Approval and Perceived Impact of Duty Hour Regulations: Survey of Pediatric Program Directors

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Approval and Perceived Impact of Duty Hour

Regulations: Survey of Pediatric Program Directors

WHAT’S KNOWN ON THIS SUBJECT: Several studies have been published evaluating the impact of 2011 Accreditation Council for Graduate Medical Education duty hour regulations. Although resident quality of life may be improved, it appears that resident education and patient care may be worse.

WHAT THIS STUDY ADDS: This is the first study to evaluate pediatric program director approval of 2011 Accreditation Council for Graduate Medical Education Common Program Requirements and the perceived impact of the regulations on patient care, resident education, and quality of life.

abstract

OBJECTIVES: To determine pediatric program director (PD) approval and perception of changes to resident training and patient care result-ing from 2011 Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements.

METHODS:All US pediatric PDs (n= 181) were identified from the ACGME. Functional e-mail addresses were identified for 164 (90.6%). Three individualized e-mail requests were sent to each PD to com-plete an anonymous 32-question Web-based survey.

RESULTS:A total of 151 responses were obtained (83.4%). Pediatrics PDs reported approval for nearly all of the 2011 ACGME duty hour reg-ulations except for 16-hour intern shift limits (72.2% disapprove). Re-garding the perceived impact of the new standards, many areas were reportedly unchanged, but most PDs reported negative effects on res-ident education (74.7%), preparation for senior roles (79.9%), resres-ident ownership of patients (76.8%), and continuity of care (78.8%). There was a reported increase in PD workload (67.6%) and use of physician extenders (62.7%). Finally, only 48.3% of PDs reported that their res-idents are“always” compliant with 2011 requirements.

CONCLUSIONS:Pediatric PDs think there have been numerous negative consequences of the 2011 Common Program Requirements. These in-clude declines in resident education and preparation to take on more senior roles, as well as diminished resident accountability and conti-nuity of care. Although they support individual aspects of duty hour regulation, almost three-quarters of pediatric PDs say there should be fewer regulations. The opinions expressed by PDs in this study should prompt research using quantitative metrics to assess the true impact of duty hour regulations.Pediatrics2013;132:819–824

AUTHORS:Brian C. Drolet, MD,aSarah B. Whittle, MD,b,c

Mamoona T. Khokhar, MD,dStaci A. Fischer, MD,eand Adam

Pallant, MD, PhDc

Departments ofaPlastic Surgery,dSurgery, andeMedicine, Rhode Island Hospital and the Warren Alpert Medical School of Brown University, Providence, Rhode Island;bTexas Childrens Cancer and Hematology Centers, Baylor College of Medicine, Houston, Texas; andcDepartment of Pediatrics, The Warren Alpert Medical School of Brown University and Hasboro Children’s Hospital, Providence, Rhode Island

KEY WORDS

duty hours, education, patient safety, residency training, quality of life, compliance

ABBREVIATIONS

ACGME—Accreditation Council for Graduate Medical Education OR—odds ratio

PD—program director PGY—postgraduate year

Dr Drolet conceptualized and designed the study, carried out data collection, interpretation, and analysis, reviewed and revised the manuscript, had full access to all data in the study; and takes responsibility for the integrity of the data and the accuracy of the data analysis; Dr Whittle carried out initial data analysis, drafted the initial manuscript, and coordinated review and revision of the manuscript; Dr Khokhar conceptualized and designed the study, carried out data collection, interpretation, and analysis, and reviewed and revised the manuscript; Dr Fischer conceptualized and designed the study and the survey instrument and critically reviewed the manuscript; Dr Pallant was involved in data analysis and drafting, review, and revision of the manuscript; and all authors approved the

final manuscript as submitted.

www.pediatrics.org/cgi/doi/10.1542/peds.2013-1045

doi:10.1542/peds.2013-1045

Accepted for publication Aug 5, 2013

Address correspondence to Brian C. Drolet, MD, Rhode Island Hospital, 2 Dudley Street, Coop 500, Providence, RI 02905. E-mail: bdrolet@lifespan.org

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2013 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE:The authors have indicated they have nofinancial relationships relevant to this article to disclose.

FUNDING:No external funding.

POTENTIAL CONFLICT OF INTEREST:The authors have indicated they have no potential conflicts of interest to disclose.

COMPANION PAPER:A companion to this article can be found on page 919, and online at www.pediatrics.org/cgi/doi/10.1542/ peds.2013-2476.

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residency program directors (PDs) with the responsibility to“implement changes based on the current accred-itation standards.”1 These standards

are described in the ACGME Common Program Requirements, which also provide guidelines for resident duty hours and supervision. Thefirst na-tional duty hour regulations were enacted by the ACGME in 2003, estab-lishing limits of an 80-hour work week and 30-hour shifts, as well as a mini-mum 1 day off in 7 for all residents averaged over a 4-week period.

After implementation of the 2003 duty hour regulations, numerous studies were conducted to evaluate their im-pact. Although several studies sug-gested that resident quality of life and burnout had improved,2,3others failed

to demonstrate that changes in duty hours had improved resident sleep or patient safety.4–7 Ultimately, no

con-sensus was established in the litera-ture on the effect of regulations on residency education or patient safety.

In 2011, additional limits were estab-lished in response to Institute of Med-icine recommendations and public pressure, including calls for the Occu-pational Safety and Health Adminis-tration to intervene.8,9Under the new

guidelines, maximum consecutive work hours were restricted to 16 hours for interns (PGY1 residents) and to 24 hours for all other residents. Addi-tionally, the new regulations required onsite supervision for interns at all times.10The goals of the new Common

Program Requirements were to im-prove resident education, increase the safety and quality of patient care, and improve resident quality of life and well-being through“provision of a safe and humanistic educational environment.”11

When the revised Common Program Requirements were proposed in 2010,

would not accomplish the proposed goals.12–16 In 3-year residency

pro-grams such as pediatrics with broad training requirements (inpatient and outpatient neonate to adolescent) there was particular concern that residents would lose educational op-portunities in favor of service obliga-tions and that training might be need to be lengthened.17–19Some critics of

the proposal thought that the 2003 regulations should be more strictly enforced before work hours were lim-ited further because a number of stud-ies after the initial ACGME regulations demonstrated noncompliance.20–23

Fi-nally, others criticized the distinction made between interns and more senior residents and the potential impact of delaying resident maturation in the de-velopmental pathway of graduate medi-cal education.19

As those primarily responsible for resident education, PDs might be pressured to impose regulations that they believe negatively affect their primary role as educators. To assess perceptions of the 2011 regulations 1 year after their implementation, a na-tional survey of residency PDs in pedi-atrics, general surgery, and internal medicine was conducted.24

METHODS

A 32-question survey was developed from key duty hours and supervision requirements in the 2011 ACGME reg-ulations and from studies previously conducted by the authors.12,25 The

survey was designed to assess PD perceptions of thefirst year of train-ing under the new duty hour stand-ards. In addition to demographic data, questions about the perceived effect of duty hour limitations on patient care, supervision, resident quality of life, and education were assessed, as was estimated resident

Island Hospital approved the study.

All PDs of ACGME-accredited pediatric, internal medicine, and general sur-gery residency programs in the United States and its territories were eligible to participate in the study. This study was conducted on these 3 large training groups to allow analysis of differences between the various spe-cialties. A total of 181 pediatric PDs were identified from the ACGME online database, and an extensive Internet search was performed to obtain in-dividual contact information. Functional e-mail addresses were identified for 164 (90.6%) PDs. Beginning in June 2012, 3 individualized e-mails were sent over the course of 6 weeks requesting par-ticipation in the anonymous electronic survey.

PDs were asked to indicate approval of 7 individual duty hour rules and their overall impression of the Common Program Requirements. They were then asked to provide positive, neutral, or negative responses about the perceived impact of the ACGME standards. Finally, they were asked to estimate their res-idents’ compliance with duty hours using a 5-point Likert scale, with an estimate of percentage compliance for standardized reporting. For data anal-ysis, noncompliance was considered any response that did not indicate“ al-ways”compliant. Two-sided 95% confi -dence intervals were calculated by using SE of proportions. Results from pediatric PDs were compared against responses from residency directors in general surgery and internal medicine. In the comparison of responses from different demographic groups, thex2 test was used to test for independence between proportions.

RESULTS

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survey (83.4% response rate). There was a nearly equal distribution of male (46.8%) and female (50.0%) respondents. The majority of respondents (61.7%) were between 41 and 60 years old, with nearly half (47.4%) reporting 0 to 5 years of experience as a PD. Of the partici-pating programs, 40.9% ranged from 30 to 49 residents, and 74.0% were

af-filiated primarily with an academic medical center (Table 1).

Approval

Most PDs reported approval for all in-dividual aspects of the Common Program Requirements, with the exception of 16-hour duty periods (72.2% disapproval) (Table 2). Despite approval for most components, when asked about their overall impression, less than half (49.0%)

reported“overall”approval of duty hour regulations.

Some differences were noted between specialties, with pediatric program directors more than twice as likely to report approval of direct PGY1 su-pervision (odds ratio [OR] 2.27, P, .01) and a required 8 hours off be-tween shifts (OR 2.42, P, .01) than surgical and internal medicine pro-gram directors.24Within the pediatric

subset, no significant differences were found based on gender, years as a pro-gram director, and propro-gram affiliation or size.

Impact

Few PDs reported perceived improve-ments in patient care or resident expe-riences as a result of the 2011 Common Program Requirements (Table 3). Areas thought to be unchanged included pa-tient safety (68.5%), quality of papa-tient care (52.7%), supervision of residents (65.6%), education versus service balance (53.6%), and resident in-service and board scores (72.1%). Although the majority of respondents (56.0%) reported resident fatigue as unchanged, pediatric PDs were sig-nificantly more likely to report wors-ened fatigue (OR 4.94,P, .01) than the other PDs surveyed. Similarly, pediatric PDs were much more likely to report worsened resident quality of life than colleagues in general surgery or internal medicine (OR 6.54,P,.01).

Beyond factors that were reportedly unchanged, PDs noted many negative consequences, including worsened resident education (74.7%), prepara-tion for more senior roles (79.9%), ownership of patients (76.8%), and continuity of care (78.8%). Nearly 90% reported an increased frequency of patient care handoffs. Although many respondents reported that the num-ber of patients seen by residents has not changed (48.7%), nearly as many (46.0%) reported that patient en-counters have decreased. Many PDs also reported an increase in their own workload (65.6%) and more coverage by physician extenders (62.7%). Pedi-atric PDs were more likely than their peers in surgery and medicine to re-port worsened education (OR 1.85,P, .01) and preparation for senior roles (OR 1.67,P,.01).

Compliance

Finally, resident adherence to Common Program Requirements was reportedly low, with only 48.3% of PDs reporting that their residents are“always” com-pliant. When pediatric residents were asked this same question in an earlier study, only 42.2% of respondents reported that they were always com-pliant.26Pediatric PDs were somewhat

more likely to report compliance than those in surgery or internal medicine (OR 1.40,P= .01). No other significant differences were noted in the subgroup analyses.

TABLE 1 Demographics of Respondents,

N(% of sample)

Gender

Male 72 (47.68%)

Female 77 (50.99%)

Not reported 5 (1.32%)

Age

,40 38 (25.17%)

41–60 95 (62.91%)

.60 17 (11.26%)

Not reported 1 (0.66%)

Years as PD

0–5 73 (48.34%)

6–10 39 (25.83%)

11–15 18 (11.92%)

16–20 10 (6.62%)

.20 10 (6.62%)

Not reported 1 (.66%)

Program Size (% of residents)

1–29 36 (23.84%)

30–49 63 (41.72%)

50–79 27 (17.88%)

.80 24 (15.89%)

Not reported 1 (0.66%)

Primary Program Affiliation

Academic medical center 114 (74.50%)

Community-based 32 (21.19%)

Veterans or military 5 (3.31%)

Not reported 1 (0.00%)

TABLE 2 PD Approval of Components of the 2011 Common Program Requirements (Question:

“Regarding the ACGME Common Program Requirements, please indicate your level of approval.”)

Disapprove Neutral Approve

Percentage of Respondents (95% Confidence Interval)

Direct supervision of PGY1 2.7% (0.1–5.2) 11.3% (6.3–16.4) 86.0%a(80.5–91.5) 80 h work week 5.3% (1.7–8.9) 14.6% (8.9–20.2) 80.1%a(73.8–86.5) 1 d off in 7 1.3% (0.0–3.1) 7.9% (3.6–12.3) 90.7%a(86.1–5.4) 16 h PGY1 shifts 72.2%a(65.0–79.3) 15.2% (9.5–21.0) 12.6% (7.3–17.9) 24+4 h senior resident shifts 21.2% (14.7–27.7) 25.2% (18.2–32.1) 53.6%a(45.7–61.6) 8 h off between shifts 5.3% (1.7–8.9) 12.6% (7.3–17.9) 82.1%a(76.0–88.2) Night shift frequency (,7 consecutive days) 14.0% (8.5–19.5) 14.7% (9.0–20.3) 71.3%a(64.1–78.5) Overall impression 21.1% (14.6–27.6) 29.9% (22.6–37.2) 49.0%a

(41.0–57.0) aIndicates signicant difference by nonoverlapping 95% condence intervals.

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DISCUSSION

Three primary objectives were pro-posed for the 2011 ACGME Common Program Requirements: improved pa-tient safety, quality of resident educa-tion, and resident quality of life.11

According to pediatric PDs in this study, patient safety is unchanged and edu-cation and quality of life are worse for residents. A similar study of pediatric residents supports these results with concordant responses; the majority of residents reported no change in pa-tient safety, inferior education, and worsened quality of life for senior residents.27The results from pediatric

PDs differed from those in general surgery and internal medicine in sev-eral areas, particularly regarding worsened education and resident pre-paredness for more senior roles. More strict regulation of duty hours is intended to improve quality of life for residents and patient safety, but con-ditions for education have reportedly worsened in pediatrics. Interns, now allowed to work a maximum of 16 consecutive hours, may admit and see

fewer patients through their course of illness and experience less continuity in each patient’s hospital course. Pe-diatric patients often have significant changes over a 24-hour period, so residents working shifts may not see the evolution of disease processes as they admit patients and sign them out to a new team shortly after admission. Under the new regulations, patients may have 2 or more completely sepa-rate teams of doctors caring for them in a 24-hour period, diminishing either team’s ability to follow patients’ prog-ress. Additionally, this may affect the feeling of accountability or “ owner-ship” of a patient and a care plan. Residents may think that they can leave tasks to the day team or night team also caring for the patient, which compromises communication with families, timeliness of appropriate treatment, and the development of critical skills in professionalism and “responsiveness to patient needs that supersedes self-interest.”10 In

pediat-rics, unlike surgical specialties, su-pervisory roles are often assigned to

PGY2 residents, necessitating a more rapid transition from intern to senior resident. Fewer experiences following the entire course of illness and communicat-ing with families as the primary provider may compromise residents’ability to make this transition smoothly. Early second-year residents may have a steeper learning curve than before the regulations while also adjusting to working longer shifts. Such negative changes in both education and continuity of care were endorsed by most pediatric PDs in this survey.

Another factor that may contribute to the sense of declining resident educa-tion is the amount of time spent on night shifts. Traditionally, didactic teaching conferences occur during daytime hours. After implementation of the 2011 standards, many residency programs have moved to a night float system in which residents may attend fewer daytime educational conferences. Res-idents may have weeks or months of nights with fewer direct mentorship and formal educational experiences. In some cases there has been a substi-tution of more passive computer-based

Worse Unchanged Better

Percentage of Respondents (95% Confidence Interval)

Patient safety 26.8% (19.8–33.9) 68.5%a(61.0–75.9) 4.7% (1.3–8.1)

Quality of patient care 40.5% (32.7–48.4) 52.7% (44.7–60.7) 6.8% (2.8–10.8)

Resident education 74.7%a(67.7–81.6) 19.3% (13.0–25.6) 6.0% (2.2–9.8)

Resident board and in-service scores 23.8% (17.0–30.6) 72.1%a(65.0–79.3) 4.1% (0.9–7.2)

Resident quality of life 40.0% (32.2–47.8) 30.0% (22.7–37.3) 30.0% (22.7–37.3)

Resident fatigue 22.0% (15.4–28.6) 56.0%a

(48.1–63.9) 22.0% (15.4–28.6)

Resident preparation for more senior roles 79.9%a

(73.5–86.3) 18.8% (12.6–25.0) 1.3% (0.0–3.2)

Education versus service balance 33.8% (26.2–41.3) 53.6%a

(45.7–61.6) 12.6% (7.3–17.9)

Resident ownership of patients 76.8%a

(70.1–83.6) 17.9% (11.8–24.0) 5.3% (1.7–8.9)

Continuity of care 78.8%a

(72.3–85.3) 13.2% (7.8–18.7) 7.9% (3.6–12.3)

Decreased Unchanged Increased

Number of patients seen, operative cases 46.0% (38.1–53.9) 48.7% (40.7–56.6) 5.3% (1.7–8.9)

Supervision of residents 2.6% (0.1–5.2) 65.6%a

(58.0–73.1) 31.8% (24.4–39.2)

Frequency of handoffs and signouts 3.3% (0.5–6.2) 9.9% (5.2–14.7) 86.8%a

(81.3–92.2)

PD workload 0.0% (0.0–0.0) 34.4% (26.9–42.0) 65.6%a

(58.0–73.1) Physician extender (nurse practitioner, physician assistant)

coverage

0.0% (0.0–0.0) 37.3% (29.6–45.0) 62.7%a

(55.0–70.4)

Disagree Neutral Agree

There should be fewer duty hour regulations 11.3% (6.3–16.4) 17.3% (11.3–23.4) 71.3% (64.1–78.5)

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curriculum for traditional experiential learning. Residency programs will need to track resident competency as current PGY1 residents take on supervisory duties and face their initial experiences of working 24 consecutive hours. Less preparation for senior-level roles may affect both patient care and the role of the attending, who may have to provide more guidance and become more “hands on”than in previous years.28

Regarding patient care, the majority of PDs reported that quality and safety have not improved as a result of 2011 ACGME regulations. In fact, many more program directors reported that safety (26.9% vs. 4.7%) and quality of care (40.5% vs 6.7%) are worse after the 2011 duty hour regulations were adopted. Although this study did not measure safety outcomes, there are several po-tential reasons for the perception of a decline in patient care. First, the in-crease in shift work caused by limited consecutive duty hours leads to frag-mentation of care, with more frequent handoffs and decreased continuity. Increasing the number of transfers between providers can create com-munication errors or omissions, which may lead to adverse outcomes.29

Sec-ond, most PDs thought supervision was unchanged. Although supervision has been a concern raised in discus-sing work hour limitations for resi-dents, it is possible that the level of supervision was already consistent with the new 2011 requirements be-fore their formal statement by ACGME. Finally, although fatigue mitigation was theorized to improve safety, PDs also reported that residents are generally not getting more rest. In

fact, pediatric PDs were nearly 5 times more likely to report worsened fatigue than surgery and internal medicine PDs. Ultimately, none of the Common Program Requirement changes are perceived to have improved the quality and safety of patient care.

A unique finding in this survey is a surprisingly low rate of resident com-pliance with current duty hour rules, which is supported by data from resi-dent surveys.26,27 Although PDs

repor-ted that residents are“mostly”compliant, this does not meet a strict definition of the duty hour rules established by the ACGME, which are core requirements in all programs and a “must,” not a “should.”30If noncompliance is

consid-ered any violation of duty hours, then more than half of residents are reportedly non-compliant. The reasons for noncompliance must be studied to determine whether and where future changes in residency train-ing rules should be made.

Although many surveys are limited by low responserates and small sample sizes, the data from this study represent most PDs from ACGME-accredited pediatric pro-grams. Given the anonymous nature of the survey, social desirability bias is also limited.31Finally, the simple nature of the

survey, with positive, neutral, and negative responses, decreases interpretation or leading of responses, which can be a problem in survey research.

The results demonstrate an interesting paradox in PDs’attitudes: Despite many negative reported perceptions, more than twice as many PDs reported ap-proval than disapap-proval of the new Common Program Requirements (49.0% vs 21.1%). This paradox may be

explained by the strongly positive perceptions of the individual compo-nents of the regulations, with 80% approval of nearly all areas measured except for shift length restrictions. At the same time, nearly three-quarters of the sample (71.3%) stated that there should be fewer duty hour reg-ulations. Therefore, it seems that although PDs agree with the principle of regu-lating duty hours, they do not neces-sarily think that the results of such regulation have been beneficial in practice.

CONCLUSIONS

This is the first published survey of pediatric PDs regarding 2011 ACGME Common Program Requirements. Al-though many PDs approve of the Com-mon Program Requirements, they think resident education, quality of life, and continuity of patient care have wors-ened, with no improvements in nu-merous areas including fatigue, patient safety, and supervision. This post-implementation study identifies a need to better study the effects of the 2011 requirements on pediatric training and the safety of children under the care of residents.

ACKNOWLEDGMENTS

The composite data (internal medicine, general surgery, pediatric PDs) from this research were published as a Per-spective Article in the New England Journal of Medicinein February 2013,24

and the pediatric PD data were pre-sented as a poster at the 2013 Associa-tion of Pediatric Program Directors meeting in Nashville, TN.32

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DOI: 10.1542/peds.2013-1045 originally published online October 7, 2013;

2013;132;819

Pediatrics

Pallant

Brian C. Drolet, Sarah B. Whittle, Mamoona T. Khokhar, Staci A. Fischer and Adam

Program Directors

Approval and Perceived Impact of Duty Hour Regulations: Survey of Pediatric

Services

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DOI: 10.1542/peds.2013-1045 originally published online October 7, 2013;

2013;132;819

Pediatrics

Pallant

Brian C. Drolet, Sarah B. Whittle, Mamoona T. Khokhar, Staci A. Fischer and Adam

http://pediatrics.aappublications.org/content/132/5/819

located on the World Wide Web at:

The online version of this article, along with updated information and services, is

by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

Figure

TABLE 2 PD Approval of Components of the 2011 Common Program Requirements (Question:“Regarding the ACGME Common Program Requirements, please indicate your level ofapproval.”)
TABLE 2 PD Approval of Components of the 2011 Common Program Requirements Question Regarding the ACGME Common Program Requirements please indicate your level ofapproval . View in document p.3
TABLE 1 Demographics of Respondents,N (% of sample)
TABLE 1 Demographics of Respondents N of sample . View in document p.3
TABLE 3 PD Perception of Changes Resulting From Implementation of the 2011 Common Program Requirements (Question: “How have the followingbeen impacted by the new ACGME regulations?”)
TABLE 3 PD Perception of Changes Resulting From Implementation of the 2011 Common Program Requirements Question How have the followingbeen impacted by the new ACGME regulations . View in document p.4