Study Finds Residents at VA Centers Report Greater Satisfaction After Duty Hour Limits Implemented

August 27, 2010 05:00 pm Barbara Bein

Resident physicians who rotated through U.S. Department of Veterans Affairs, or VA, medical centers between 2001 and 2007 report being more satisfied with their clinical training environment after the 2003 implementation of revised duty hour standards from the Accreditation Council for Graduate Medical Education, or ACGME. That's the key finding from a study published in the July issue of Academic Medicine.

But family medicine educators caution that the finding may not hold true in non-VA settings.

The study notes that previous research has demonstrated that resident sleep deprivation is linked to a number of problems on the job, including high rates of medical errors, poor clinical performance, adverse events and so-called attentional failures. Sleep deprivation in residents also has been tied to personal difficulties, including motor vehicle injuries, obstetric complications, depression, burnout and poor quality of life.

Responding to those safety concerns, the ACGME implemented mandatory standards on July 1, 2003, that limited duty hours for medical residents in accredited U.S. GME programs.

According to the study(, 25 percent more residents in medical specialty and subspecialty areas -- internal medicine, physical medicine and rehabilitation, and neurology -- and 33 percent more in surgical specialties -- surgery and anesthesiology -- reported being satisfied with the VA clinical environment after the mandatory 2003 changes.

Furthermore, medical residents reported being 11 percent more satisfied with VA preceptors and faculty members after the changes, and 12 percent of surgical residents reported greater satisfaction in this area.

Satisfaction with the overall working environment was mixed.

The study's authors acknowledged that the study did not address the reasons for the increased satisfaction levels, and they said the shift could be explained by "many factors in addition to duty hour limits, including changes in workload, work life, resident cross-coverage, night-float systems, redistribution of workload, reassignment of noneducational tasks to midlevel and lower-level providers, clinical schedules that minimize sleep interruption, or reduced in-house call duties."

Nevertheless, the authors said, the 2003 standards "significantly and materially enhanced learning satisfaction rates for medicine and surgery residents rotating through VA medical centers."

AAFP Board Chair Ted Epperly, M.D., of Boise, Idaho, who is program director and CEO of the Family Medicine Residency of Idaho in Boise, told AAFP News Now the study's findings may not be transferable to non-VA settings, such as community hospitals in which many family medicine residents train.

"This is a qualitative study of residents' perceptions of satisfaction at VA hospitals," he said. "It is probably generalizable to academic teaching health centers and medical school-based residency program environments. It may not be generalizable to family medicine residencies, where much more focus is on the patient than on institutional systems."

Using the responses of more than 19,600 residents to the VA's annual Learners' Perception Survey, the authors compared the responses received before 2003 with those received after 2003. Residents answered specific questions regarding their satisfaction in five domains: faculty/preceptors, learning environment, clinical environment, working environment and physical environment. Residents' overall satisfaction with their clinical training was rated on a scale of 0 to 100, with 100 being a perfect score and 70 being a passing score.

Beginning with the 2004 survey, the VA added a question on duty hour limits that read: "In July 2003, the Accreditation Council for Graduate Medical Education instituted changes in requirements in duty hours/scheduling for resident education. In your opinion, what effect have these changes had on your educational experience at the VA facility…?"

Study authors reported that, "Overall, respondents tended to report higher satisfaction with their VA clinical training environment when duty hours limits applied."

According to the study, the findings were consistent with associations between reduced work hours and residents' perceptions of more time to read and learn independently, greater attending supervision, and attending physicians' increased role in patient care.

The study noted that one-third of the nation's residents rotate through VA medical centers under VA affiliation agreements with 107 U.S. medical schools. The VA is second only to Medicare and Medicaid as a primary funder of residency training in the United States, it said.

The authors also noted that their survey was the largest to measure physician resident satisfaction to date and involved a variety of facility sizes and medical school affiliations in diverse geographic areas across the United States.

But they also acknowledged that their study has several limitations. Those limitations include:

  • VA clinic rotations may not necessarily represent experiences at non-VA locations;
  • respondents may not know when duty hour limits affected their training environments, leading to overreporting of "no effect" when they were asked about duty hour limits; and
  • it is not known if resident satisfaction with clinical training is related to measures of education outcomes, such as in-service competencies examinations, board scores and attending physician evaluations.

In addition, the study authors said significant questions remain about the effects of any additional duty hour limits. The ACGME recently has been considering new proposals on duty hours.

"It is unknown whether further restrictions on duty schedules will continue to improve resident satisfaction," the authors said.

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