The scope of duty hour-associated residency structure modifications.

OBJECTIVE: The purpose of this study was to characterize the duty hours-associated modifications made to the educational and patient care structure of obstetrics and gynecology residency programs, and the relationship of these modifications to residency program setting and size. STUDY DESIGN: A survey of accredited obstetrics and gynecology residency programs in the United States (excluding New York State) was performed between June 21st and July 16th, 2004. Program representatives were queried on the difficulty encountered in complying with each of the 6 components of the ACGME common duty hour requirements and the prevalence of residency modifications affecting the educational and patient care structure. RESULTS: Fifty-eight percent (123/211) of the study population completed the questionnaire. Ensuring a minimum 10-hour rest period between shifts was rated the most difficult requirement. Ninety-eight percent of respondents reported various types of modifications to program structure, including modification of on-call structure (94%), redistribution of responsibilities among resident levels (85%), modification of resident participation in patient care processes (80%), and modification of resident assignments to clinical services (75%). A minimum of 38% of programs reported reductions in resident participation in patient care, regardless of clinical service type or care setting. The prevalence of hiring attending physicians was significantly higher among non-university-based programs (18%), compared to university-based programs (3%, P = .007). CONCLUSION: Duty hour-related changes have resulted in near universal program modifications. One third of programs have made modifications that have resulted in a decrease in the available clinical experiences for residents.

The perceived impact of duty hour restrictions on the residency environment: a survey of residency program directors.

OBJECTIVE: The purpose of this study was to characterize residency program director baseline perceptions regarding the effect of resident duty hour limitations on key components of the graduate medical education environment. STUDY DESIGN: This was a survey of directors of accredited obstetrics and gynecology residency programs in the United States (excluding New York State) between June 21st and July 16th, 2004. Participants were queried on views regarding the need for duty hour limitations, and the perceived effect of these changes on various issues related to the residency environment. RESULTS: Fifty-eight percent (123/211) of the study population completed the questionnaire. Seventy-one percent of respondents supported duty hour restrictions, 19% opposed restrictions, and 10% were undecided. Forty-one percent of respondents preferred a maximum duty hour limitation of 80 hrs/wk or less, 55% preferred one at least 90 hrs/wk, and 4% preferred no upper limit. A significantly greater proportion of female program directors supported limits > 80 hrs/wk than males (73% vs 53%, P = .04). A majority of participants believed resident education, surgical skills, and work ethic have been negatively impacted by the limitations, while patient safety and the overall quality of patient care have remained unchanged or declined, and resident well-being has improved. Opposition to duty hour regulations and a preference for higher limits was associated with a higher prevalence of negative impressions regarding the impact of duty hour regulations on the residency environment. CONCLUSION: Variations in current opinions regarding the impact of residency duty hour restrictions reflect ongoing bias in those most influential to resident education.

The relationship between practice setting and management of preterm premature rupture of membranes.

OBJECTIVE: To compare preterm premature rupture of membranes (PPROM) management between maternal-fetal medicine (MFM) providers practicing in an academic university (AU) versus other settings (NAU). METHODS: Secondary analysis of a national survey of 1375 MFM providers of whom 504 (37%) responded and answered queries on demographic and practice characteristics and various PPROM management issues. RESULTS: Fifty-three percent of the respondents were in an AU practice setting. Providers in AU and NAU settings reported a similar prevalence of corticosteroid (99% vs. 100%), antibiotic (99% vs. 100%), and tocolytic (74% vs. 76%) use. There was significant variability between NAU and AU providers in issues related to the evaluation and expectant management of PPROM. NAU providers, as compared to AU providers, more commonly reported performing diagnostic amniocentesis in the acute evaluation of PPROM (72% vs. 61%, p = 0.02). There was a higher prevalence of fetal lung maturity assessment among NAU providers (84%) as compared to AU providers (73%, p = 0.005) and significant variability was noted with respect to the fetal lung maturity tests used (p < 0.0001). NAU providers continued expectant management later into gestation than AU providers (p = 0.002). Significant variability was also noted in the use of antepartum surveillance techniques (p = 0.01). CONCLUSION: MFM practitioners from academic universities and non-academic settings utilize similar management strategies for PPROM in regard to corticosteroid, tocolytic, and antibiotic use. However, differences are evident in issues related to the evaluation and expectant management of patients with PPROM.

Contemporary management of preterm premature rupture of membranes (PPROM): a survey of maternal-fetal medicine providers.

OBJECTIVE: This study was undertaken to characterize variations in the management for women with preterm premature rupture of membranes (PPROM) among maternal-fetal medicine (MFM) specialists in the context of current recommendations for clinical practice and evidenced-based practice. STUDY DESIGN: We performed a Web-based survey of 1375 MFM providers. Participants were queried on practice characteristics and management issues including use of tocolytics, antibiotics, steroids, and timing of delivery. RESULTS: A total of 508 providers (37%), representing all 50 states and 13 countries, responded to the survey. Only 30% reported a formal departmental protocol for managing women with PPROM. Consistent use of steroids (99.4%) and antibiotics (99.6%) were reported. Administration of steroids was confined to < or =32 weeks by 37%, and < or =34 weeks by 51% of practitioners. Repeated dosing of steroids was uncommon (16%). The antibiotics use and rationale for use varied among respondents. Tocolytics were used by 73% of respondents with magnesium sulfate the main agent used (98%). Use of tocolytics was generally used for 48 hours or less to attain steroid benefit (88%). Amniocentesis was used by 66% of practitioners in the acute evaluation of PPROM. Fetal lung maturity testing was reported by 78% with variability noted with respect to the test used. Outpatient management of women with PPROM after viability was noted by 43% of respondents. Gestational age at which expectant management is abandoned in women with PPROM varied significantly between respondents: > or =34 weeks by 56%, > pr =35 weeks by 26%, > or =36 weeks by 12%, and > or =37 weeks by 4.0%. CONCLUSION: Although many management practices for women with PPROM are consistent with currently available evidence and practice recommendations, substantial variations still exist among MFM providers.