The 80-hour Work Week for Residents: Views from Obstetric and Gynecology Program Directors

Abstract

Introduction

In July 2003 the ACGME (Accreditation Council for Graduate Medical Education) implemented a new nationwide work hour policy for all residents in medical programs. Limitations on residency duty hours developed after the unexpected death of a patient, Libby Zion, in 1984 in a New York City hospital. Her father thought that her death was due to the long hours the residents worked when his daughter came under their care. This tragedy served as the catalyst for a new public awareness and subsequent change in philosophy regarding resident duty hours. It was felt that the long work hours result in fatigue and this could negatively impact patient care. Other public consumer advocates and medical professionals expressed concern of excessive work hours for medical residents and its effect on quality of care and safety. The new guidelines mandate an 80 hour work hour restriction for all residency programs. This resulted immediately in two effects. First, it sought to standardize the number of hours worked in medical residencies over different specialties but also across different programs throughout the country. Second, it restricted the work hours in the hospital to no more than 80 hours on average per week. This limitation of work hours has resulted in less time spent in both the clinical and surgical setting with overall less patient contact,¹ including reducing continuity of patient care.^2-4 To accommodate for these new changes, programs have had to adjust the overall module for patient care^5,6 as well as develop new innovative methods.^7,8

There has been some literature in the field of psychiatry examining the educational impact of decreased duty hours¹ which showed a negative effect. In addition a publication from Jagannathan J et al voiced some concerns from neurosurgery program directors regarding decreased educational experience.⁹ Winslow ER et al looked at four surgical subspecialty faculty members and their perception on the resident education, which they thought had deteriorated.¹⁰ Although obstetrics and gynecology is considered as a surgical subspecialty, it faces unique challenges of meeting the educations needs of its residents just by virtue of the nature of the job. We were unable to find any literature, reporting the views of Program Directors in Obstetrics and Gynecology (OBGYN) on these new hour requirements and what impact they think it has had on their residents’ educational experience. Espey et al. surveyed a number of general OBGYN educators at a national education meeting in 2005 and noted that 63% reported that overall resident education is worse and that resident surgical volume had diminished.¹¹ As far as the residents’ perspective is concerned, there has been an article published looking at their views in Internal Medicine.¹² In this article the residents felt that their quality of life had improved although there was no mention regarding their educational experience. There is no published data regarding obstetrics and gynecology resident views in relation to the restricted duty hours.

Our objective in this study was to assess residency program directors perceptions of the new mandate specifically in regards to the six ACGME core competencies as well as their perception about resident performance on the national standardized Council on Resident Education in Obstetrics and Gynecology (CREOG) annual test. CREOG is a branch of the national society ACOG (American College of Obstetrics and Gynecology). Each year every resident in Obstetrics and Gynecology sits for a standardized test known as the CREOG's. This test is written and administered by CREOG. This is an important way in which programs can assess how their residents are doing relative to those in the rest of the country. In addition, it gives the residents a chance to see where they stand in relation to others in the same year of training. It is a good indicator for medical knowledge and the application of this knowledge in clinical scenarios.

Methods

Authors sent an email survey utilizing Survey Monkey software to available email addresses of all program directors of OBGYN programs in the United States of America from May 6, 2011 through August 6, 2011. The email list was obtained from the American College of Obstetrics and Gynecology (ACOG) website under the Council for Resident Education in Obstetrics and Gynecology (CREOG) available to members only. The Canadian program directors were not included in the list. All five physician investigators are members and fellows of the College and had access to the list. Authors mailed the survey with a letterhead cover page introducing the research and clarifying the voluntary nature of the questionnaire. A link was provided to the survey with multiple-choice questions. Estimated survey completion time was 10 minutes. The completed survey was then accessible to the investigators via a unique login password account with Survey Monkey created specifically for this project. The survey was open for three months from the initial email request. Authors sent a reminder email two weeks prior to the survey closure. Responses were cross tabulated by the following characteristics that were presented as categorical variables: program location, number of years in practice, number of years as program director, specialty, gender, fellowships offered, type of program, and number or residents per year. These data were then reviewed and analyzed by a statistician using either Fisher's exact test or Pearsons. All p values were two-tailed, and p<0.05 was considered statistically significant.

Results

The survey was sent to 180 email addresses available on the website. A total of 50 (28%) program directors of OBGYN programs across the U.S. completed the survey, which is a typical response rate for online surveys. Over half were from the East Coast. Slightly more (56%: 28/50) were university affiliated, than with a community program (44%:22/50) and most, 88% (44/50) were from small to medium size programs, admitting 8 or fewer residents per year. The majority (70%) of respondents had over 15 years in practice. The gender distribution consisted of 70% male program directors and 30% female program directors. Survey respondent characteristics are shown in Table 1. These characteristics were then tabulated against the educational endeavors questions specifically targeted at the six ACGME core competencies and the standardized CREOG test.

As a result of the 80 hour work restriction, 72% of program directors acknowledged that their program altered the curriculum for residents. Respondent frequencies are reported in Tables 2 and ​and3.3. Of the significant values (p<0.05), four of these were related to gender differences of program directors (see Figure 1) and one of them was based on the program size. Overall, only 28% (14/50) responded that the program had improved, with significantly less men (5/14; 16.1%) than women (47.4%: 9/19; p<0.0169) directors reporting this.

Open in a separate window

Figure 1

Areas with significant difference between male and female program director responses.

Overall = Residency program overall; CREOG = CREOG scores; Pt Care = Patient Care; Comm = Interpersonal and communication skills; M = Male; F = Female

Regarding whether the 80-hour work week restriction has improved CREOG scores, 0% (0/31) of male program directors felt that it had improved scores compared to 15.8% (3/19); p=0.022 of female program directors. Of the six ACGME core competencies measured with this survey, two showed significant differences between male and female directors. Regarding patient care, only 3.2% of male directors (1/22) and 26.3% of female directors (5/19); reported improvement (0.0147). On the issue of what the directors thought about the effect the 80 hour work restriction has had on interpersonal and communication skills, 9.7% (3/31) of male program directors thought there was improvement vs. 36.8% (7/19) of female program directors (p=0.0198).

When size of the programs was tabulated against the six ACGME core competencies, the 80-hour work week had a significant effect only on the systems based practice with the following results: 100% (6/6) of program directors from large, 90.9% (20/22) from medium and 72.7% (16/22) from small programs felt that there was no improvement in the systems based practice learning since implementation of the 80 hour work week (p=0.0452). For a complete list of survey responses by male, female and overall, please see Tables 2 and ​and3.3. In addition we found no association between gender and experience (defined as <5, 5-10 and >10 years; Cochran-Armitage Exact Trend Test p= 0.3174).

Discussion

Although the response rate for our survey was only 28%, it reflects the typical response rate for most online surveys. Our response rate may have also been impacted by the limitation of using the addresses provided online which may have not been updated or corrected. Nonetheless, we were still able to demonstrate significant differences between the opinions based mostly on gender and program size. We think that the results are important to share as it gives us some insight into our profession.

Based on our study, most male and female program directors thought that the new rules had caused a decline in the quality of the program, had made no change to the standardized national yearly test score (CREOG) administered by ACOG and did not improve communication skills or patient care. This replicates a similar finding in the study by Jagannathan J et al looking at standardized testing scores in neurosurgical residents. In that study, he showed that not only was there no improvement but, in fact, there was an actual decrease in their test scores after the new duty hour restrictions.⁹

The programs were arbitrarily divided into small programs based on having less than 5 residents per year, to medium size programs having 5-8 residents in the program and large programs as having more than 8 residents per year. When this was tabulated against the six ACGME core competencies, the 80-hour work week had a significant effect only on the systems based practice with the following results: 81% (18/22) of program directors from large programs felt that there was no change in the systems based practice learning since implementation of the 80 hour work week (p=0.0425). Overall 68% (34/50) of program directors regardless of program size felt that there was no improvement in the systems based competency since implementation of the 80 hour work week.

During the analysis of this study we came across an interesting finding. When we compared responses from program directors that had trained both before and after the era of the new work mandates (n= 35) as well as those that trained only after the mandate (n=15) we found an interesting trend. Although the results did not meet statistical significance we found that, program directors that trained before the era of the 80 hours were more likely to feel a decline in the all the six ACGME core competencies. This is important, as this is where the heart of the study is, since these respondents have a perspective that only comes from having experienced both eras. Those program directors that trained after the 80 hour work week have no comparison of the two periods and therefore may not have an appropriate perspective to compare their experiences.

There were limitations to our study. Our sample size is small. Perhaps we could increase our numbers by extending out the survey to other surgical programs across the country which may help us capture better the educational experience with reduced work hours especially in relation to some of the core competencies which did not reach statistical significance. In addition, one may argue that the differences in gender opinion may simply reflect that more newer female directors came on after the change. It could be that “new” male and “new” female” directors have no statistical difference and the differences shown are simply a reflection that more females have assumed the position more proportionately than in the past. Older male and female directors who lived through the change might have a similar opinion. However a closer analysis of our data did not indicate that the males had served as residency program directors any longer than the females as there was no association between gender and experience when tested with the Cochran-Armitage Exact Trend Test (p= 0.3174). The difference in gender view may however be explained by the fact that more men were program directors (31) than women (19).

Another limitation to our study relates to the fact that the survey asked directors whether or not they thought the CREOG scores had improved rather than have them present empirical CREOG data. Although it would have been better to get objective rather than perceptive data, we were limited by the way in which the study was conducted. Being that it was a survey and that getting objective empirical data would be time consuming and hence lead to incomplete answers we opted to ask the question as a perception rather than a fact. It would indeed be interesting if we could follow up on this study finding with actual objective measures including the question regarding actual CREOG scores. The limitation falls in that these respondents are recollecting information which may be influenced by their own biases toward the 80 hour work restriction, or their ability to remember accurately.

Conclusion

This is the first study we know of that assesses the views of educators who are not only intimately involved in implementing the ACGME 80 hour work week but also in educating the next generation of health professionals. They have implemented new rules and have experienced first-hand the effects at the grassroots level. Although our study looks at the impact of the duty hour restriction in a subjective manner, it is still important to acknowledge the views of program directors. If they feel there is no benefit or worsening of our educational process with these new rules then, it invites research on more objective measurements of evaluating the impact of this mandate. Our study demonstrates that at least subjectively the program directors’ perceptions are that patient care is no safer nor communications skills any better and perceived objective measurements of medical knowledge have not improved with the implementation of the work hour restriction on trainees. In addition, they also did not think that the overall quality of the program had improved with these changes.

As educators it is our goal to produce competent physicians. As we go through numerous changes to our profession we should invite evaluations to the method and model in which we train residents of the future. We hope that this survey study stimulates more research into objective endpoints of education so that society and medical education in general may benefit from changing learning environments. The availability of such research findings can help programs to modify their curriculum to enhance education. Lawmakers and national bodies can also use the information to understand the impact of non-evidence based mandates on the training of physicians and make appropriate recommendations using evidence-based information in the same way that physicians are expected to implement in the medical arena. It is wrong for us to assume that the learning model that we used prior to the 80 hour work week can be just as effective or even sustainable in the face of the changing work and learning environments. Work hours may have to be modified based on specialties as surgical and non surgical fields have different demands on learning experiences as well as overall development of skills.²³ Finally, one must not forget too that the realities of actual clinical practice hours after residency are much different and we must not rush to adopt practices that may not be beneficial or realistically translated into actual practice after completion of training.²⁴

Acknowledgements

Contributor Information

Jabin Janoo, Department of Obstetrics & Gynecology, West Virginia University.

Mahreen Hashmi, Department of Obstetrics & Gynecology, West Virginia University.

Dara J. Seybold, Charleston Area Medical Center Health Education & Research Institute.

Robert Shapiro, Department of Obstetrics & Gynecology, West Virginia University.

Byron C. Calhoun, Department of Obstetrics & Gynecology, West Virginia University, Charleston Division.

Stephen H. Bush, Department of Obstetrics & Gynecology, West Virginia University Charleston Division.

References