Changes to Pediatric Clerkships’ Nighttime Structure After Introduction of the 2011 ACGME Resident Duty Hour Standards Andrew Smith, MD; Adam Stevenson, MD From the Department of Pediatrics, University of Utah, Salt Lake City, Utah The authors declare that they have no conflict of interest. Address correspondence to Andrew Smith, MD, 100 N Mario Cappechi Dr, Salt Lake City, UT 84113 (e-mail: [email protected]. edu). Received for publication June 21, 2013; accepted November 23, 2013.
ABSTRACT OBJECTIVE: To report changes in pediatric clerkship nighttime clinical structures before and after implementation of the 2011 Accreditation Council for Graduate Medical Education (ACGME) resident duty hour standards. METHODS: As part of the 2011 Council on Medical Student Education in Pediatrics (COMSEP) member annual survey, we surveyed leaders of pediatric undergraduate medical education on their medical school’s current nighttime clinical structure, changes in nighttime structure between 2010 and 2011, and their school’s student duty hour standards. RESULTS: Fifty-six percent (n ¼ 83) of Liaison Committee for Medical Education (LCME)-accredited medical schools responded to the survey. Of received responses, 98% of pediatric clerkships have some form of nighttime clinical experience; 49% of clerkships have medical students stay late, 24% of clerkships utilize night shifts, and 16% use a traditional call structure.
Forty-five percent of clerkships report changing their nighttime clinical experience after implementation of the 2011 ACGME duty hour standards; 46% of clerkships that changed had previously used traditional call. Seventy-six percent of clerkships report having medical student duty hour standards at their medical school. CONCLUSIONS: The majority of pediatric clerkships in our survey include nighttime clinical experiences in their curriculum, although variability exists in the type of structure. Additionally, the new ACGME duty hour standards appear to affect clerkships directors’ choice of structure.
KEYWORDS: duty hour standards; medical student call; pediatric education; undergraduate medical education
ACADEMIC PEDIATRICS 2014;14:155–158
WHAT’S NEW
the American Council for Graduate Medical Education (ACGME) resident duty hour standards in 2003. These standards limited resident duty hours to 80 hours per week and not more than 24 hours of continuous work, with an additional 6 hours allowed for continuity of care and education.2 The ACGME duty hour standards stemmed largely from studies documenting adverse effects of sleep deprivation in residents.3 After the introduction of the 2003 ACGME duty hour standards, a 2004 survey of Liaison Committee for Medical Education (LCME)-accredited schools found that inpatient night call was less common than 10 years before. Eightysix percent of schools required pediatric night call in 1994 and 79% in 2004 (the article did not define “night call”).4 In 2011, the ACGME updated the standards and reduced postgraduate year 1 (PGY-1) duty hours to not more than 16 hours, eliminating the traditional 24-hour call schedule for PGY-1 physicians. PGY-2 and above residents could continue to remain on clinical service for 24 hours in a single period.2 There are no studies that discuss the interaction of the 2011 ACGME resident duty hour standards on medical student clerkships’ nighttime clinical structure. The present study had 3 specific aims: 1) to describe the nighttime clinical structures across pediatric clerkships, 2)
Pediatric clerkships use a variety of nighttime clinical structures and are altering clerkships’ curriculum in response to changes in residents’ nighttime clinical experiences.
THE COUNCIL ON Medical Student Education in Pediatrics (COMSEP) developed a national curriculum for pediatric clerkships in 1995. The curriculum established universal and core pediatric competencies for third-year medical students. After 2 revisions, the curriculum has since been adopted by more than 90% of pediatric clerkships in North America.1 Although the curriculum outlines methods for meeting core competencies, it does not specifically address nighttime clinical experiences in pediatrics. Additionally, there are no published standards for the structure of student nighttime clinical experiences during internal medicine, obstetrics and gynecology, surgery, psychiatry, neurology, or family medicine clerkships. Despite the lack of standards, third-year medical students have traditionally participated in patient care at night during core clerkships, including pediatrics. In contrast, graduate medical education has had duty hour standards for over a decade with the introduction of ACADEMIC PEDIATRICS Copyright ª 2014 by Academic Pediatric Association
155
Volume 14, Number 2 March–April 2014
156
SMITH AND STEVENSON
to identify changes in nighttime clinical structures since implementation of the 2011 ACGME standards, and 3) to quantify the number of medical schools with medical student duty hour standards.
METHODS COMSEP conducts an annual survey of its members to collect general demographic information and address specific research topics of interests from its members. COMSEP allows independent researchers to add questions to each year’s survey. We contributed survey questions regarding nighttime clinical structures in pediatric clerkships to the 2011 annual COMSEP survey. The institutional review board at the University of Utah deemed our study exempt. The annual COMSEP survey is a voluntary online cohort study. The study population includes all members of COMSEP, a diverse group of leaders of medical student education in pediatrics across North America. Membership includes clerkship directors, clinical site directors, directors of medical student education in pediatrics, and pediatricians who serve in medical school dean’s offices and pediatric department leadership. In 2011, all 147 LCMEaccredited medical schools were represented in COMSEP membership; therefore, all LCME schools had the opportunity to participate in the survey. The survey consisted of 102 questions. The first 20 survey questions assessed general demographic information. The remaining 82 questions were dedicated to 4 additional research topics. There were 11 questions on pediatric clerkship nighttime clinical structure, including those that addressed current nighttime structure, modifications to nighttime structure in the past year, goals for nighttime clinical experiences, and whether the new ACGME standards affected the pediatric clerkship’s nighttime clinical structure (Appendix). We also surveyed the COMSEP membership on whether their medical school had medical student duty hour standards. “Night call” was defined as staying in the hospital overnight after a full workday and then rounding in the morning. “Stay late” was defined as working until a predetermined hour late in the night after a full workday. “Night shift” was defined as working overnight without any daytime responsibilities. “Other” was defined as a combination of various nighttime clinical experiences. Questions regarding nighttime clinical structure were pilot tested for clarity, reliability, and length of time required for completion by 4 academic pediatricians, and then again as a part of the entire survey by a pilot group that consisted of members of the COMSEP executive committee. All COMSEP members received a personalized link to the survey via e-mail with encouragement to participate; subsequently, those who did not respond were sent a maximum of 3 reminder e-mails. Data were gathered from October 2011 through December 2011. Responses were saved in a confidential database, deidentified, and analyzed. We included a single response from the central campus of each medical school in our analysis. If multiple re-
ACADEMIC PEDIATRICS
sponses were received, we preferentially choose the clerkship director’s response when a single clerkship director could be identified. When the clerkship director could not be identified, we included the survey response with the most complete data. We excluded all responses from secondary clinical sites and osteopathic medical schools. Descriptive statistics were completed by SPSS version 21 (IBM, Armonk, NY).
RESULTS Eighty-three of 147 LCME-accredited schools completed the questions on pediatric clerkship nighttime clinical structure, for a response rate of 56%. Ninety-eight percent (n ¼ 81) of responding clerkships required some form of nighttime clinical experience in the 2011–2012 academic year. Variation in the type of nighttime clinical structure existed (Fig. 1). The most common structure (49%, n ¼ 41) involved students staying late after daytime clinical work. Of these, 75% (n ¼ 36) of clerkships had students remain on clinical duty until between 10 PM and midnight. Twenty-four percent (n ¼ 20) of clerkships used night shifts. The number of night shifts varied by program with a range of 1 to 7 shifts, with 5 night shifts per rotation being the most common. Sixteen percent (n ¼ 13) of clerkships used traditional night call. Traditional night call frequency typically varied between every fourth and seventh night. Three programs reported requiring only 1 night of traditional night call per rotation. Two programs required no nighttime clinical experiences. Forty-four percent (n ¼ 37) of responding clerkships reported changing their nighttime clinical structure in 2011. Figure 2 demonstrates changes in nighttime clinical structures between the 2010–2011 and 2011–2012 academic years among these clerkships. Of those reporting a change in nighttime clinical structure, 65% (n ¼ 24) did so in response to the 2011 ACGME standards or changes to institution-specific resident nighttime schedules. Fortysix percent (n ¼ 17) of clerkships that changed their nighttime clinical structure had previously required traditional night call. COMSEP members report a variety of goals for having students participate in nighttime clinical experiences. Fifty-four percent responded that increased clinical
Figure 1. Pediatric clerkship nighttime clinical experience by type in 2011.
ACADEMIC PEDIATRICS
Figure 2. Pediatric clerkship nighttime clinical experiences in 2010 and 2011 for those clerkships that changed nighttime curriculum beginning in 2011.
exposure is a primary objective. Less common reasons include teaching cross cover skills (31%) and providing greater autonomy (29%). Seventy-six percent (n ¼ 63) of medical schools reported having student duty hour standards. Of these, 35% (n ¼ 22) adhered to the 2011 ACGME PGY-1 standard. Thirty-seven percent (n ¼ 23) followed the 2011 ACGME PGY-2 standard.
DISCUSSION Our study delineates the variety of nighttime clinical structures in pediatric clerkships during the 2011–2012 academic year. Many pediatric clerkships have changed their nighttime clinical structures since the institution of the 2011 ACGME resident duty hour standards. Traditional night call in pediatric clerkships has been replaced by night shifts or having students stay late. This is parallel to changes occurring in graduate medical education where traditional night call is becoming less frequent.5,6 The majority of pediatric clerkships report making changes in student nighttime curriculum because of the 2011 ACGME resident duty hour standards. However, the effectiveness of the 2011 ACGME resident duty hour standards has yet to be determined for residents, let alone medical students. At 1 institution, current surgical interns appear to perform fewer operative cases than surgical interns from before 2011.7 A singleinstitution study found that current pediatric interns’ experience in the well-baby nursery is equivalent with interns from before 2011.8 In the only randomized study regarding the 2011 ACGME guidelines, interns randomized to 2011 ACGME duty hour–compliant night shifts reported deteriorations in continuity of patient care and quality of care compared with interns randomized to traditional night call every fourth night.9 Overall, pediatric program directors viewed the 2011 ACGME duty hour standards negatively.10 Undergraduate medical education and graduate medical education often have different goals and objectives for clinical experiences. Leaders of pediatric undergraduate medical education identified increased exposure to patients as a common goal for nighttime clinical experiences. Current
CHANGES IN PEDIATRIC CLERKSHIPS
157
literature reporting the effects of using the 2011 ACGME resident duty hour standard for student duty hours and the impact on medical students’ exposure to patients is lacking. However, a single institution’s report about their internal medicine clerkship brought on by the adoption of the 2003 ACGME standards found that students had fewer patient encounters.11 Other educational benefits and consequences of various medical student nighttime clinical structures remain elusive. A surgical clerkship reported improved scores on the National Board of Medical Examiners (NMBE) surgical exam after switching from intermittent night call to a stay late structure with increased self-directed, case-based learning.12 In contrast, a pediatric clerkship found no change in NMBE pediatric exam scores or student satisfaction after transitioning to a night shift curriculum from a stay late model.13 Ideally, additional research comparing educational outcomes for different medical student nighttime clinical structures will offer insight into which is the most effective and best meets educators’ goals. Despite the LCME standard requiring medical schools to develop policies governing the amount of time students spend in clinical activities,14 we found that some clerkships report not having a student duty hour policy. In addition, the specifics of student duty hour policies vary by school. Of note, a recent survey of LCME-accredited medical school deans found that approximately half desired a national medical student duty hour standard, and 84% thought that medical students should not work more than 80 hours per week.15 Limitations to this study include a moderate response rate and a focus on activities occurring at major teaching hospitals (central campuses), with the exclusion of satellite clinical teaching sites. Clerkship structure is often dictated by available resources and can differ significantly between a major teaching hospital and outreach sites. In addition, although this study reports changes to nighttime clinical structure after implementation of the 2011 ACGME resident duty hour standard, it does not report any educational outcomes. Linking clinical structure with educational outcomes would have added significant depth to our investigation. Our data demonstrate that modifications to pediatric undergraduate medical education in response to changes in resident duty hour standards are varied. Only some schools have a student duty hour policy despite the LCME standard related to determination of the time students spend in clinical activities. Those that do have policies mimic the ACGME standards. As pediatric clerkships modify their current nighttime structures, we challenge leaders to develop nighttime clinical structures and student duty hour policies that reflect the goals of undergraduate medical education, not necessarily those that simply reflect ACGME resident standards.
ACKNOWLEDGMENTS We thank Chris Maloney, MD.
158
SMITH AND STEVENSON
REFERENCES 1. Council on Medical Student Education in Pediatrics. Third year curriculum. Available at: http://www.comsep.org/educationalresources/ currthirdyear.cfm. Accessed April 21, 2013. 2. Accreditation Council for Graduate Medical Education. Duty hour. Available at: http://www.acgme.org/acgmeweb/GraduateMedical Education/DutyHours. Accessed May 9, 2013. 3. Veasey S, Rosen R, Barzansky B, et al. Sleep loss and fatigue in residency training: a reappraisal. JAMA. 2002;288:1116–1124. 4. Barzansky B, Etzel SI. Educational programs in US medical schools, 2004–2005. JAMA. 2005;294:1068–1074. 5. Rosenbluth G, Landrigan CP. Sleep science, schedules, and safety in hospitals: challenges and solutions for pediatric providers. Pediatr Clin North Am. 2012;59:1317–1328. 6. Hayman AV, Tarpley JL, Berger DH, et al. How is the Department of Veterans Affairs addressing the new Accreditation Council for Graduate Medical Education intern work hour limitations? Solutions from the Association of Veterans Affairs Surgeons. Am J Surg. 2012;204: 655–662. 7. Schwartz SI, Galante J, Kaji A, et al. Effect of the 16-hour work limit on general surgery intern operative case volume: a multi-institutional study. JAMA Surg. 2013;148:829–833.
ACADEMIC PEDIATRICS 8. Delaroche A, Riggs T, Maisels MJ. Impact of the new 16-hour duty period on pediatric interns’ neonatal education. Clin Pediatr (Phila). 2014 Jan;53(1):51–59. Epub 2013 Sep 3. 9. Desai SV, Feldman L, Brown L, et al. Effect of the 2011 vs 2003 duty hour regulation-compliant models on sleep duration, trainee education, and continuity of patient care among internal medicine house staff: a randomized trial. JAMA Intern Med. 2013;25:1–7. 10. Drolet BC, Whittle SB, Khokhar MT, et al. Approval and perceived impact of duty hour regulations: survey of pediatric program directors. Pediatrics. 2013;132:819–824. 11. Lindquist LA, Tschoe M, Neely D, et al. Medical student patient experiences before and after duty hour regulation and hospitalist support. J Gen Intern Med. 2010;25:207–210. 12. McLean SF, Horn K, Tyroch AH. Case based review questions, review sessions, and call schedule type enhance knowledge gains in a surgical clerkship. J Surg Educ. 2013;70:68–75. 13. Talib N, Toy S, Moore K, et al. Can incorporating inpatient overnight work hours into a pediatric clerkship improve the clerkship experience for students? Acad Med. 2013;88:376–381. 14. LCME ED-38. Available at: http://www.lcme.org/connections/ connections_2013-2014/ED-38_2013-2014.htm. Accessed October 16, 2013. 15. Friedman E, Karani R, Fallar R. Regulation of medical student work hours: a national survey of deans. Acad Med. 2011;86:30–33.
ACADEMIC PEDIATRICS
CHANGES IN PEDIATRIC CLERKSHIPS
APPENDIX SURVEY QUESTIONS 1. What is your night call structure at the primary clinical site of your third-year pediatric clerkship for the 2011– 2012 academic year? A. No call (daytime responsibilities but no nighttime responsibilities). B. Stay late (physically remain after daytime responsibilities until a specified time at night, ie, midnight). C. Overnight call (stay overnight and round the next morning). D. Night shift (nighttime responsibility but no daytime responsibilities). E. Other. 2. If your night call structure at the primary clinical site of your third-year pediatric clerkship is stay late, until what time are students expected to stay? 3. If your night call structure at the primary clinical site of your third-year pediatric clerkship is overnight, how frequent is the call? (every ____ night) 4. If your night call structure at the primary clinical site of your third-year pediatric clerkship is night shifts, how many night shifts do students complete during their clerkship? 5. If your clerkship uses multiple locations for the clinical experience, does night call vary by location? A. Yes. B. No. C. Not applicable.
158.e1
6. If your clerkship incorporates overnight clinical responsibilities, what is your clerkship’s primary objective or objectives? Choose all that apply. A. Increase patient exposure. B. Teach cross-cover skills. C. Provide greater autonomy. D. Other. 7. Have you changed your third-year student call structure between the 2010–2011 and 2011–2012 academic years? A. Yes. B. No. 8. If yes, what was your previous call structure? A. No call. B. Stay late. C. Overnight call. D. Night shift. E. Other. 9. If yes, why did you change call structure? A. To be consistent with the new ACGME guidelines. B. To be consistent with current local resident nighttime responsibilities. C. To comply with a new local student duty hour policy. D. Internal clerkship reason. E. Other. 10. Does your institution have a student duty hour policy? A. Yes. B. No. C. Do not know. 11. If yes, which guidelines does the policy parallel? A. ACGME PGY-1 guidelines. B. ACGME PGY-2 and above guidelines. C. Other.
ABSTRACT OBJECTIVE: To report changes in pediatric clerkship nighttime clinical structures before and after implementation of the 2011 Accreditation Council for Graduate Medical Education (ACGME) resident duty hour standards. METHODS: As part of the 2011 Council on Medical Student Education in Pediatrics (COMSEP) member annual survey, we surveyed leaders of pediatric undergraduate medical education on their medical school’s current nighttime clinical structure, changes in nighttime structure between 2010 and 2011, and their school’s student duty hour standards. RESULTS: Fifty-six percent (n ¼ 83) of Liaison Committee for Medical Education (LCME)-accredited medical schools responded to the survey. Of received responses, 98% of pediatric clerkships have some form of nighttime clinical experience; 49% of clerkships have medical students stay late, 24% of clerkships utilize night shifts, and 16% use a traditional call structure.
Forty-five percent of clerkships report changing their nighttime clinical experience after implementation of the 2011 ACGME duty hour standards; 46% of clerkships that changed had previously used traditional call. Seventy-six percent of clerkships report having medical student duty hour standards at their medical school. CONCLUSIONS: The majority of pediatric clerkships in our survey include nighttime clinical experiences in their curriculum, although variability exists in the type of structure. Additionally, the new ACGME duty hour standards appear to affect clerkships directors’ choice of structure.
KEYWORDS: duty hour standards; medical student call; pediatric education; undergraduate medical education
ACADEMIC PEDIATRICS 2014;14:155–158
WHAT’S NEW
the American Council for Graduate Medical Education (ACGME) resident duty hour standards in 2003. These standards limited resident duty hours to 80 hours per week and not more than 24 hours of continuous work, with an additional 6 hours allowed for continuity of care and education.2 The ACGME duty hour standards stemmed largely from studies documenting adverse effects of sleep deprivation in residents.3 After the introduction of the 2003 ACGME duty hour standards, a 2004 survey of Liaison Committee for Medical Education (LCME)-accredited schools found that inpatient night call was less common than 10 years before. Eightysix percent of schools required pediatric night call in 1994 and 79% in 2004 (the article did not define “night call”).4 In 2011, the ACGME updated the standards and reduced postgraduate year 1 (PGY-1) duty hours to not more than 16 hours, eliminating the traditional 24-hour call schedule for PGY-1 physicians. PGY-2 and above residents could continue to remain on clinical service for 24 hours in a single period.2 There are no studies that discuss the interaction of the 2011 ACGME resident duty hour standards on medical student clerkships’ nighttime clinical structure. The present study had 3 specific aims: 1) to describe the nighttime clinical structures across pediatric clerkships, 2)
Pediatric clerkships use a variety of nighttime clinical structures and are altering clerkships’ curriculum in response to changes in residents’ nighttime clinical experiences.
THE COUNCIL ON Medical Student Education in Pediatrics (COMSEP) developed a national curriculum for pediatric clerkships in 1995. The curriculum established universal and core pediatric competencies for third-year medical students. After 2 revisions, the curriculum has since been adopted by more than 90% of pediatric clerkships in North America.1 Although the curriculum outlines methods for meeting core competencies, it does not specifically address nighttime clinical experiences in pediatrics. Additionally, there are no published standards for the structure of student nighttime clinical experiences during internal medicine, obstetrics and gynecology, surgery, psychiatry, neurology, or family medicine clerkships. Despite the lack of standards, third-year medical students have traditionally participated in patient care at night during core clerkships, including pediatrics. In contrast, graduate medical education has had duty hour standards for over a decade with the introduction of ACADEMIC PEDIATRICS Copyright ª 2014 by Academic Pediatric Association
155
Volume 14, Number 2 March–April 2014
156
SMITH AND STEVENSON
to identify changes in nighttime clinical structures since implementation of the 2011 ACGME standards, and 3) to quantify the number of medical schools with medical student duty hour standards.
METHODS COMSEP conducts an annual survey of its members to collect general demographic information and address specific research topics of interests from its members. COMSEP allows independent researchers to add questions to each year’s survey. We contributed survey questions regarding nighttime clinical structures in pediatric clerkships to the 2011 annual COMSEP survey. The institutional review board at the University of Utah deemed our study exempt. The annual COMSEP survey is a voluntary online cohort study. The study population includes all members of COMSEP, a diverse group of leaders of medical student education in pediatrics across North America. Membership includes clerkship directors, clinical site directors, directors of medical student education in pediatrics, and pediatricians who serve in medical school dean’s offices and pediatric department leadership. In 2011, all 147 LCMEaccredited medical schools were represented in COMSEP membership; therefore, all LCME schools had the opportunity to participate in the survey. The survey consisted of 102 questions. The first 20 survey questions assessed general demographic information. The remaining 82 questions were dedicated to 4 additional research topics. There were 11 questions on pediatric clerkship nighttime clinical structure, including those that addressed current nighttime structure, modifications to nighttime structure in the past year, goals for nighttime clinical experiences, and whether the new ACGME standards affected the pediatric clerkship’s nighttime clinical structure (Appendix). We also surveyed the COMSEP membership on whether their medical school had medical student duty hour standards. “Night call” was defined as staying in the hospital overnight after a full workday and then rounding in the morning. “Stay late” was defined as working until a predetermined hour late in the night after a full workday. “Night shift” was defined as working overnight without any daytime responsibilities. “Other” was defined as a combination of various nighttime clinical experiences. Questions regarding nighttime clinical structure were pilot tested for clarity, reliability, and length of time required for completion by 4 academic pediatricians, and then again as a part of the entire survey by a pilot group that consisted of members of the COMSEP executive committee. All COMSEP members received a personalized link to the survey via e-mail with encouragement to participate; subsequently, those who did not respond were sent a maximum of 3 reminder e-mails. Data were gathered from October 2011 through December 2011. Responses were saved in a confidential database, deidentified, and analyzed. We included a single response from the central campus of each medical school in our analysis. If multiple re-
ACADEMIC PEDIATRICS
sponses were received, we preferentially choose the clerkship director’s response when a single clerkship director could be identified. When the clerkship director could not be identified, we included the survey response with the most complete data. We excluded all responses from secondary clinical sites and osteopathic medical schools. Descriptive statistics were completed by SPSS version 21 (IBM, Armonk, NY).
RESULTS Eighty-three of 147 LCME-accredited schools completed the questions on pediatric clerkship nighttime clinical structure, for a response rate of 56%. Ninety-eight percent (n ¼ 81) of responding clerkships required some form of nighttime clinical experience in the 2011–2012 academic year. Variation in the type of nighttime clinical structure existed (Fig. 1). The most common structure (49%, n ¼ 41) involved students staying late after daytime clinical work. Of these, 75% (n ¼ 36) of clerkships had students remain on clinical duty until between 10 PM and midnight. Twenty-four percent (n ¼ 20) of clerkships used night shifts. The number of night shifts varied by program with a range of 1 to 7 shifts, with 5 night shifts per rotation being the most common. Sixteen percent (n ¼ 13) of clerkships used traditional night call. Traditional night call frequency typically varied between every fourth and seventh night. Three programs reported requiring only 1 night of traditional night call per rotation. Two programs required no nighttime clinical experiences. Forty-four percent (n ¼ 37) of responding clerkships reported changing their nighttime clinical structure in 2011. Figure 2 demonstrates changes in nighttime clinical structures between the 2010–2011 and 2011–2012 academic years among these clerkships. Of those reporting a change in nighttime clinical structure, 65% (n ¼ 24) did so in response to the 2011 ACGME standards or changes to institution-specific resident nighttime schedules. Fortysix percent (n ¼ 17) of clerkships that changed their nighttime clinical structure had previously required traditional night call. COMSEP members report a variety of goals for having students participate in nighttime clinical experiences. Fifty-four percent responded that increased clinical
Figure 1. Pediatric clerkship nighttime clinical experience by type in 2011.
ACADEMIC PEDIATRICS
Figure 2. Pediatric clerkship nighttime clinical experiences in 2010 and 2011 for those clerkships that changed nighttime curriculum beginning in 2011.
exposure is a primary objective. Less common reasons include teaching cross cover skills (31%) and providing greater autonomy (29%). Seventy-six percent (n ¼ 63) of medical schools reported having student duty hour standards. Of these, 35% (n ¼ 22) adhered to the 2011 ACGME PGY-1 standard. Thirty-seven percent (n ¼ 23) followed the 2011 ACGME PGY-2 standard.
DISCUSSION Our study delineates the variety of nighttime clinical structures in pediatric clerkships during the 2011–2012 academic year. Many pediatric clerkships have changed their nighttime clinical structures since the institution of the 2011 ACGME resident duty hour standards. Traditional night call in pediatric clerkships has been replaced by night shifts or having students stay late. This is parallel to changes occurring in graduate medical education where traditional night call is becoming less frequent.5,6 The majority of pediatric clerkships report making changes in student nighttime curriculum because of the 2011 ACGME resident duty hour standards. However, the effectiveness of the 2011 ACGME resident duty hour standards has yet to be determined for residents, let alone medical students. At 1 institution, current surgical interns appear to perform fewer operative cases than surgical interns from before 2011.7 A singleinstitution study found that current pediatric interns’ experience in the well-baby nursery is equivalent with interns from before 2011.8 In the only randomized study regarding the 2011 ACGME guidelines, interns randomized to 2011 ACGME duty hour–compliant night shifts reported deteriorations in continuity of patient care and quality of care compared with interns randomized to traditional night call every fourth night.9 Overall, pediatric program directors viewed the 2011 ACGME duty hour standards negatively.10 Undergraduate medical education and graduate medical education often have different goals and objectives for clinical experiences. Leaders of pediatric undergraduate medical education identified increased exposure to patients as a common goal for nighttime clinical experiences. Current
CHANGES IN PEDIATRIC CLERKSHIPS
157
literature reporting the effects of using the 2011 ACGME resident duty hour standard for student duty hours and the impact on medical students’ exposure to patients is lacking. However, a single institution’s report about their internal medicine clerkship brought on by the adoption of the 2003 ACGME standards found that students had fewer patient encounters.11 Other educational benefits and consequences of various medical student nighttime clinical structures remain elusive. A surgical clerkship reported improved scores on the National Board of Medical Examiners (NMBE) surgical exam after switching from intermittent night call to a stay late structure with increased self-directed, case-based learning.12 In contrast, a pediatric clerkship found no change in NMBE pediatric exam scores or student satisfaction after transitioning to a night shift curriculum from a stay late model.13 Ideally, additional research comparing educational outcomes for different medical student nighttime clinical structures will offer insight into which is the most effective and best meets educators’ goals. Despite the LCME standard requiring medical schools to develop policies governing the amount of time students spend in clinical activities,14 we found that some clerkships report not having a student duty hour policy. In addition, the specifics of student duty hour policies vary by school. Of note, a recent survey of LCME-accredited medical school deans found that approximately half desired a national medical student duty hour standard, and 84% thought that medical students should not work more than 80 hours per week.15 Limitations to this study include a moderate response rate and a focus on activities occurring at major teaching hospitals (central campuses), with the exclusion of satellite clinical teaching sites. Clerkship structure is often dictated by available resources and can differ significantly between a major teaching hospital and outreach sites. In addition, although this study reports changes to nighttime clinical structure after implementation of the 2011 ACGME resident duty hour standard, it does not report any educational outcomes. Linking clinical structure with educational outcomes would have added significant depth to our investigation. Our data demonstrate that modifications to pediatric undergraduate medical education in response to changes in resident duty hour standards are varied. Only some schools have a student duty hour policy despite the LCME standard related to determination of the time students spend in clinical activities. Those that do have policies mimic the ACGME standards. As pediatric clerkships modify their current nighttime structures, we challenge leaders to develop nighttime clinical structures and student duty hour policies that reflect the goals of undergraduate medical education, not necessarily those that simply reflect ACGME resident standards.
ACKNOWLEDGMENTS We thank Chris Maloney, MD.
158
SMITH AND STEVENSON
REFERENCES 1. Council on Medical Student Education in Pediatrics. Third year curriculum. Available at: http://www.comsep.org/educationalresources/ currthirdyear.cfm. Accessed April 21, 2013. 2. Accreditation Council for Graduate Medical Education. Duty hour. Available at: http://www.acgme.org/acgmeweb/GraduateMedical Education/DutyHours. Accessed May 9, 2013. 3. Veasey S, Rosen R, Barzansky B, et al. Sleep loss and fatigue in residency training: a reappraisal. JAMA. 2002;288:1116–1124. 4. Barzansky B, Etzel SI. Educational programs in US medical schools, 2004–2005. JAMA. 2005;294:1068–1074. 5. Rosenbluth G, Landrigan CP. Sleep science, schedules, and safety in hospitals: challenges and solutions for pediatric providers. Pediatr Clin North Am. 2012;59:1317–1328. 6. Hayman AV, Tarpley JL, Berger DH, et al. How is the Department of Veterans Affairs addressing the new Accreditation Council for Graduate Medical Education intern work hour limitations? Solutions from the Association of Veterans Affairs Surgeons. Am J Surg. 2012;204: 655–662. 7. Schwartz SI, Galante J, Kaji A, et al. Effect of the 16-hour work limit on general surgery intern operative case volume: a multi-institutional study. JAMA Surg. 2013;148:829–833.
ACADEMIC PEDIATRICS 8. Delaroche A, Riggs T, Maisels MJ. Impact of the new 16-hour duty period on pediatric interns’ neonatal education. Clin Pediatr (Phila). 2014 Jan;53(1):51–59. Epub 2013 Sep 3. 9. Desai SV, Feldman L, Brown L, et al. Effect of the 2011 vs 2003 duty hour regulation-compliant models on sleep duration, trainee education, and continuity of patient care among internal medicine house staff: a randomized trial. JAMA Intern Med. 2013;25:1–7. 10. Drolet BC, Whittle SB, Khokhar MT, et al. Approval and perceived impact of duty hour regulations: survey of pediatric program directors. Pediatrics. 2013;132:819–824. 11. Lindquist LA, Tschoe M, Neely D, et al. Medical student patient experiences before and after duty hour regulation and hospitalist support. J Gen Intern Med. 2010;25:207–210. 12. McLean SF, Horn K, Tyroch AH. Case based review questions, review sessions, and call schedule type enhance knowledge gains in a surgical clerkship. J Surg Educ. 2013;70:68–75. 13. Talib N, Toy S, Moore K, et al. Can incorporating inpatient overnight work hours into a pediatric clerkship improve the clerkship experience for students? Acad Med. 2013;88:376–381. 14. LCME ED-38. Available at: http://www.lcme.org/connections/ connections_2013-2014/ED-38_2013-2014.htm. Accessed October 16, 2013. 15. Friedman E, Karani R, Fallar R. Regulation of medical student work hours: a national survey of deans. Acad Med. 2011;86:30–33.
ACADEMIC PEDIATRICS
CHANGES IN PEDIATRIC CLERKSHIPS
APPENDIX SURVEY QUESTIONS 1. What is your night call structure at the primary clinical site of your third-year pediatric clerkship for the 2011– 2012 academic year? A. No call (daytime responsibilities but no nighttime responsibilities). B. Stay late (physically remain after daytime responsibilities until a specified time at night, ie, midnight). C. Overnight call (stay overnight and round the next morning). D. Night shift (nighttime responsibility but no daytime responsibilities). E. Other. 2. If your night call structure at the primary clinical site of your third-year pediatric clerkship is stay late, until what time are students expected to stay? 3. If your night call structure at the primary clinical site of your third-year pediatric clerkship is overnight, how frequent is the call? (every ____ night) 4. If your night call structure at the primary clinical site of your third-year pediatric clerkship is night shifts, how many night shifts do students complete during their clerkship? 5. If your clerkship uses multiple locations for the clinical experience, does night call vary by location? A. Yes. B. No. C. Not applicable.
158.e1
6. If your clerkship incorporates overnight clinical responsibilities, what is your clerkship’s primary objective or objectives? Choose all that apply. A. Increase patient exposure. B. Teach cross-cover skills. C. Provide greater autonomy. D. Other. 7. Have you changed your third-year student call structure between the 2010–2011 and 2011–2012 academic years? A. Yes. B. No. 8. If yes, what was your previous call structure? A. No call. B. Stay late. C. Overnight call. D. Night shift. E. Other. 9. If yes, why did you change call structure? A. To be consistent with the new ACGME guidelines. B. To be consistent with current local resident nighttime responsibilities. C. To comply with a new local student duty hour policy. D. Internal clerkship reason. E. Other. 10. Does your institution have a student duty hour policy? A. Yes. B. No. C. Do not know. 11. If yes, which guidelines does the policy parallel? A. ACGME PGY-1 guidelines. B. ACGME PGY-2 and above guidelines. C. Other.
