok vydání: | 2013 |
| Předmět: |
Male
medicine.medical_specialty Time Factors Graduate medical education Personnel Staffing and Scheduling Standardized test Workload Article Education Patient safety Case mix index Recall bias Internal medicine Work Schedule Tolerance Internal Medicine Medicine Humans Medical education Academic Medical Centers business.industry Attendance Internship and Residency General Medicine Tennessee Test (assessment) Systematic review Education Medical Graduate Family medicine Female Clinical Competence business |
| Popis: | Medical resident duty hours have been increasingly scrutinized over the past two decades. Following the implementation of Code 405 by the New York Department of Health in 1989, the Accreditation Council for Graduate Medical Education (ACGME) first placed limitations on resident duty hours in July 2003.1 The Institute of Medicine recommended further restrictions in 2008, citing concern that extended shifts could contribute both to reduced resident well-being and also increased medical errors.2 The ACGME further revised duty hour limits to include a maximum of 16 hours per shift for postgraduate year one residents (i.e., interns), effective July 2011.3 These updated limitations generated substantial debate, as they effectively eliminated all overnight calls for interns. Since the beginning of duty hour reform in the late 1980s, more than 100 studies have evaluated the impact of these progressive restrictions on both patient care and resident outcomes across the spectrum of medical specialties. Several recent systematic reviews demonstrated that these investigations varied widely in methodology but were primarily single-institution, pre–post, or cross-sectional studies.4–6 While many focused on patient safety outcomes and resident or faculty satisfaction, several focused on resident education metrics — a growing concern in a rapidly changing educational environment. To date, the methods used to assess the effect of previous duty hour restrictions on resident education have included procedural/operative volume,7–13 standardized medical knowledge testing,7,9,11,14–16 didactic lecture attendance,17,18 and time spent reading.19–23 Many of these studies largely relied on self-reported data, which is subject to recall bias, and manual chart review. Most studies did not demonstrate a significant impact on procedural volume or didactic participation. Standardized test scores were largely unchanged or slightly improved after duty hour limitations, and residents generally reported an improvement in time available for reading. Studies using objective data have demonstrated no difference in the number of patients admitted, mean census,24 standardized medical knowledge test scores,25 or didactic lecture attendance. 26,27 Unintended consequences of duty hour changes, particularly the impact on resident education, are a major concern at academic medical centers (i.e., teaching hospitals). Rigorous evaluation of these changes is critical. A 2005 systematic review noted that there are “no studies that measured actual experience of residents in internal medicine, pediatrics, family medicine.”5 In the interim, several studies4,6,9–15 from different specialties evaluated some factors that affect resident education; however, objective evaluation of internal medicine resident education has lagged relative to other specialties. Prior to implementation of the 2011 ACGME duty hour restrictions, a survey by the Association of Program Directors in Internal Medicine demonstrated that 79.2% of residency program directors perceived that the quality of the learning environment would somewhat or strongly decrease.28 Another study evaluating the cost of implementing the ACGME rules suggested that educational opportunities may decline due to a shift in the service–learning balance.29 Prior studies have largely relied on resident and faculty perceptions of educational experience, but have not directly measured patient case mix, clinical documentation, or procedure logs. Few studies have evaluated the effects of the comprehensive changes implemented in July 2011. We utilized an informatics-based approach, allowing near-complete objective capture of resident educational exposures, to evaluate the impact of the new 16-hour limitation on five key areas of intern education: (1) patient volume, (2) note characteristics, (3) exposure to common presenting problems, (4) procedural experience, and (5) structured didactic experiences. We hypothesized that, despite substantial structural changes, there would be no significant difference in any of the five areas. |
| Databáze: | OpenAIRE |
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