2011년 ACGME 레지던트 근무시간 규정에 대한 내과 전공의들의 인식

A qualitative assessment of internal medicine resident perceptions of graduate medical education following implementation of the 2011 ACGME duty hour standards

Christa R Nevin1*, Andrea Cherrington1, Brita Roy2, David D Daly3, J Martin Rodriguez1, Mukesh Patel4,

Erin D Snyder1, Angelo L Gaffo1, Joseph Barney1 and James H Willig1*

Background

2003년 7월 ACGME는 레지던트에 대한 근무시간의 축소를 강제(mandated)하였다. 이 가이드라인에 따르면 모든 연차의 레지던트는 30시간 이상 연속근무를 할 수 없으며, 주당 80시간 이상 근무할 수 없다. 이러한 규제는 레지던트의 근무피로에 의한 실수를 줄이고, 레지던트의 삶의 질을 향상시키기 위한 것이었다. 그러나 2003년의 이러한 ACGME 근무시간 규제에 대해서 충분히 이해하지 못한 경우가 많아, 이것이 미치는 영향(impact)에 대한 연구 결과도 다양하다.

In July 2003, the Accreditation Council for Graduate Medical Education (ACGME) mandated a reduction in duty hours for medical residents in accredited programs. These guidelines limited residents of all levels to no more than 30-hours of continuous work and to an 80-hour work week. This was done primarily to reduce the number of errors attributed to resident fatigue and to improve resident quality of life [1]. The impact of the 2003 ACGME duty hour standards on graduate medical education is not fully understood, and study results thus far have been mixed. While some studies indicate that few, if any, educational outcomes have been impacted by the decrease in duty hours, others indicate that residents have fewer clinical experiences, lower scores on standardized tests, fewer publications and less participation in academic medicine, and decreases in attending physician teaching and other educational opportunities [2-17].

추가적으로, IOM의 권고에 따라서 ACGME는 2011년 7월부터 레지던트 근무시간에 대한 규제를 수정하여 졸업후 첫 해(PGY1)의 레지던트는 연속16시간, 그 이상 레벨의 레지던트는 연속28시간 이상 근무할 수 없다. 2011년의 ACGME 근무시간 기준이 레지던트 교육에 미치는 영향에 대해서는 알려진 바가 별로 없다. 2003년 가이드라인에 따른 영향에 대한 논란, 그리고 2011년에 더욱 강화된 가이드라인을 고려하면 레지던트 교육에 어떠한 영향이 있었는지 연구할 필요가 있다.

Additionally, in response to recommendations by the Institute of Medicine (IOM), the ACGME further revised duty hour guidelines in July 2011 that limited continuous work hours for PGY-1 medical residents to no more than 16-hours and upper level residents to 28-hours [1]. Little is known about the impact of the 2011 ACGME duty hour standards on resident education. The controversy surrounding educational outcomes from the 2003 guidelines, in addition to further restrictions in the 2011 guidelines, merits an in-depth understanding of how work-hour changes have specifically impacted resident learning. In this study, we assess perceptions among internal medicine residents regarding the impact of the 2011 ACGME duty hour standards on graduate medical education.

Methods

Setting

The University of Alabama at Birmingham (UAB) Internal Medicine Residency program is a large training program affiliated with an academic medical center in Birmingham, Alabama. During the 2011–2012 academic year, 128 total residents were completing their internal medicine training at UAB. Internal medicine residents at UAB completed their inpatient rotations at three large medical centers: UAB Hospital, a quarternary care academic center, the Birmingham Veteran’s Administration Hospital, and Cooper Green Mercy Hospital, a county hospital. Inpatient rotations occured on general internal medicine and subspecialty wards, including pulmonology, gastroenterology, nephrology, hematology/oncology, cardiology, and intensive care.

2011년 이전의 General IM ward team의 구성

Prior to the 2011 duty hour restrictions, general internal medicine ward teams were composed of 1 attending physician, 1 senior resident (PGY 2–3), 2 interns (PGY-1), and 1–2 third or fourth year medical student. Senior residents were responsible for new admissions every fourth or fifth day, completing 12-hour shifts on weekdays and 30-hour shifts on weekends. A night float senior resident worked 5 consecutive weeknights (Sunday-Thursday) with primary responsibility for new admissions from 7 pm-7 am. Interns completed 30-hour shifts every fourth to eighth night and a 30-hour shift on weekends. A separate night float intern took responsibility for cross-coverage from 7 pm-7 am, Sunday-Thursday.

After the implementation of 2011 AGME duty hour restrictions, the composition of general medicine ward teams and night float coverage did not change. The schedule for senior residents remained the same, albeit limiting overnight shifts to 28 hours. Interns alternated day (7 am-7 pm) and night shifts (7 pm-7 am) for new admissions every fourth or fifth day.

Study design

We designed a qualitative study to assess perceptions of internal medicine residents regarding the 2011 ACGME duty hours. We conducted a series of eight focus groups with internal medicine residents at UAB between 06/2012-07/2012. The Institutional Review Board at UAB approved this study and all participants provided verbal consent for participation.

Study recruitment

Investigators invited all postgraduate year one (PGY-1), PGY-2, and PGY-3 internal medicine residents to participate in focus group discussions via recruitment emails and verbal announcements at program conferences. Groups were divided by residency year and no more than eight residents were allowed to participate per group. Participants received a small financial incentive ($35 gift card) for participating.

Focus groups

Discussions were guided by a series of open-ended questions outlined in a moderator’s (CRN) guide including, “How do you feel the 2011 ACGME work hour restrictions have impacted your graduate medical education?” (List 1). In addition, focus group participants were asked to complete a brief survey to collect basic demographic information and future medical practice plans.

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List 1: Moderator questions used to guide focus group discussions regarding the impact of the 2011 ACGME duty hour standards on graduate medical education.

1. In what ways and/or what methods do the faculty at UAB employ to teach you while rounding in the hospital wards (e.g. bedside teaching, chalk talks)?

a. [PROBE] Which of these methods do you feel is most useful?

b. [PROBE] Which of these methods do you feel is least useful?

2. How do you feel that graduate medical education has changed following implementation of the 2011 ACGME work-hour restrictions?

a. [PROBE] In what ways are these changes positive?

b. [PROBE] In what ways are these changes negative?

3. How do you feel graduate medical education can be improved?

a. [PROBE] Using traditional teaching methods?

b. [PROBE] Using novel teaching methods?

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Data analysis

Focus groups were audio recorded and transcribed verbatim. Common themes were then coded using a combined deductive and inductive approach until convergence of themes was reached. The transcript of the initial focus group was analyzed first by the principal investigator (CRN) and used to generate preliminary themes that were used as a guide for analysis of remaining transcripts. The transcript was then analyzed by two additional reviewers (JHW and AC) who confirmed preliminary themes. Transcripts from all subsequent focus groups were coded by two independent reviewers (CRN and JHW or AC) and preliminary themes were modified and emerging themes identified and included. Each participant’s response could potentially contribute to more than one identified theme and emerging themes were discussed among the research team prior to inclusion.

Results

A total of 34 internal medicine residents at UAB participated in eight focus group discussions. The majority of participants (65%) was male and planned to go into subspecialty practice (73%, n = 25). 16 (47%) were PGY-1 residents, 12 (35%) were PGY-2 residents, and six (18%) were PGY-3 residents during the 2011–2012 academic year. Half of participants (50%, n = 73) reported regular study for in-service and board examinations and most (68%, n = 23) stated they spent 0–5 hours per week dedicated solely to preparation for these examinations (Table 1).

교육 감소

Decreased teaching

레지던트들은 근무시간 제한으로 인해서 교육이 종종 임상업무 뒤로 밀린다고 응답하였다. 근무시간을 제한하더라도 해야할 일이 줄지 않는다고 하였다.

Residents reported that since implementation of the 2011 work-hour restrictions, they felt education was often deferred in order to complete basic patient-care tasks in a timely manner explaining that although the number of work-hours allowed had declined following the ACGME-mandated restrictions, the amount of work to be completed did not decrease.

경험 중심 학습 감소

Decreased experiential learning

PGY1 레지던트가 충분한 임상경험을 하고 있지 못하며, 임상추론 능력과 술기 능력에 부정적 영향을 준다고 응답하였다.

All residents voiced concern that PGY-1 residents were not receiving an adequate amount of clinical experience and that clinical reasoning and procedural skills were being negatively impacted. 

교대근무정신

Shift-work mentality

모든 연차의 전공의들은 2011 ACGME 근무시간 제한 규정으로 인해서 '교대근무정신'이 생겨서 PGY1 레지던트들 사이에서 주도성(ownership)이 줄었다고 응답하였다.

All resident classes, including the PGY-1 s, reported that the 2011 ACGME duty hour standards had fostered an environment of “shift-work mentality” and decreased ownership of patients among PGY-1 residents

레지던트 연차간 갈등

Tension between residency classes

2011년의 ACGME 근무시간 규제가 도입된 이후에 팀워크(팀 다이나믹스)가 저하되었고, 연차간 갈등(resentment)이 생기고 있다고 응답하였다. 일부 높은 연차 레지던트들은 이러한 좌절감이 PGY1 레지던트들을 가르치는데 안 좋은 영향을 주고 있다고 했다.

Resentment across the classes and a less positive team dynamic was reported after the implementation of the 2011 ACGME work hour guidelines. Some upper level residents report that these frustrations have impacted their ability to effectively teach PGY-1 residents.

이득 및 기회

Benefits and opportunities

레지던트들의 우려에도 불구하고 2011년의 근무시간 규제는 일부 긍정적인 효과도 보이고 있다. 한 PGY1 레지던트는 휴식 시간을 잘 보냄으로써 더 학습이 잘 이뤄진다고 응답했다.

Despite concerns raised by residents regarding the impact of the 2011 ACGME work hour restrictions on graduate medical education, some positive changes following implementation of the work-hour restrictions were reported. PGY-1 residents reported feeling well-rested and, as a result, more capable of learning:

Discussion

많은 레지던트들은 교수와 윗년차들의 교육이 감소하였고, 병원에서 보내는 시간이 줄어서 직접 해보면서 임상을 배울 수 있는 기회가 줄었다고 응답하였다. 이러한 우려는 임상추론능력 뿐만 아니라 환자에게 직접 해봐야지만 향상될 수 있는 술기 능력에까지 뻗쳐 있었다. 

Our study is one of the first reports to gauge the impact of the new 2011 ACGME duty hour standards among internal medicine residents. Resident perceptions regarding the impact of the July 2011 ACGME work-hour restrictions on graduate medical education were reported to affect learning in many ways. Most residents noted a decline in teaching by both faculty and upper level residents, and were concerned with the decrease in “hands-on” clinical education due to spending fewer hours in the hospital. These concerns extended to both procedural, as well as clinical reasoning skills that they perceived could only be honed via hands-on patient care.

(...)

모든 연차의 레지던트들이 근무시간 규제에 우려를 하고 있었지만 그들의 의견은 다양했다. 가장 의견이 갈리는 부분은 윗 연차로 올라갈 준비정도(preparedness)에 대한 것이었다. 근무시간 규제에 따른 레지던트의 역할과 책임의 변화, 그리고 술기 역량에 대한 다양한 의견 차이가 팀의 응집력을 저하시켜서 팀 내에 의학 지식의 공유에까지 부정적 영향을 줄 수도 있어 보인다. 이러한 영향이 모든 연차 레지던트가 동일하게 근무시간 규제를 받으면 없어질 것인지, 아니면 계속될 것인지는 두고 볼 일이다. 

While all residency classes reported many of the same concerns regarding the impact of the work hour restrictions on graduate medical education, their opinions varied. The most notable divergence was regarding the preparedness of interns for their role as upper level residents. These diverging opinions on competency of skill set, as well as the shift in resident roles and responsibilities that have accompanied the changes in duty hour standards, have led to a reported disruption in team cohesiveness that may negatively impact the sharing of medical knowledge among these groups. Whether this impact on team dynamics will diminish as all residents are trained under the same duty hour standards, or whether it is an early indicator of a schism that will persist between residents of different training levels is yet to be seen.

2011년 ACGME 근무시간 규제 도입 이후에 긍정적인 변화도 관찰된다. 인턴의 피로가 줄었고, PGY1 레지던트가 스스로 공부할 수 있는 시간이 늘었다. 이러한 긍정적 변화는 2003년에 도입되었던 근무시간 규제에서도 동일하게 관찰되었던 것이다. 이러한 레지던트들의 삶의 질 향상이 환자안전, 임상성과(clinical outcome)까지 영향을 줄 것인지는 두고 봐야 한다. 최근 소아과 레지던트들의 수면 패턴을 비교한 것에서 2011년 근무시간 규제의 적용을 받고 있는 레지던트들이 더 스트레스를 받는 것으로 나타났다. 또한 교육도 덜 받고 있다고 느끼며, 더 짧은 시간에 일을 압축적으로 해내기 위한 스트레스도 받는 것으로 나타났다. 

Positive changes were also reported after the implementation of the 2011 ACGME duty hour standards. Both decreased intern fatigue and the increased availability of independent study time for PGY-1 residents were highlighted. Such positives were also reported in the literature following the 2003 ACGME duty hour standards [7,8,13,17,21]. Whether these improvements in resident quality of life result in enhanced patient safety and better clinical outcomes is still being determined and the impact of these changes on resident education remain underexplored. A more recent study assessing sleep patterns among pediatric residents in a control group (every fourth night, 30-hour call) versus an intervention group adhering to the 2011 guidelines suggested that despite being better rested, residents in the intervention arm were often more stressed and reported a poorer educational experience compared to their control group counterparts due to the compression of their workload into a shorter day [22]. Our residents generally reported feeling as though being more rested improved their ability to learn both inside and outside of the hospital; however, the long-term impact of fewer hours in the hospital on educational experience remains unknown. Though the impact of work hour changes on patient safety and clinical outcomes are not yet clear, questions surrounding the impact of these changes on our graduate medical education process need to be explored concomitantly, as poorly trained residents would certainly negatively impact patient outcomes.

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BMC Med Educ. 2014 Apr 22;14(1):84. [Epub ahead of print]

A qualitative assessment of internal medicine resident perceptions of graduate medical education followingimplementation of the 2011 ACGME duty hour standards.

Nevin CR, Cherrington A, Roy B, Daly DD, Rodriguez JM, Patel M, Snyder ED, Gaffo AL, Barney J, Willig JH.

Abstract

BACKGROUND:

In 2011, the Accreditation Council of Graduate Medical Education implemented updated guidelines for medical resident duty hours, further limiting continuous work hours for first-year residents. We sought to investigate the impact of these restrictions on graduate medical educationamong internal medicine residents.

METHODS:

We conducted eight focus groups with internal medicine residents at the University of Alabama at Birmingham in 06/2012-07/2012. Discussion questions included, "How do you feel the 2011 ACGME work hour restrictions have impacted your graduate medical education?" Transcripts of the focus groups were reviewed and themes identified using a deductive/inductive approach. Participants completed a survey to collect demographic information and future practice plans.

RESULTS:

Thirty-four residents participated in our focus groups. Five themes emerged: decreased teaching, decreased experiential learning, shift-work mentality, tension between residency classes, and benefits and opportunities. Residents reported that since implementation of the guidelines, teaching was often deferred to complete patient-care tasks. Residents voiced concern that PGY-1 s were not receiving adequate clinical experience and that procedural and clinical reasoning skills are being negatively impacted. PGY-1 s reported being well-rested and having increased time for independent study.

CONCLUSIONS:

Residents noted a decline in teaching and are concerned with the decrease in "hands-on" clinical education that is inevitably impacted by fewer hours in the hospital, though some benefits were also reported. Future studies are needed to further elucidate the impact of decreased resident work hours on graduate medical education.

PMID:

 

24755276

 

[PubMed - as supplied by publisher] 

PMCID:

 

PMC4012765

 

Free PMC Article