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Duty-Hour Surveys Parse Perceptions of Interns, Program Directors

Major Finding: The majority of interns (80.3%) thought the new restrictions would decrease their ability to achieved continuity with hospitalized patients and that there would be a decrease in the coordination of patient care (57.6%). Fewer than half (48%) believed it would interfere with their acquisition of new medical knowledge.

Data Source: Researchers analyzed the results of a survey of 215 surgical interns in general surgery residency programs and compared them with those of an earlier survey of 134 national surgical program directors.

Disclosures: The authors reported they had no financial disclosures.

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No One Wants Even More Restrictions

Eliminating two important limitations of this study might have put the interns more "in sync" with the program directors. First, large university programs constituted 10 of the 11 surveyed, and I suspect that those residents would be less concerned about duty-hour restrictions (because more of them subsequently choose fellowships and are less likely to go straight into general surgery practice) than would those from nonuniversity or community programs. Second, for 42.5% of the interns surveyed, there was no distinction made between those hoping to go into general surgery vs. those on track for surgical subspecialties, who are less likely to be concerned for the same reason of expecting additional training.

Even when we ignore the limitations of this study, I believe it shows that the "line in the sand" for the entire surgical community – residents and attendings – is no further resident duty-hour restrictions.

Mark L. Friedell, M.D., is from the department of surgery at the University of Missouri–Kansas City. His remarks are abstracted from an invited critique that accompanied the article (Arch. Surg. 2012;147:541). He reported having no disclosures.


 

FROM THE ARCHIVES OF SURGERY

Interns beginning their surgical training under the new resident duty-hour standards appear to be less pessimistic than program directors, but they still show significant concern that these new regulations will have a detrimental effect on the quality of their training, according to the results of separate surveys of surgical interns in general surgery residency programs and national surgical program directors.

The Accreditation Council for Graduate Medical Education (ACGME) implemented the new standards in July 2011 to include increased supervision and a 16-hour shift maximum for postgraduate year 1 residents, according to a report published in the June issue of Archives of Surgery.

Dr. Mark Friedell

In the summer of 2011, the researchers surveyed all 215 surgical interns in 11 general surgical residency programs distributed across the country to assess their perceptions of how the new duty-hour requirements would affect continuity of care, resident fatigue, and development in the six core ACGME competencies, according to Dr. Ryan M. Antiel of the Mayo Clinic, Rochester, Minn., and his colleagues. Perceptions were measured using a 3-point scale (increase, decrease, no change) for each item. A total of 179 (83.3%) completed the survey. Most respondents (68.7%) were men and were younger than 29 years of age (73%), with 102 categorical interns (57%) and 76 preliminary interns (42.5%), and 1 nonrespondent to this question (Arch. Surg. 2012;147:536-41).

Results of the resident survey were compared with those of an earlier survey of 134 program directors conducted by Dr. Antiel and his colleagues (Mayo Clin. Proc. 2011;86:185-91).

The great majority of the interns (80.3%) indicated that the new restrictions would decrease their ability to achieve continuity with hospitalized patients, and more than half (57.6%) stated that there would be a decrease in the coordination of patient care. Slightly fewer than half (48%) believed it would interfere with their acquisition of new medical knowledge.

"Most of the surgical interns (67.4%) believed that the duty-hour restrictions will decrease their time spent in the operating room," the researchers added. They also indicated that the new standards would decrease their development of surgical skills (52.8%); their time spent with patients on the floor (51.1%); and their overall educational experience (51.1%). Categorical interns were significantly more likely to believe that the changes would decrease both quality and safety of patient care (odds ratio, 2.6).

However, some optimism was also expressed: In all, 61.5% of interns believed that the new standards would decrease resident fatigue; 66.5% indicated that the new hours would increase or not change quality and safety of patient care; 72.1% indicated the same for the ability to effectively communicate with patients, families, and other health professionals; 74.7% indicated the same for the resident’s investigation and self-evaluation of their own patient care; and 70.2% felt that the impact would be neutral or favorable in the area of responsiveness to patient needs that supersede self-interest.

Compared with the program directors surveyed, a significantly higher proportion of interns believed that the new changes would improve or not change residents’ performance. And a significantly larger percentage of program directors agreed that the new changes would decrease coordination of patient care and residents’ acquisition of medical knowledge (76.9% vs. 48.0%). Perhaps most notably in terms of cross-perceptions, most interns (61.5%) believed that the new changes would decrease fatigue, whereas 85.1% of program directors believed that the new hours would increase fatigue, presumably by increasing the intensity of effort and accomplishments required in that shorter amount of time, according to the authors.

Dr. Antiel and his colleagues pointed out several limitations to their study beyond those intrinsic to the nature of surveys. Attitudes of residents may change over time, although the survey was most concerned with the perception of incoming interns. Also, program directors were not chosen randomly, and some regions may have been underrepresented. In addition, attitudes cannot be taken as evidence of the actual results of duty-hour restrictions on training, only the perceptions of that effect. But in the absence of defined metrics for assessing the effect of duty-hour restrictions on training, the attitudes of those most intimately involved in training may be the best metric available, the researchers noted.

"As residency programs attempt to adapt to the new regulations, surgical interns have significant concerns about the implications of these regulations on their training. The opinions of these interns, although markedly more optimistic than those of surgical program directors, reflect a persistent concern within the surgical community regarding the effects of work-hour restrictions on surgical training," the researchers concluded.

Eliminating two important limitations of this study might have put the interns more "in sync" with the program directors, noted Dr. Mark L. Friedell, who wrote an invited critique of the report (Arch. Surg. 2012;147:541). "First, large university programs constituted 10 of the 11 surveyed, and I suspect that those residents would be less concerned about duty-hour restrictions" (because more of them subsequently choose fellowships and are less likely to go straight into general surgery practice) than would those from nonuniversity or community programs, he wrote. Second, for 42.5% of the interns surveyed, there was no distinction made between those hoping to go into general surgery vs. those on track for surgical subspecialties, who are less likely to be concerned for the same reason of expecting additional training.

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