The impact of duty hour restrictions on teaching by surgical residents

Abstract

Context and setting Traditionally, surgical residency programmes in the USA have demanded that residents work very long hours, but this has now changed due to the Accreditation Council of Graduate Medical Education (ACGME) duty-hour restrictions adopted in 2002. Much has been written in the surgical literature as to how the 80-hour per week work restrictions on surgical residents impact on the care of surgical patients and the education of residents. On the other hand, very little has been published on how the duty-hour restrictions on surgery residents impact their teaching of medical students. Why the idea was necessary Surgical residents play a major role in the surgical education of medical students. At our institution, Year 3 students report that 35–40% of their learning during their 3-month surgical clerkship is derived from their interactions with surgical residents. The goal of our surgery ‘Resident-as-Teacher’ programme is to optimise residents' teaching of medical students within the new reality of duty-hour restrictions. Thus, it was crucial to determine if and how the duty-hour restrictions impacted the residents' teaching so that we could effectively address these challenges. What was done In December 2003, an anonymous online survey was distributed via e-mail to all 173 surgery residents in 3 Harvard Medical School-affiliated general surgical residency programmes: Beth Israel Deaconess Medical Center, Brigham and Women's Hospital, and Massachusetts General Hospital. Two research questions were asked: rate the impact of the 80-hour per week work restrictions on the teaching of medical students by surgical residents (on a 5-point scale), and list 2 examples of how the 80-hour per week work restrictions have impacted your teaching of medical students. Quantitative data were analysed utilising t-tests and analyses of variance. Qualitative data were coded for themes by 2 independent reviewers. Institution review board approval was obtained. Evaluation of results and impact The survey response rate was 65%. Residents perceived that duty-hour restrictions had a minor negative impact on their teaching of students (mean rating 2.82 on a 5-point scale; SD 0.87). A total of 35% of residents felt that the working hour limitations had a negative impact on teaching (ratings 1 or 2), while 44% felt the impact to be neutral (rating 3), and 21% cited a positive impact (ratings 4 or 5). No significant differences in ratings were identified between institution, gender or postgraduate year. Thematic coding of qualitative data yielded an intercoder agreement of 91%. Residents most commonly cited the decreased time they had available to teach students (39% of respondents). They also noted decreased interactions and teaching opportunities between residents and students (35%), often resulting from structural changes such as night-float teams instituted to accommodate duty-hour limits. The elimination of pre-rounding by both students and residents at 1 institution was cited as a major educational disadvantage (14%), resulting in reduced student participation on the surgical team. On the other hand, a number of residents (26%) perceived that the duty-hour restrictions had allowed them to become more effective as teachers through reduced exhaustion and increased opportunities for reading. This survey has identified specific benefits and challenges stemming from the duty-hour restrictions, of which the latter will be targeted for improvement through our surgery Resident-as-Teacher programme.