We report the perspectives of a national sample of teaching faculty regarding the impact of residency duty hour regulations on medical students’ education at 39 U.S. schools of medicine with affiliated academic internal medicine residency programs. While faculty were more likely to report worsening than improvement in all the outcomes studied, a substantial proportion of faculty did not perceive a change in most aspects of medical students’ education.
More than half of key clinical faculty reported worsening in the overall quality of the educational experience for medical students on inpatient internal medicine clerkships as a result of duty hour regulations, while less than 3% reported improvement. The adverse effects of duty hour regulations on medical students’ educational experience may have important implications for the recruitment of students to internal medicine because students’ career choice is influenced, in part, by their satisfaction with internal medicine clerkships in medical school.27–29
Our results suggest that students may experience decreased levels of responsibility, less continuity with patients, and poorer relationships with residents in medicine clerkships as a result of duty hour reform, all of which may attenuate students’ interests in internal medicine.
Approximately one third of faculty in this study believed that students’ ability to follow patients throughout hospitalization had worsened as a result of duty hour reform. Continuity with individual patients is an important element of clinical skills training for medical students.30
Residency duty hour regulations may result in decreased patient care experiences for students because students are working limited hours similar to residents,31
and therefore may not be present for certain clinical experiences, or residents have less time available to supervise students’ clinical activities. Additionally, duty hour regulations may have increased the work load of clinical faculty,8,10,32,33
making it unlikely that faculty will have additional time available to supervise students. To improve continuity with patients in the era of duty hour reform, medical schools may encourage students to follow individual patients longitudinally throughout a variety of ambulatory and impatient clinical encounters during the principal clinical year, as was done in the Harvard Medical School–Cambridge Integrated Clerkship model.34
A substantial portion (45%) of KCF surveyed did not meet the teaching requirement (≥15 hours per week on average) established by the ACGME. Faculty who met the ACGME requirement were significantly more likely to perceive adverse effects of duty hour limits on medical students’ education than faculty with less teaching responsibilities. Our results do not suggest an explanation for this observation; however, we speculate that faculty with the greatest involvement in teaching may have more opportunities to observe the effects of duty hour changes on medical students’ education. Additionally, these faculty may be more likely to experience potential adverse effects of ACGME duty hours on their own careers such as increased workload and decreased satisfaction,8,9,10
making them more sensitive to duty hour issues. Finally, the 2004–2005 academic year (when our survey was conducted) was a period of adjustment for many programs, as faculty struggled to adapt to this major policy shift in graduate medical education. Highly involved teaching faculty may have experienced temporary resistance to this substantial change,35
and views may be different once faculty have fully adjusted to the new requirements.
This study has several limitations. First, this is an observational study that relies on self-report of faculty regarding the impact of duty hour limitations on students’ education. Second, this is a study of faculty at academic residency programs affiliated with medical schools; therefore, their views may not reflect those of faculty at community-based programs where a substantial portion of medical student education occurs.36
Third, although we demonstrate some degree of content validity for survey items based on our iterative process of survey development among teaching faculty, we do not provide any measure of criterion validity for survey items. Fourth, we did not collect data on teaching methods (e.g., didactic vs. bedside), and therefore, we can not examine differences in KCF views based on this variable. Fifth, we categorized KCF specialties as general internal medicine versus subspecialty internal medicine; we did not ask faculty whether they were hospitalists. Finally, this survey was conducted 1 y after ACGME duty hour requirements were instituted, and it is likely that some programs may not have achieved full compliance.37
These limitations notwithstanding, the results of this study indicate that key clinical faculty believe duty hour regulations have worsened important aspects of medical students’ education in internal medicine. Medical schools and residency programs must identify ways to ensure optimal educational experiences in internal medicine for medical students while maintaining compliance with residency duty hour requirements.