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PubMed1998

Learning, satisfaction, and mistreatment during medical internship: a national survey of working conditions.

CONTEXT: Concerns about the working and learning environment of residency training continue to surface. Previous surveys of residents have focused on work hours and income, but have shed little light on how residents view their training experience. OBJECTIVE: To provide a description of the internship year as seen by a large cross section of second-year residents. DESIGN: Mail survey conducted in 1991. SETTING: Residency programs in the United States. PARTICIPANTS: Random 10% sample (N=1773) of all second-year residents listed in the American Medical Association's medical research and information database. MAIN OUTCOME MEASURES: What and who contributes most to residents' learning during internships, degree of satisfaction with the internship experience, on-call and sleep schedules, incidents of perceived mistreatment or abuse, observations of unethical behavior, and experiences of harassment or discrimination. RESULTS: A total of 1277 surveys (72%) of 1773 mailed were returned. Overall, respondents reported a moderate level of satisfaction with their first year of residency. On a scale of 0 to 3, residents rated other residents as contributing most (score of 2.3) to their learning, with special patients ranked second (2.1). During a typical work week, residents reported that they spent an average of 56.9 hours on call in the hospital. A total of 1185 (93%) residents reported experiencing at least 1 incident of perceived mistreatment, with 53% reporting being belittled or humiliated by more senior residents. Among women residents, 63% reported having experienced at least 1 episode of sexual harassment or discrimination. A total of 45% of residents reported having observed another individual falsifying medical records, and 70% saw a colleague working in an impaired condition, most often lack of sleep. Regression analyses suggest that satisfaction with the residency experience was associated with the presence of factors that enhanced learning, and fewer experiences of perceived mistreatment. CONCLUSIONS: Residents report significant problems during their internship experience. Satisfaction with internship is enhanced by positive learning experiences and lack of mistreatment.

Attitude of Health Personnel↗
PubMed2005

Neurobehavioral performance of residents after heavy night call vs after alcohol ingestion.

CONTEXT: Concern exists about the effect of extended resident work hours; however, no study has evaluated training-related performance impairments against an accepted standard of functional impairment. OBJECTIVES: To compare post-call performance during a heavy call rotation (every fourth or fifth night) to performance with a blood alcohol concentration of 0.04 to 0.05 g% (per 100 mL of blood) during a light call rotation, and to evaluate the association between self-assessed and actual performance. DESIGN, SETTING, AND PARTICIPANTS: A prospective 2-session within-subject study of 34 pediatric residents (18 women and 16 men; mean age, 28.7 years) in an academic medical center conducted between October 2001 and August 2003, who were tested under 4 conditions: light call, light call with alcohol, heavy call, and heavy call with placebo. INTERVENTIONS: Residents attended a test session during the final week of a light call rotation (non-post-call) and during the final week of a heavy call rotation (post-call). At each session, they underwent a 60-minute test battery (light and heavy call conditions), ingested either alcohol (light call with alcohol condition) or placebo (heavy call with placebo condition), and repeated the test battery. Performance self-evaluations followed each test. MAIN OUTCOME MEASURES: Sustained attention, vigilance, and simulated driving performance measures; and self-report sleepiness, performance, and effort measures. RESULTS: Participants achieved the target blood alcohol concentration. Compared with light call, heavy call reaction times were 7% slower (242.5 vs 225.9 milliseconds, P<.001); commission errors were 40% higher (38.2% vs 27.2%, P<.001); and lane variability (7.0 vs 5.5 ft, P<.001) and speed variability (4.1 vs 2.4 mph, P<.001) on the driving simulator were 27% and 71% greater, respectively. Speed variability was 29% greater in heavy call with placebo than light call with alcohol (4.2 vs 3.2 mph, P = .01), and reaction time, lapses, omission errors, and off-roads were not different. Correlation between self-assessed and actual performance under heavy call was significant for commission errors (r = -0.45, P = .01), lane variability (r = -0.76, P<.001), and speed variability (r = -0.71, P<.001), but not for reaction time. CONCLUSIONS: Post-call performance impairment during a heavy call rotation is comparable with impairment associated with a 0.04 to 0.05 g% blood alcohol concentration during a light call rotation, as measured by sustained attention, vigilance, and simulated driving tasks. Residents' ability to judge this impairment may be limited and task-specific.

Adult↗
PubMed2005

Educational programs in US medical schools, 2004-2005.

CONTEXT: The educational environment affects the outcomes of medical education, including the characteristics and distribution of medical school graduates. OBJECTIVE: To report the status of variables related to medical education that represent areas that recently have been in flux or have potential impact on health care delivery. DESIGN, SETTING, AND PARTICIPANTS: Descriptive survey study comparing selected results of the Liaison Committee on Medical Education Annual Medical School Questionnaire between 2004-2005 and 1994-1995. The questionnaire was sent to the deans of all 125 LCME-accredited medical schools. Response rate was 100% in both years. MAIN OUTCOME MEASURES: Overall trends between 1994-1995 and 2004-2005 in the size and composition of the medical school faculty, the numbers of medical school applicants and students, requirements for passage of the US Medical Licensing Examination, medical student work hours, the use of computers in the educational program, the geographic pipeline from entry to medical school to entry to graduate medical education, and the educational background of medical school deans. RESULTS: The number of full-time faculty members increased from 90 016 in 1994-1995 to 119 025 in 2004-2005 (a 32% increase) while the number of medical students remained constant at about 67 000. In 2004-2005, 11% of medical school deans held MD and PhD degrees, 6% held MD and MBA degrees, 4% held MD and MPH degrees, and 2% held an MD and another degree (such as JD). In 2004-2005, 68% of all first-year medical students were residents of the state in which the medical school is located and a mean of 43% of 2005 graduates remained in the same state as the medical school for graduate medical education; results were similar in 1995. In 2004-2005, 58 schools (46%) required students to have their own computers and 35 (28%) to have their own personal digital assistants. In 2004-2005, night call was less common in the family medicine, internal medicine, pediatrics, and psychiatry clerkships compared with 1994-1995. CONCLUSIONS: Although most students remain in their home state for medical school, most students leave the medical school state for residency. Factors external to the medical school, such as funding mechanisms and regulations from the public and private sectors, may be having an impact on faculty size and composition, and on the geographic pipeline of students into medical school and residency training.

Clinical Clerkship↗
PubMed2005

Effects of work hour reduction on residents' lives: a systematic review.

CONTEXT: The Accreditation Council for Graduate Medical Education implemented mandatory work hour limitations in July 2003, partly out of concern for residents' well-being in the setting of sleep deprivation. These limitations are likely to also have an impact on other aspects of the lives of residents. OBJECTIVE: To summarize the literature regarding the effect of interventions to reduce resident work hours on residents' education and quality of life. DATA SOURCES: We searched the English-language literature about resident work hours from 1966 through April 2005 using MEDLINE, EMBASE, and Current Contents, supplemented with hand-search of additional journals, reference list review, and review of abstracts from national meetings. STUDY SELECTION: Studies were included that assessed a system change designed to counteract the effects of resident work hours, fatigue, or sleep deprivation; included an outcome directly related to residents; and were conducted in the United States. DATA EXTRACTION: For each included study, 2 investigators independently abstracted data related to study quality, subjects, interventions, and findings using a standard data abstraction form. DATA SYNTHESIS: Fifty-four articles met inclusion criteria. The interventions used to decrease resident work hours varied but included night and day float teams, extra cross-coverage, and physician extenders. Outcomes included measures of resident education (operative experience, test scores, satisfaction) and quality of residents' lives (amount of sleep, well-being). Interventions to reduce resident work hours resulted in mixed effects on both operative experience and on perceived educational quality but generally improved residents' quality of life. Many studies had major limitations in their design or conduct. CONCLUSIONS: Past interventions suggest that residents' quality of life may improve with work hour limitations, but interpretation of the outcomes of these studies is hampered by suboptimal study design and the use of nonvalidated instruments. The long-term impact of reducing resident work hours on education remains unknown. Current and future interventions should be evaluated with more rigorous methods and should investigate links between residents' quality of life and quality of patient care.

Education, Medical↗
PubMed2006

Extended work duration and the risk of self-reported percutaneous injuries in interns.

CONTEXT: In their first year of postgraduate training, interns commonly work shifts that are longer than 24 hours. Extended-duration work shifts are associated with increased risks of automobile crash, particularly during a commute from work. Interns may be at risk for other occupation-related injuries. OBJECTIVE: To assess the relationship between extended work duration and rates of percutaneous injuries in a diverse population of interns in the United States. DESIGN, SETTING, AND PARTICIPANTS: National prospective cohort study of 2737 of the estimated 18,447 interns in US postgraduate residency programs from July 2002 through May 2003. Each month, comprehensive Web-based surveys that asked about work schedules and the occurrence of percutaneous injuries in the previous month were sent to all participants. Case-crossover within-subjects analyses were performed. MAIN OUTCOME MEASURES: Comparisons of rates of percutaneous injuries during day work (6:30 am to 5:30 pm) after working overnight (extended work) vs day work that was not preceded by working overnight (nonextended work). We also compared injuries during the nighttime (11:30 pm to 7:30 am) vs the daytime (7:30 am to 3:30 pm). RESULTS: From a total of 17,003 monthly surveys, 498 percutaneous injuries were reported (0.029/intern-month). In 448 injuries, at least 1 contributing factor was reported. Lapse in concentration and fatigue were the 2 most commonly reported contributing factors (64% and 31% of injuries, respectively). Percutaneous injuries were more frequent during extended work compared with nonextended work (1.31/1000 opportunities vs 0.76/1000 opportunities, respectively; odds ratio [OR], 1.61; 95% confidence interval [CI], 1.46-1.78). Extended work injuries occurred after a mean of 29.1 consecutive work hours; nonextended work injuries occurred after a mean of 6.1 consecutive work hours. Injuries were more frequent during the nighttime than during the daytime (1.48/1000 opportunities vs 0.70/1000 opportunities, respectively; OR, 2.04; 95% CI, 1.98-2.11). CONCLUSION: Extended work duration and night work were associated with an increased risk of percutaneous injuries in this study population of physicians during their first year of clinical training.

Accidents, Occupational↗
PubMed2006

Interns' compliance with accreditation council for graduate medical education work-hour limits.

CONTEXT: Sleep deprivation is associated with increased risk of serious medical errors and motor vehicle crashes among interns. The Accreditation Council for Graduate Medical Education (ACGME) introduced duty-hour standards in 2003 to reduce work hours. OBJECTIVE: To estimate compliance with the ACGME duty-hour standards among interns. DESIGN, SETTING, AND PARTICIPANTS: National prospective cohort study with monthly Web-based survey assessment of intern work and sleep hours using a validated instrument, conducted preimplementation (July 2002 through May 2003) and postimplementation (July 2003 through May 2004) of ACGME standards. Participants were 4015 of the approximately 37 253 interns in US residency programs in all specialties during this time; they completed 29 477 reports of their work and sleep hours. MAIN OUTCOME MEASURE: Overall and monthly rates of compliance with the ACGME standards. RESULTS: Postimplementation, 1068 (83.6%; 95% confidence interval [CI], 81.4%-85.5%) of 1278 of interns reported work hours in violation of the standards during 1 or more months. Working shifts greater than 30 consecutive hours was reported by 67.4% (95% CI, 64.8%-70.0%). Averaged over 4 weeks, 43.0% (95% CI, 40.3%-45.7%) reported working more than 80 hours weekly, and 43.7% (95% CI, 41.0%-46.5%) reported not having 1 day in 7 off work duties. Violations were reported during 3765 (44.0%; 95% CI, 43.0%-45.1%) of the 8553 intern-months assessed postimplementation (including vacation and ambulatory rotations), and during 2660 (61.5%; 95% CI, 60.0%-62.9%) of 4327 intern-months during which interns worked exclusively in inpatient settings. Postimplementation, 29.0% (95% CI, 28.7%-29.7%) of reported work weeks were more than 80 hours per week, 12.1% (95% CI, 11.8%-12.6%) were 90 or more hours per week, and 3.9% (95% CI, 3.7%-4.2%) were 100 or more hours per week. Comparing preimplementation to postimplementation responses, reported mean work duration decreased 5.8% from 70.7 (95% CI, 70.5-70.9) hours to 66.6 (95% CI, 66.3-66.9) hours per week (P<.001), and reported mean sleep duration increased 6.1% (22 minutes) from 5.91 (95% CI, 5.88-5.94) hours to 6.27 (95% CI, 6.23-6.31) hours per night (P<.001). However, reported mean sleep during extended shifts decreased 4.5%, from 2.69 (95% CI, 2.66-2.73) hours to 2.57 (95% CI, 2.52-2.62) hours (P<.001). CONCLUSION: In the first year following implementation of the ACGME duty-hour standards, interns commonly reported noncompliance with these requirements.

Adult↗