Faculty and Resident Perceptions Regarding Overnight Student Call During the Third Year OB/GYN Clerkship

Abstract

Objectives

The objective of this study is to identify university faculty, community physician, and resident perceptions of how a schedule that employs overnight call in addition to a traditional weekday schedule affects medical student education, well being, and patient care during the third year obstetrics and gynecology clerkship.

Methods

In July 2007, a descriptive study was performed by distributing surveys to community teaching physicians, current residents, and faculty in the University of Hawai‘i Department of Obstetrics and Gynecology. A total of 114 surveys were distributed to all current residents, clinical faculty and full-time faculty in the University of Hawai‘i Department of Obstetrics and Gynecology. The survey included questions regarding the effect of the student call/work hour restrictions.

Results

A response rate of 45.6% was obtained (52/114). Results demonstrate that 84.6% (44/52) of residents, faculty, and community attendings agree that third year medical students should take call during their obstetrics and gynecology clerkship. Data was analyzed utilizing Spearman correlation and Cochran-Mantel-Haenszel statistics. No statistical difference was detected in terms of age or physician type (resident vs faculty vs community attending).

Conclusion

Most physician-educators believe that medical students benefit from taking overnight call during their obstetrics and gynecology clerkship. Careful consideration should be given prior to elimination of overnight call in the obstetrics and gynecology clerkship.

Introduction

In 2002, the Accreditation Council on Graduate Medical Education (ACGME) established guidelines that restrict the resident work week to 80 hours per week averaged over a 4-week period.¹ Effective July 2003, this was mandated for all resident training programs. This represented a significant change relative to the standard at the time. Surgical based residencies such as obstetrics and gynecology have seen the most dramatic changes in work hours. Like many other programs around the country, the University of Hawai‘i now employs a night float system to limit the resident work shift to 12–14 hours during the weekdays. Subsequently, the Liaison Committee on Medical Education (LCME) officials added a directive regarding student work hour regulations to its accreditation standards. In ED-38, the LCME recommended that attention should be paid to the time commitment required of students especially during their clinical years.² Student hours should be set taking into account the effects of fatigue and sleep deprivation on learning, clinical activities, and student health and safety.² Although not yet mandated, many student clerkships have eliminated 24 hour call/work shifts in their third year clerkships. Some now employ night float systems similar to ones employed in the residencies programs. Proponents believe the elimination of 24-hour call for students will increase student safety, improve retention, and improve clerkship satisfaction. Changes have been instituted despite limited evidence to support the potential benefits. In fact, it has been reported by some that 24-hour call has minimal impact in mood in this new era of the 80-hour work week.³

The University of Hawai‘i John A. Burns School of Medicine continues to require medical students to take overnight call as part of their third year obstetrics and gynecology clerkship. Thus, we were interested in identifying university faculty, clinical teaching staff, and resident perceptions of how a schedule that employs 24-hour call affects medical student education, well-being, and patient care during their third year obstetrics and gynecology clerkship. Although this has been studied in other specialties, there has been little to no research looking at benefits or detriments of long call hours of students while on the obstetrics and gynecology clerkship.

Methods

This study was deemed exempt by the University of Hawai‘i Institutional Review Board. The survey instrument was pre-tested to assure clarity. Surveys were distributed to all current residents (n=25) and faculty (n=26) in the University of Hawai‘i Department of Obstetrics and Gynecology. They were also distributed to the private practitioners (n=63) who held clinical teaching privileges. All physicians were active in both medical student and resident teaching. They were familiar with the current student curriculum and course objectives.

All participants were provided with an explanation of the study and were informed that information garnered would be used for curriculum development and research purposes. A total of 114 surveys were distributed. The data was collected in an anonymous fashion. Responses were rated on a Likert scale of 1 to 5 with “strongly agree” assigned a value of 5 and “strongly disagree” a value of 1. Surveys included demographic information and opinions on the effect of the student call/work hour restrictions.

All descriptive statistics were performed using the SAS statistical software Version 9.1 (SAS Institute Inc., Cary, NC). Spearman correlation coefficient statistics were utilized to test for any possible gender differences in responses to certain items. Cochran-Mantel-Haenszel statistics were utilized to determine if any differences in physician type were present. Chi-square statistics were used to compare the group responding “strongly agree” or “agree” with the group responding “neither agree nor disagree,” “disagree,” or “strongly disagree.” The level of significance was alpha <0.05.

Results

A total of 52 of 114 surveys were completed with an overall response rate of 45.6%. Of the 52 surveys returned, 14 were from University faculty, 19 from community attendings, and 18 from resident physicians. One respondent did not indicate his/her provider type. Refer to Table 1 for the full demographic data of the respondents. Overall, respondents (84.6%, P<0.001) agree or strongly agree that third year medical students should take call during their obstetrics and gynecology clerkship. Respondents agreed that there were increased learning opportunities during overnight call (88.46%, P<0.001) and did not believe that overnight call posed patient (94.23%, P<0.001) or student (94.23%, P<0.001)safety concerns. Overall survey results are displayed in Table 2. The results of each provider type was found to be significant and there was no difference detected between provider types (resident vs faculty vs community attending). These results per provider type are presented in Table 3.

Table 1.

Demographics

Characteristics		Number	Percent
Gender	Male	25	48.1%
	Female	27	51.9%
Median Age		40.98 years	(SD 11.73)
Race/ethnicity	Caucasian	16	30.77%
	Asian	28	53.85%
	Pacific Islander	1	1.92%
	Hispanic	1	1.92%
	Other	6	11.54%
Subspecialty	Generalist	50	96.2%
	MFM*	2	3.8%

^*MFM = Maternal Fetal Medicine

Table 2.

Overall Survey Results

Question	Agree/ Strongly Agree (%)	Neither/ Disagree/Strongly Disagree (%)	P value
Medical students benefit and should take overnight call	84.63	15.37	<0.001
Overnight call allows students to experience how schedule is in residency	86.54	13.46	<0.001
Overnight call prepares students for life as an attending	67.31	32.69	0.01
Overnight call allows students to learn how to function when tired	63.46	36.54	0.052
Overnight call provides a better environment to evaluate clinical performance	44.23	55.77	0.41
Overnight call provides more clinical/procedural experience	90.38	9.62	<0.001
Overnight call provides more opportunity for active student participation in cases	86.54	13.46	<0.001
Overnight call allows for more learning opportunities.	88.46	11.54	<0.001
Overnight call results in fatigue that detracts from learning while on call.	28.85	71.15	0.002
Overnight call provides less clinical/procedural experience due to the post call period	17.31	82.69	<0.001
Overnight call compromises patient care	5.77	94.23	<0.001
Overnight call is dangerous to students	5.77	94.23	<0.001
Overnight call discourages students from choosing ob/gyn as a specialty	7.69	92.31	<0.001

Table 3.

Survey Results per Provider Type

Question	University Faculty (n=14)		Community Attending (n=19)		Resident Physician (n=18)		P value
	Agree/ Strongly Agree (%)	Neither/ Disagree/Strongly Disagree (%)	Agree/ Strongly Agree (%)	Neither/ Disagree/Strongly Disagree (%)	Agree/ Strongly Agree (%)	Neither/ Disagree/Strongly Disagree (%)
Medical students benefit and should take overnight call	85.71	14.29	78.95	21.05	88.89	11.11	0.527
Overnight call allows students to experience how schedule is in residency	85.72	14.28	84.21	15.79	88.88	11.12	0.771
Overnight call prepares students for life as an attending	78.57	21.43	68.42	31.58	55.55	44.45	0.291
Overnight call allows students to learn how to function when tired	50.00	50.00	57.90	42.10	77.78	22.22	0.778
Overnight call provides a better environment to evaluate clinical performance	35.72	64.28	36.83	63.17	55.55	44.45	0.198
Overnight call provides more clinical/ procedural experience	85.71	14.29	94.74	5.26	88.89	11.11	0.402
Overnight call provides more opportunity for active student participation in cases	100.00	0	78.92	21.05	83.33	16.67	0.371
Overnight call allows for more learning opportunities.	100.00	0	78.92	21.05	88.89	11.11	0.232
Overnight call results in fatigue that detracts from learning while on call.	21.43	78.57	10.53	89.47	5.56	94.44	0.338
Overnight call provides less clinical/procedural experience due to the post call period	28.57	71.43	31.58	68.42	22.22	77.78	0.921
Overnight call compromises patient care	7.14	92.86	26.32	73.68	16.67	83.33	0.158
Overnight call is dangerous to students	7.14	92.86	89.47	10.53	100.00	0	0.312
Overnight call discourages students from choosing ob/gyn as a specialty	7.14	92.86	89.47	10.53	100.00	0	0.281

Discussion

Past studies involving residents have demonstrated fatigue and sleep deprivation to be significantly related to worsening mood, increased levels of anger, and poor cognitive function.⁴ Students on hospital ward rotations or those requiring overnight call were more likely to have burnout than those not requiring overnight call.⁵ The new work hour restrictions are a response to some of these issues. Third year medical student clerkships in many specialties have eliminated overnight and/or 24-hour call in response to some of these issues. However, are these issues pertinent to six to eight week long medical student clerkships?

Prior studies have demonstrated that students prefer not taking 24-hour call. Student perception of the overall quality of the clerkship increases significantly with fewer hours worked while on the clerkship.⁶ In addition, medical students often overestimate the number of hours worked during more labor intensive clerkships such as obstetrics and gynecology.⁶ These findings suggest that student opinions should not be given too much weight when making decisions regarding call hours. This being said, it cannot be ignored that third year clerkship satisfaction is an important factor in specialty choice and that call hour restrictions may result in increased interest in our specialty.⁷

Although interest is important, having some exposure to life as an attending can be helpful for students to make career choices. Residents may rarely take overnight call anymore; however attendings often continue to do so. This survey demonstrates a large majority of university faculty and community attendings believe that overnight call prepares students better for life as an attending. Studies that have looked at factors influencing a medical student to choose obstetrics and gynecology show that lifestyle, career opportunities, prestige, liability, and the predominance of females in the profession are important to students.^{8, 9} Thus, while student overnight call may negatively affect a medical student's lifestyle, an attending's lifestyle may play a bigger factor when making career choices and overnight call may provide a more realistic experience upon which students may base their career choices.

ACGME resident work hour restrictions have often resulted in decreased resident presence and increased faculty clinical workload. It is unclear whether this impacts medical student education negatively or positively. Some have reported an improvement in medical student education¹⁰ and others a negative impact.¹¹ Student evaluations have mentioned that, since the advent of the resident night float schedule, students who are on call are often working longer shifts than residents. This can result in a misperception that students are working harder than the residents, leading to negative interactions and conflicts between students and residents. Ultimately, this may result in poor clerkship satisfaction.

Care must be taken that training and experience are not sacrificed. There are valid concerns regarding taking less call hours. The students may receive less teaching or may obtain suboptimal amounts of clinical experience, effectively shortening the clinical rotation. A negative outcome was demonstrated at one institution when the duration of the obstetrics and gynecology clerkship was cut from 8 weeks down to 6 weeks. This resulted in lower student performance on the National Board of Medical Examiners (NBME) subject examination in obstetrics and gynecology at the end of the clerkship.¹² Although this suggests that overnight call may be beneficial in providing more clinical opportunities, other studies have suggested that this is actually not the case. At the University of Utah, students on their general surgery clerkship appeared to spend significantly more time involved in educational activities during the regular weekday shifts, than during any of their call shifts.¹³ Thus, leading them to conclude that overnight call had limited educational benefit to medical students. Some people may argue that working too many hours may negatively affect test scores. A study performed at Creighton University compared NBME test scores of students during their surgery clerkship who had a “slow” rotation vs. a “busy” rotation. Those on the slow rotation worked an average of 8–10 hours/day while those in the busy rotation worked an average of 12–14 hours/day. NBME test scores showed no significant difference between the two groups.¹⁴ This suggests that there is a fine balance in determining the optimum length of the clerkship as well as the numbers of hours worked and how those hours are spread throughout the day.

As the residency education landscape undergoes dramatic changes, the medical student educational process has come under scrutiny. Clerkships in many specialties have eliminated overnight call. Although the elimination of overnight call may positively influence student perceptions of the overall quality of the clerkship, clinical experience must not be sacrificed. The results from this survey demonstrate that educators feel very strongly that overnight call provides valuable student training and helps to provide a more realistic exposure to the lifestyle of an attending physician. Overnight call, while beneficial to the student educational experience, does not compromise student or patient safety. Future studies should seek to gather more information regarding overnight call and student performance so that curricular decisions can be made based on outcomes data. Careful thought must be given prior to making dramatic curriculum changes such as the elimination of overnight call during the third year clerkships.