- Email: [email protected]
Medical students self-reported work hours: Perception versus reality
American Journal of Obstetrics and Gynecology (2005) 193, 1780–4
www.ajog.org
Medical students self-reported work hours: Perception versus reality Colleen Casey, MD,a Sangeeta Senapati, MD,a Casey B. White, PhD,b Larry D. Gruppen, PhD,c Maya M. Hammoud, MDa Department of Obstetrics and Gynecology,a Office of Medical Education,b Department of Medical Education,c University of Michigan Medical School, Ann Arbor, MI Received for publication February 21, 2005; revised July 3, 2005; accepted August 8, 2005
KEY WORDS Quality of clerkship Medical student Work hours Obstetrics and gynecology clerkship
Objective: The objective of this study was to compare the students’ actual work hours with their self-reported work hours during the obstetrics and gynecology clerkship, and to determine whether the number of hours worked correlate with the amount of ‘‘scut’’ reported or students’ rating of the quality of the clerkship. Study design: Students self-reported work hours were compared against their actual scheduled hours over 2 different academic years. Pearson’s correlation was performed to correlate the actual hours with the amount of reported ‘‘scut’’ work and the overall rating of the quality of the clerkship. Results: The actual hours per week worked by students averaged 59 hours in 2003 and 48 hours in 2004. Students overestimated their work hours both years. Students who worked more hours rated the clerkship lower and the quality of the clerkship significantly improved from 2003 to 2004 (4.2 vs 3.8 P ! .03). Conclusion: The majority of third-year students overestimate their work hours in obstetrics and gynecology. The rating of the overall quality of the clerkship increase significantly with fewer hours worked, and it is not affected by the amount of ‘‘scut’’ work. Ó 2005 Mosby, Inc. All rights reserved.
The adoption of the 80-hour work week has resulted in major changes in residency programs in the United States. Although the airline, trucking, and railway industries have a longstanding history of having work hours regulated by the government,1 until recently work hour restrictions in the medical field were not mandated. However, on June 11, 2002, the Accreditation Council for Graduate Medical Education (ACGME) passed universal standards limiting resident work hours to 80 hours per week. These new regulations became effective July 1, 2003. Reprints not available from the authors. 0002-9378/$ - see front matter Ó 2005 Mosby, Inc. All rights reserved. doi:10.1016/j.ajog.2005.08.017
In February 2004, the Liaison Committee on Medical Education (LCME) officials added an annotation regarding student work hour regulations to its accreditation standards.2 They recommended that in addition to monitoring the amount of classroom time and examination frequency, medical schools should pay attention to the hours that medical students work during the clinical years and the educational value of their clinical activities. Student duty hours should be set taking into account the effects of fatigue and sleep deprivation on learning and patient care, and medical students should not be required to work longer hours than residents. Soon after this decision by the LCME, the Medical
Casey et al
1781
Student Section (MSS) of the American Medical Association (AMA) passed a resolution (MSS Resolution 16: Medical Student Clinical Training and Education Condition),3 asking the AMA to encourage the LCME to follow the lead of the ACGME and include specific limits on the workload of students in its accreditation standards. Namely, the resolution for medical student education called for an 80-hour work week, a 24-hour limit on shifts, and on call no more than once every 3 nights. As early as 2001, 17 of 124 US medical schools reported having formal policies on medical students hours4; however, little is known about the number of actual or reported student work hours. Burke et al5 published self-reported students’ work hours during their third-year required clerkships; in that study students indicated an average between 47 to 87 hours per week depending on the clerkship, with 2 clerkships reaching more than 80 hours. A study by Chen et al6 at Harvard Medical School, which asked medical students to track their daily hours for 1 week, indicated that students spent a mean of 74 hours per week in the hospital, with some reporting as many as 106 hours per week. Mean work hours were dramatically higher on inpatient rotations (90 hours per week) than on outpatient rotations (45 hours per week). Students on surgery rotations worked the longest hours, with a mean of more than 94 hours per week spent in the hospital during an inpatient rotation. At the University of Michigan Medical School, when the 80-hour work week regulation was adopted for residents, medical students began to report anecdotally an increase in their work hours. In addition, curriculum leaders considered adopting similar restrictions on medical students work hours, so starting in 2003, students on all required clerkships (internal medicine, surgery, obstetrics and gynecology, pediatrics, family medicine, neurology, psychiatry) were asked at the end of the rotation to report how many hours they were required to be in the hospital per week. When we reviewed the number of hours students reported working during their third-year obstetric and gynecologic (Ob-Gyn) clerkship, we found a sizeable discrepancy between their reports and the hours they were scheduled to work. We undertook this study to compare the students’ scheduled or actual hours versus their perceived or self-reported work hours in 2003 and 2004. In addition, we wanted to determine whether the number of work hours correlated with the amount of academically unproductive (‘‘scut’’) work they performed, as well as their overall rating of the quality of the clerkship.
work schedule. The schedule specified their daily assignments including clinics, inpatient services, and on-call responsibilities. At the end of the clerkship, all students completed a confidential online survey rating the quality of their experiences on a 5-point Likert scale from 1 to 5 (1 = poor; 5 = excellent). The questionnaire covered several areas of their experiences including the overall quality of the clerkship. They were also asked to estimate the amount of time spent in academically unproductive work on a scale of 1 to 5 (1 = too little; 3 = just right; 5 = too much), and the average number of hours per week they were required to be in the hospital or clinics on a 4-point categorical scale as follows: 1 = less than 60 hours; 2 = 61 to 70 hours; 3 = 71 to 80 hours; 4 = more than 80 hours. To reduce the number of medical student work hours, a student ‘‘night float’’ system was initiated in 2004, where students’ on-call responsibilities consisted of 3 consecutive 12-hour night shifts and a 12-hour shift on the weekend. This replaced the regular once-a-week call from the previous year. For the purposes of this study, we considered each year separately because of the curriculum change. After institutional review board exemption was obtained, all the students rotating at the University Hospital (70 in 2003 and 65 in 2004) were considered for the study. Although data were available on the reported work hours for most of the students because more than 95% filled out a clerkship survey, we were unable to retrieve all the actual work schedules that resulted in available data for 35 students from 2003 and 42 students from 2004. In calculating the actual hours, we added the number of hours scheduled each day to compute the hours per week. The hours per week were then combined and divided by 6 to calculate average hours per week worked. To compare students’ scheduled or actual work hours with their reported or perceived work hours, the students were separated into 4 groups on the basis of their reported work hours category 1 to 4 (1 = !60 hours; 2 = 61-70 hours; 3 = 71-80 hours; 4 = 80 hours). These were compared against the actual work hours we calculated for them. In addition, Pearson’s correlation was performed to correlate the actual hours with the amount of reported scut work and the overall rating of the quality of the clerkship. The c2 analysis was performed to check if the amount of scut work was different between 2003 and 2004, and an analysis of variance was performed to compare the overall quality of the clerkship between the 2 years.
Methods
The actual hours per week worked by students were higher in 2003 (59 hours, range: 52-68) than in 2004 (48 hours, range: 43-52). The estimated hours worked per week were also much higher in 2003 than 2004 as
At the beginning of the 6-week Ob-Gyn clerkship, all students rotating at the University Hospital were given a
Results
1782
Casey et al
Table I The reported number of hours and the actual number of hours worked by third-year medical students during the obstetrics and gynecology clerkship Year
Number of students
Student percent
Reported hours
Actual hours (range)
2003 2003 2003 2003
1 9 21 4
3 26 60 11
!60 61-70 71-80 O80
60 59 (53-68) 59 (52-64) 59 (56-61)
2004 2004 2004 2004
20 17 5 0
48 41 12 0
!60 61-70 71-80 O80
47 (44-50) 49 (43-52) 49 (48-51) n/a
shown in Table I. At least 71% of the students overestimated their work hours in 2003 compared with 53% of the students in 2004. More interestingly, although the actual hours worked was only about 10 more hours in 2003 than it was in 2004, 71% of the students reported working more than 70 hours per week in 2003 and only 12% reported working that many hours in 2004. Students reporting less than 60 hours per week were the most accurate, whereas those reporting more than 80 hours were the least accurate (Figure). The actual hours worked correlated negatively with the overall rating of the quality of the clerkship for 2004 and for both years combined. Students who worked more hours rated the clerkship lower (Table II). In addition, the actual number of hours worked correlated with the amount of scut work for both years combined. This relationship did not hold true when considering each year separately. There was no significant correlation between the rating of the overall quality of the clerkship and the amount of scut work. There was no significant distribution difference in the amount of scut work reported between 2003 and 2004; however, the overall quality of the clerkship did significantly improve in 2004 (4.2 vs 3.8 P ! .03).
Comment The reported hours and the actual hours worked by medical students decreased in 2004, which reflected a restructuring of the clerkship. Students no longer had regular on-call duties, which eliminated 24- to 36-hour shifts, so the actual number of hours worked per week decreased from 59 hours in 2003 to 48 hours in 2004. Although a large number of students were still overestimating their hours in 2004, they represented a smaller percentage than the students who overestimated their hours in 2003. These findings indicate that students tend to overestimate their work hours more when they are actually working more. In addition, the more hours students worked, the more scut they reported. This
Figure Differences between perceived and actual hours worked. Table II Correlations between the overall quality of the clerkship, actual work hours, and amount of scut work Year 2003 Overall quality of clerkship Amount of scut work
2004 Overall quality of clerkship Amount of scut work
2003 and 2004 Overall quality of clerkship Amount of scut work
Actual hours
Amount of scut work
R P R P
= = = =
0.0312* .859y 0.2789 .105
R = 0.0437 P = .80
R P R P
= = = =
0.3452 .025 0.0993 .531
R = 0.0313 P = .844
R P R P
= = = =
0.2685 .018 0.3004 .008
R = 0.0488 P = .67
* R = Correlation coefficient. y P = P value.
could indicate that with longer hours, students are either spending more time in academically unproductive activities or the students potentially perceive less quality to their learning experience because they are tired. Our data show that decreasing the number of work hours and providing a structured schedule contributed to higher student ratings of the Ob/Gyn clerkship. Several studies support the notion that a structured work schedule results in increased student satisfaction with the clerkship.7-10 Considering that the Ob/Gyn clerkship has been the lowest rated clerkship by medical students,11 these findings support the importance of developing a structured clerkship with reasonable hours to improve the quality of the educational experience for third-year medical students.
Casey et al It is interesting that third-year medical students reported spending more hours at the hospital than what they were scheduled to work. We thought one explanation for this might be that some students elected to stay and work beyond their scheduled hours. However, a discussion with students and residents indicated this was not the case. Although there were occasional instances where a student stayed late for an interesting case, students on gynecology call were also often sent home ahead of schedule. Students were also often excused early and they were not expected to be present for gynecology afternoon rounds. In addition, when we calculated their hours, we tried to err on the side of overestimating. For example, we added extra hours for students on gynecologic oncology, assuming they stayed late every day although this only happened on average 2 times a week. We also assumed students were at the hospital 1 hour before rounds, which is often not true. In any case, even if there were instances where a student might have worked more hours than scheduled, it was impossible to account for all of the extra reported hours, which in some cases reached more than 20 hours per week. A second possibility might be that students simply are not able to estimate their work hours accurately. It has been suggested that medical students’ estimations of their work hours may actually be a reflection of residents’ work hours observed by the students.12 In addition, previous studies in medical and higher education have shown that students are not very accurate in selfassessing their performance.13 When looking specifically at medical student self-assessment, investigators have found that the less experience a student has (ie, transitioning from the familiarity of the classroom to the clinical clerkships), the more self-assessment accuracy and performance suffers.14 Student work hours can potentially fall into this category where third-year medical students are simply not experienced enough to accurately assess their hours. A third possibility for these findings might be that students think they are working more hours because they are working hard or because of the many variations in their daily schedule. The Ob-Gyn clerkship is a challenging clerkship. Students rotate through so many different services including the operating room, labor and delivery, clinic, or night float. Some of these services can be very demanding and stressful and students might tend to recall these experiences more than others. This makes it difficult for students to accurately recall the hours by simple reflection. It would be interesting to perform similar analyses for other clerkships, specifically, some of the less demanding ones with more outpatient setting and no on-call duties to check if there would be similar findings. Whatever the causes are, this perception by medical students that they are working longer hours than they
1783 actually are can have serious implications. The perceived work hours required in surgical residencies play a part in a decreased interest in those specialties.12,15,16 For example, Miller et al17 surveyed 134 third- and fourthyear medical students to determine factors that influenced their decision in choosing a specialty. They found that 38% would not consider a residency program with a reputation for long work hours. In a separate study, Miller et al18 looked at how students entering surgical fields developed their personal rank list. They found that 40% of the applicants ranked higher those programs that strictly adhered to work hour limitations. Thus, as students estimate long working long hours in obstetrics and gynecology they might also consider those hours negatively as they consider their residency choices. This is of special importance to the Ob-Gyn specialty because of the decreased number of students choosing to enter the field.19 The adoption of the 80-hour work week regulation mandated by the ACGME has resulted in a restructuring of several residency programs nationwide. Much discussion has been generated about its impact on residents’ experience and job satisfaction.20,21 When considering restricted work hours for medical students we must remind ourselves of the role of the medical student in the hospitaldmedical students are in the hospital to learn. It is our duty to create an ideal environment for them to learn by maximizing good educational opportunities and minimizing ‘‘scut’’ work. Furthermore, we have to consider how those perceptions of long hours might be impacting students’ career choices especially in obstetrics and gynecology.
References 1. Leach DC. Resident duty hours. The ACGME perspective. Neurology 2004;62:E1-2. 2. Current LCME Accreditation Standards. Available at: http: //www.lcme.org/standard.htm. Accessed on February 21, 2005. 3. Student Work Hours. Available at: http://www.ama-assn.org/ ama/pub/category/12141.html. Accessed on February 21, 2005. 4. Barzansky B, Etzel SI. Educational programs in US medical schools, 2001-2002 [see comment] JAMA 2002;288:1067-72. 5. Burke W, Williams JA, Fenner DE, Hammoud MM. The obstetrics and gynecology clerkship: building a better model from past experience. Am J Obstet Gynecol 2004;191:1772-6. 6. Chen J, Kamath R, Lam A, Litrovnik B, Leight K, Miller S, et al. How will changes in resident work hours affect medical students? Curr Surg 2003;60:268-70. 7. Ko CY, Escarce JJ, Baker L, Klein D, Guarino C. Predictors for medical students entering a general surgery residency: national survey results. Surgery 2004;136:567-72. 8. Sumit KD, Henke PK, Ailawadi G, Dimick JB, Colleti LM. Attending, house officer, and medical student perceptions about teaching in the third-year medical school general surgery clerkship. J Am Coll Surg 2004;199:932-42. 9. Pogacnik M, Juznic P, Kosorok-Drobnic M, Pogacnik A, Cestnik V, Kogovsek J, et al. An attempt to estimate student workload. J Vet Med Educ 2004;31:255-60.
1784 10. Dunn TS, Wolf D, Beuler J, Coddington CC. Increasing recruitment of quality students to obstetrics and gynecology: impact of a structured clerkship. Am Coll Obstet Gynecol 2004;103: 339-41. 11. AAMC Medical School Graduation Questionnaire, 1978-2003. Washington (DC): Association of American Medical Colleges; 2003. 12. O’Herrin JK, Lewis BJ, Rikkers LF, Chen H. Why do students choose careers in surgery? J Surg Res 2004;119:124-9. 13. Ward M, Gruppen L, Regehr G. Measuring self-assessment: current state of the art. Adv Health Sci Educ 2002;7:63-80. 14. Fitzgerald JT, White CB, Gruppen LD. A longitudinal study of self-assessment accuracy. Med Educ 2003;37:645-9. 15. Azizzadeh H, McCollum CH, Miller CC 3rd, Holliday KM, Shilstone HC, Lucci A Jr. Factors influencing career choice among medical students interested in surgery. Curr Surg 2003;60: 210-3.
Casey et al 16. Gelfand DV, Podnos YD, Wilson SE, Cooke J, Williams RA. Choosing general surgery: insights into career choices of current medical students. Arch Surg 2002;137:941-7. 17. Miller G, Bamboat ZM, Allen F, Biernacki P, Hopkins MA, Gouge TH, et al. Impact of mandatory resident work hour limitations on medical students’ interest in surgery. J Am Coll Surg 2004;199:615-9. 18. Miller G, Bamboat ZM, Allen F, Hopkins MA, Gouge TH, Riles TS, et al. Attitudes of applicants for surgical residency toward work hour limitations. Am J Surg 2004;188:131-5. 19. National Resident Matching Program Match Data. Advanced data tables 2004. Available at: http://www.nrmp.org/res_match/ tables/table5_04.pdf. Accessed on February 21, 2005. 20. Killelea BK, Chao L, Scarpinato V. The 80 hour workweek. Surg Clin N Am 2004;84:1557-72. 21. Lund KJ, Alvero R, Teal SB. Resident job satisfaction: will 80 hours make a difference? Am J Obstet Gynecol 2004;191:1805-10.
www.ajog.org
Medical students self-reported work hours: Perception versus reality Colleen Casey, MD,a Sangeeta Senapati, MD,a Casey B. White, PhD,b Larry D. Gruppen, PhD,c Maya M. Hammoud, MDa Department of Obstetrics and Gynecology,a Office of Medical Education,b Department of Medical Education,c University of Michigan Medical School, Ann Arbor, MI Received for publication February 21, 2005; revised July 3, 2005; accepted August 8, 2005
KEY WORDS Quality of clerkship Medical student Work hours Obstetrics and gynecology clerkship
Objective: The objective of this study was to compare the students’ actual work hours with their self-reported work hours during the obstetrics and gynecology clerkship, and to determine whether the number of hours worked correlate with the amount of ‘‘scut’’ reported or students’ rating of the quality of the clerkship. Study design: Students self-reported work hours were compared against their actual scheduled hours over 2 different academic years. Pearson’s correlation was performed to correlate the actual hours with the amount of reported ‘‘scut’’ work and the overall rating of the quality of the clerkship. Results: The actual hours per week worked by students averaged 59 hours in 2003 and 48 hours in 2004. Students overestimated their work hours both years. Students who worked more hours rated the clerkship lower and the quality of the clerkship significantly improved from 2003 to 2004 (4.2 vs 3.8 P ! .03). Conclusion: The majority of third-year students overestimate their work hours in obstetrics and gynecology. The rating of the overall quality of the clerkship increase significantly with fewer hours worked, and it is not affected by the amount of ‘‘scut’’ work. Ó 2005 Mosby, Inc. All rights reserved.
The adoption of the 80-hour work week has resulted in major changes in residency programs in the United States. Although the airline, trucking, and railway industries have a longstanding history of having work hours regulated by the government,1 until recently work hour restrictions in the medical field were not mandated. However, on June 11, 2002, the Accreditation Council for Graduate Medical Education (ACGME) passed universal standards limiting resident work hours to 80 hours per week. These new regulations became effective July 1, 2003. Reprints not available from the authors. 0002-9378/$ - see front matter Ó 2005 Mosby, Inc. All rights reserved. doi:10.1016/j.ajog.2005.08.017
In February 2004, the Liaison Committee on Medical Education (LCME) officials added an annotation regarding student work hour regulations to its accreditation standards.2 They recommended that in addition to monitoring the amount of classroom time and examination frequency, medical schools should pay attention to the hours that medical students work during the clinical years and the educational value of their clinical activities. Student duty hours should be set taking into account the effects of fatigue and sleep deprivation on learning and patient care, and medical students should not be required to work longer hours than residents. Soon after this decision by the LCME, the Medical
Casey et al
1781
Student Section (MSS) of the American Medical Association (AMA) passed a resolution (MSS Resolution 16: Medical Student Clinical Training and Education Condition),3 asking the AMA to encourage the LCME to follow the lead of the ACGME and include specific limits on the workload of students in its accreditation standards. Namely, the resolution for medical student education called for an 80-hour work week, a 24-hour limit on shifts, and on call no more than once every 3 nights. As early as 2001, 17 of 124 US medical schools reported having formal policies on medical students hours4; however, little is known about the number of actual or reported student work hours. Burke et al5 published self-reported students’ work hours during their third-year required clerkships; in that study students indicated an average between 47 to 87 hours per week depending on the clerkship, with 2 clerkships reaching more than 80 hours. A study by Chen et al6 at Harvard Medical School, which asked medical students to track their daily hours for 1 week, indicated that students spent a mean of 74 hours per week in the hospital, with some reporting as many as 106 hours per week. Mean work hours were dramatically higher on inpatient rotations (90 hours per week) than on outpatient rotations (45 hours per week). Students on surgery rotations worked the longest hours, with a mean of more than 94 hours per week spent in the hospital during an inpatient rotation. At the University of Michigan Medical School, when the 80-hour work week regulation was adopted for residents, medical students began to report anecdotally an increase in their work hours. In addition, curriculum leaders considered adopting similar restrictions on medical students work hours, so starting in 2003, students on all required clerkships (internal medicine, surgery, obstetrics and gynecology, pediatrics, family medicine, neurology, psychiatry) were asked at the end of the rotation to report how many hours they were required to be in the hospital per week. When we reviewed the number of hours students reported working during their third-year obstetric and gynecologic (Ob-Gyn) clerkship, we found a sizeable discrepancy between their reports and the hours they were scheduled to work. We undertook this study to compare the students’ scheduled or actual hours versus their perceived or self-reported work hours in 2003 and 2004. In addition, we wanted to determine whether the number of work hours correlated with the amount of academically unproductive (‘‘scut’’) work they performed, as well as their overall rating of the quality of the clerkship.
work schedule. The schedule specified their daily assignments including clinics, inpatient services, and on-call responsibilities. At the end of the clerkship, all students completed a confidential online survey rating the quality of their experiences on a 5-point Likert scale from 1 to 5 (1 = poor; 5 = excellent). The questionnaire covered several areas of their experiences including the overall quality of the clerkship. They were also asked to estimate the amount of time spent in academically unproductive work on a scale of 1 to 5 (1 = too little; 3 = just right; 5 = too much), and the average number of hours per week they were required to be in the hospital or clinics on a 4-point categorical scale as follows: 1 = less than 60 hours; 2 = 61 to 70 hours; 3 = 71 to 80 hours; 4 = more than 80 hours. To reduce the number of medical student work hours, a student ‘‘night float’’ system was initiated in 2004, where students’ on-call responsibilities consisted of 3 consecutive 12-hour night shifts and a 12-hour shift on the weekend. This replaced the regular once-a-week call from the previous year. For the purposes of this study, we considered each year separately because of the curriculum change. After institutional review board exemption was obtained, all the students rotating at the University Hospital (70 in 2003 and 65 in 2004) were considered for the study. Although data were available on the reported work hours for most of the students because more than 95% filled out a clerkship survey, we were unable to retrieve all the actual work schedules that resulted in available data for 35 students from 2003 and 42 students from 2004. In calculating the actual hours, we added the number of hours scheduled each day to compute the hours per week. The hours per week were then combined and divided by 6 to calculate average hours per week worked. To compare students’ scheduled or actual work hours with their reported or perceived work hours, the students were separated into 4 groups on the basis of their reported work hours category 1 to 4 (1 = !60 hours; 2 = 61-70 hours; 3 = 71-80 hours; 4 = 80 hours). These were compared against the actual work hours we calculated for them. In addition, Pearson’s correlation was performed to correlate the actual hours with the amount of reported scut work and the overall rating of the quality of the clerkship. The c2 analysis was performed to check if the amount of scut work was different between 2003 and 2004, and an analysis of variance was performed to compare the overall quality of the clerkship between the 2 years.
Methods
The actual hours per week worked by students were higher in 2003 (59 hours, range: 52-68) than in 2004 (48 hours, range: 43-52). The estimated hours worked per week were also much higher in 2003 than 2004 as
At the beginning of the 6-week Ob-Gyn clerkship, all students rotating at the University Hospital were given a
Results
1782
Casey et al
Table I The reported number of hours and the actual number of hours worked by third-year medical students during the obstetrics and gynecology clerkship Year
Number of students
Student percent
Reported hours
Actual hours (range)
2003 2003 2003 2003
1 9 21 4
3 26 60 11
!60 61-70 71-80 O80
60 59 (53-68) 59 (52-64) 59 (56-61)
2004 2004 2004 2004
20 17 5 0
48 41 12 0
!60 61-70 71-80 O80
47 (44-50) 49 (43-52) 49 (48-51) n/a
shown in Table I. At least 71% of the students overestimated their work hours in 2003 compared with 53% of the students in 2004. More interestingly, although the actual hours worked was only about 10 more hours in 2003 than it was in 2004, 71% of the students reported working more than 70 hours per week in 2003 and only 12% reported working that many hours in 2004. Students reporting less than 60 hours per week were the most accurate, whereas those reporting more than 80 hours were the least accurate (Figure). The actual hours worked correlated negatively with the overall rating of the quality of the clerkship for 2004 and for both years combined. Students who worked more hours rated the clerkship lower (Table II). In addition, the actual number of hours worked correlated with the amount of scut work for both years combined. This relationship did not hold true when considering each year separately. There was no significant correlation between the rating of the overall quality of the clerkship and the amount of scut work. There was no significant distribution difference in the amount of scut work reported between 2003 and 2004; however, the overall quality of the clerkship did significantly improve in 2004 (4.2 vs 3.8 P ! .03).
Comment The reported hours and the actual hours worked by medical students decreased in 2004, which reflected a restructuring of the clerkship. Students no longer had regular on-call duties, which eliminated 24- to 36-hour shifts, so the actual number of hours worked per week decreased from 59 hours in 2003 to 48 hours in 2004. Although a large number of students were still overestimating their hours in 2004, they represented a smaller percentage than the students who overestimated their hours in 2003. These findings indicate that students tend to overestimate their work hours more when they are actually working more. In addition, the more hours students worked, the more scut they reported. This
Figure Differences between perceived and actual hours worked. Table II Correlations between the overall quality of the clerkship, actual work hours, and amount of scut work Year 2003 Overall quality of clerkship Amount of scut work
2004 Overall quality of clerkship Amount of scut work
2003 and 2004 Overall quality of clerkship Amount of scut work
Actual hours
Amount of scut work
R P R P
= = = =
0.0312* .859y 0.2789 .105
R = 0.0437 P = .80
R P R P
= = = =
0.3452 .025 0.0993 .531
R = 0.0313 P = .844
R P R P
= = = =
0.2685 .018 0.3004 .008
R = 0.0488 P = .67
* R = Correlation coefficient. y P = P value.
could indicate that with longer hours, students are either spending more time in academically unproductive activities or the students potentially perceive less quality to their learning experience because they are tired. Our data show that decreasing the number of work hours and providing a structured schedule contributed to higher student ratings of the Ob/Gyn clerkship. Several studies support the notion that a structured work schedule results in increased student satisfaction with the clerkship.7-10 Considering that the Ob/Gyn clerkship has been the lowest rated clerkship by medical students,11 these findings support the importance of developing a structured clerkship with reasonable hours to improve the quality of the educational experience for third-year medical students.
Casey et al It is interesting that third-year medical students reported spending more hours at the hospital than what they were scheduled to work. We thought one explanation for this might be that some students elected to stay and work beyond their scheduled hours. However, a discussion with students and residents indicated this was not the case. Although there were occasional instances where a student stayed late for an interesting case, students on gynecology call were also often sent home ahead of schedule. Students were also often excused early and they were not expected to be present for gynecology afternoon rounds. In addition, when we calculated their hours, we tried to err on the side of overestimating. For example, we added extra hours for students on gynecologic oncology, assuming they stayed late every day although this only happened on average 2 times a week. We also assumed students were at the hospital 1 hour before rounds, which is often not true. In any case, even if there were instances where a student might have worked more hours than scheduled, it was impossible to account for all of the extra reported hours, which in some cases reached more than 20 hours per week. A second possibility might be that students simply are not able to estimate their work hours accurately. It has been suggested that medical students’ estimations of their work hours may actually be a reflection of residents’ work hours observed by the students.12 In addition, previous studies in medical and higher education have shown that students are not very accurate in selfassessing their performance.13 When looking specifically at medical student self-assessment, investigators have found that the less experience a student has (ie, transitioning from the familiarity of the classroom to the clinical clerkships), the more self-assessment accuracy and performance suffers.14 Student work hours can potentially fall into this category where third-year medical students are simply not experienced enough to accurately assess their hours. A third possibility for these findings might be that students think they are working more hours because they are working hard or because of the many variations in their daily schedule. The Ob-Gyn clerkship is a challenging clerkship. Students rotate through so many different services including the operating room, labor and delivery, clinic, or night float. Some of these services can be very demanding and stressful and students might tend to recall these experiences more than others. This makes it difficult for students to accurately recall the hours by simple reflection. It would be interesting to perform similar analyses for other clerkships, specifically, some of the less demanding ones with more outpatient setting and no on-call duties to check if there would be similar findings. Whatever the causes are, this perception by medical students that they are working longer hours than they
1783 actually are can have serious implications. The perceived work hours required in surgical residencies play a part in a decreased interest in those specialties.12,15,16 For example, Miller et al17 surveyed 134 third- and fourthyear medical students to determine factors that influenced their decision in choosing a specialty. They found that 38% would not consider a residency program with a reputation for long work hours. In a separate study, Miller et al18 looked at how students entering surgical fields developed their personal rank list. They found that 40% of the applicants ranked higher those programs that strictly adhered to work hour limitations. Thus, as students estimate long working long hours in obstetrics and gynecology they might also consider those hours negatively as they consider their residency choices. This is of special importance to the Ob-Gyn specialty because of the decreased number of students choosing to enter the field.19 The adoption of the 80-hour work week regulation mandated by the ACGME has resulted in a restructuring of several residency programs nationwide. Much discussion has been generated about its impact on residents’ experience and job satisfaction.20,21 When considering restricted work hours for medical students we must remind ourselves of the role of the medical student in the hospitaldmedical students are in the hospital to learn. It is our duty to create an ideal environment for them to learn by maximizing good educational opportunities and minimizing ‘‘scut’’ work. Furthermore, we have to consider how those perceptions of long hours might be impacting students’ career choices especially in obstetrics and gynecology.
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