How Surgical Faculty and Residents Assess the First Year of the ACGME Duty-Hour Restrictions Results of a Multi-Institutional Study

James Coverdill, William Finlay University of Georgia, Athens, GA John D. Mellinger, Gina L. Adrales Medical College of Georgia, Augusta, GA Kimberly D. Anderson University of Texas, Houston, TX Bruce W. Bonnell Michigan State University, Grand Rapids, MI Joseph B. Cofer University of Tennessee, Chattanooga, TN Douglas Dorner Iowa Health, Des Moines, IA Carl Haisch East Carolina University, Greenville, NC Kristi L. Harold Mayo Clinic, Scottsdale, AZ Paula Termuhlen Wright State University, Dayton, OH Alexandra L. B. Webb, Emory University, Atlanta, GA Acknowledgements: Mary Anne Park, Medical College of Georgia; Jim Bason, University of Georgia, Daniel Hall, University of Georgia

“80-hour/week” restriction 1987 NY ad hoc Advisory committee established to evaluate GME 1984 Libby Zion wrongful death suit filed 1988-99 Baldwin et al survey: average surgical intern hours 102/wk 2003 ACGME “80-hour/week” restriction 1995 3 doctors found negligent in Libby Zion case 1989 NY “405” regulations 1999 NIM report 44-98K deaths/yr due to medical error

The Doctor Is Out Some fourteen years after the Libby Zion case changed the way hospitals are run—and medicine is taught—it’s clear that residents are getting more sleep. But many doctors say that patients—and even the residents—are being shortchanged. New York metro.com November 3, 2003

Objective Examine the views of residents and faculty regarding the duty-hour restrictions (DHR) within a multi-institutional study Determine whether faculty and resident assessments diverge Explore factors that influence the differences in views among faculty and residents

Methods 9 general surgery residencies in 8 states 5 traditional academic programs 4 non-academic programs 2 community programs 2 “hybrid” programs Surgical residents, PGY-2 or greater Faculty beyond their first year of practice IRB approval at the coordinating centers (UGA, MCG) and the local boards Hybrid programs-non-university programs with strong research emphasis and dedicated full-time faculty

Methods Questionnaire surveys were distributed in June-August 2004 Items critiqued by director of Survey Research Center, University of Georgia 4-point likert responses (1=strongly agree, 4=strongly disagree) 37-item resident survey 39-item faculty survey 21 items common to both surveys were analyzed for comparison Mean differences were examined with two-tailed t-tests (p<.05)

Results Response rates Respondents predominantly male Program type 63% for faculty (N=146) 58% for residents (N=113) Respondents predominantly male 85.6% of faculty 70.8% of residents Program type Academic 49% residents, 47% faculty respondents Non-academic 51% residents, 53% faculty

Residency Program and Training * Table 2- significant differences between residents and faculty, 16/21 items showed large and significant differences between resident and faculty responses *Mean responses significantly different, p<.05

Patient Care * *Mean responses significantly different, p<.05 Table 2- significant differences between residents and faculty *Mean responses significantly different, p<.05

Quality of Life/Overall Assessment * Table 2- significant differences between residents and faculty *Mean responses significantly different, p<.05

Results Few differences were found among faculty responder groups AGE Deviations from resident responses were significantly different on only 3 of 21 items. Older faculty were more aligned with residents than younger faculty CLINICAL DUTIES 4 of 21 items significantly different. No consistent differences between clinical faculty and research faculty views GENDER No significant difference among 21 items No differences based on program type There were significant differences based on resident gender. Mean responses on 11 of 21 items were significantly different. Tables 3,4-Deviations from resident responses were statistically different between younger and older faculty on only three items Decrease in faculty standards, increased number of errors, and adherence to DHR is good for patient care

Gender Differences Resident Program and Training * Table 5 *Mean responses between male and female residents significantly different, p<.05

Gender Differences Patient Care * *Mean responses between male and female residents significantly different, p<.05

Gender Differences Overall Assessment of DHR * *Mean responses between male and female residents significantly different, p<.05

Conclusions Apparent tension between support of DHR and concern about their consequences Majority of residents and faculty believe that lack of familiarity, not fatigue, are the major cause of medical error Significant divergence between residents and faculty regarding DHR effects on training and patient care; Residents view DHR more favorably

Conclusions Faculty age, faculty gender, program type did not systematically factor into the differences between faculty and resident views Resident gender was a strong and consistent factor in the faculty-resident gap This may lead to discord in residency programs and create tension between female residents and faculty

Conclusions Limitations Relies on subjective assessments Subgroup sizes fairly small (Faculty gender, program type) Could not evaluate reliably differences due to level of resident training Gender issues in regard to DHR should be an area of more intensive investigation