1. Use of a PDA to Monitor Surgery Student Work and Sleep Hours Susan Steinemann, MD, FACS Jill Omori, MD University of Hawaii School of Medicine

2. TOP 10 SIGNS YOU’VE BEEN IN SURGICAL EDUCATION TOO LONG…. 10. You never argue…..you exchange summative and formative comments 9. Your girlfriend gets a Needs Assessment instead of foreplay 8. Your toddler was potty trained by cognitive task analysis 7. Your statistics may be rusty, but you know dozens of ways to achieve a sum of “80”

3. Medical Student Work Hours LCME Guidelines, Feb 2004 Duty hours should be set Not longer than residents 26% of medical schools had written work hours policy in 2003-4 LCME Part II survey Monitored? Enforced?

4. U Hawaii Work Hours Policy Developed Fall 2003 Guidelines specify Average <80 hours/wk Leave early post-call Eliminate non- educational activities 1 day/week off

5. Faculty and residents were advised of the work hours policy Students were encouraged to report transgressions Students rarely reported noncompliance (….. to US)

6. Pilot study using PDA to record work hours data September 2004 – March 2005 7 consecutive days in mid-point of clerkship HanDBase software Students logged real- time work and sleep hours

7. Work hours log Activities performed during work hours categorized and logged in 15-minute increments Noted if they “would have left” if their presence was not expected or required All sleep hours (home & work) logged

8. Logs reviewed Identify transgressions from work hours policy Correlate logged work hours with Estimated work hours Sleep hours NBME subject exam score Clinical evaluation by faculty

9. All students successfully collected work hours data Better compliance than with patient logs 3 of 35 students failed to log sleep hours at home Only positive comments about PDA log system

10. Transgressions from Work Hour Policy 24 students (69%) deviated from the written work hour policy 12 students worked >80 hours 17 students worked late post-call 49% of students reported non- educational activities No two students reported the same activity on the same day

11. Estimated vs. logged work hours Mean work hours = 73 (range 41-99) Estimated work hours ranged from 60- 110 Estimated hours did not correlate well with logged hours (r=0.19) 63% of students overestimated work hours Median overestimated time was 19 hours/week

12. Sleep Average sleep over 7 days ranged from 3.9-8.25 hours / 24-hour period (median 5.5 hrs) No significant correlation with work hours

13. NBME Subject Exam Scores No significant correlation with work hours Trend toward positive correlation with more sleep (r=0.25)

14. NBME Scores: Effects of more work and less sleep HOURS WORKED / HOURS SLEPT nMEAN NBME EXAM SCORE NATIONAL PERCENTILE RANK  80 work AND <5.5 sleep 766.6*40 th % <80 and/or  5.5 2372.7*70 th % *p<.05 by t-test

15. Clinical Evaluations Directly Correlated with Work Hours HOURS WORKED HONORS NOT HONORS >75 8 3 <75 3 9 *P<.05 Fisher’s Exact Test

16. Conclusions Students’ estimated work hours may be inaccurate PDA may be a useful tool to monitor work hours Sleep deprivation common, may not improve with work hour limitations

17. Students who spend more time at the hospital…. And who get less sleep (<5.5 hours/day) have lower scores on standardized written examinations of knowledge Receive higher ratings of their knowledge and clinical skills by faculty surgeons

18. Get it as it happens Be aware.. the pitfalls of overextension