Medical Student Workload on Clinical Rotations

Medical student workloads on clinical clerkships in Harvard-affiliated clinical institutions must support students’ learning while maintaining an appropriate level of engagement with the clinical environment. The specific details of these expectations will vary somewhat with the clinical specialty or rotation, but must:

• Ensure that educational priorities outweigh the service needs of the clinical setting.
• Take into account the impact of fatigue on learning.
• Reinforce the fact that duty-hours restrictions, like other compliance requirements for physicians, are consistent with the necessity of meeting professional standards.

Duty Hours

The directors of each core clerkship, subinternship, and clinical elective determine how best to accomplish the educational goals and objectives for students and, on that basis, design the experience to provide the best opportunity for student learning and to achieve a balance that favors learning over service. While time spent during regular working hours may suffice for most learning experiences, overnight call or participation in early morning work rounds with the medical or surgical team may be necessary to accomplish other clerkship goals (e.g., delivering babies during overnight call in OB/GYN; the unique learning experience a student shares with an on-call intern during overnight call; experience in surgical trauma; review of patients with the team at the beginning of the day, etc.).

Student duty hours in Harvard Medical School core and elective clerkships should follow the ACGME standard that limits duty hours to not more than 80 hours per week, averaged over a four-week period, inclusive of all in-house call activities, with the following caveats:

• Adequate time for rest and personal activities must be provided. Optimally, this should be a 10-hour time period provided between all daily duty periods and after in-house call.
• The on-duty time medical students spend delivering patient care services of marginal or no educational value should be minimized.
• If a student believes that he/she is being asked to remain on duty beyond the duty hour limits, the student should immediately consult with the Clerkship Director and/or the PCE Director.
• Religious holidays* must be respected. Students requesting time off for religious observances must notify supervising faculty in advance and assure appropriate clinical coverage by another student, resident, or faculty member. Students may be required to make up any missed academic or clinical work at the discretion of the clerkship director.

Limiting required duty hours does not imply that medical students must cease providing essential patient care services at arbitrary cut-off times. Priority must always be given to patient safety and well-being and to avoiding transferring patient care responsibilities to others at inappropriate times in the continuum of care (e.g., during an operative procedure or in the midst of a rapidly evolving clinical event). A tired medical student who is intimately familiar with a sick patient is often better able to provide quality care than is a fully rested medical student who is unfamiliar with the details of the case.

Like residents, however, students are expected to respect and operate within HMS duty-hour policy limits. Working longer than 80 hours/week leads to fatigue that can both degrade your ability to learn and put patients at risk; therefore, violation of duty-hour limits represents a lapse in professional responsibility. Residencies do not expect students to take, and actually discourage students from taking, the responsibility of bridging between rotating teams of residents, and you should avoid the temptation to violate duty hours in order to do so. Worth reiterating, it is a matter of professionalism and a responsibility to patients for students to monitor their own hours to assure that voluntary violations of duty hours limits do not occur.

Adapted from: AAMC Policy Guidance on Graduate Medical Education- Assuring Quality Patient Care and Quality Education and from ACGME's Approach to Limit Resident Duty Hours 12 Months after Implementation).

Monitoring

Monitoring of these guidelines is the responsibility of the Clerkship Director, the PCE Director, and the Dean for Medical Education. The Program in Medical Education surveys Core Clerkship Directors annually regarding the amount of time medical students spend in required activities, including the total number of hours medical students are required to spend in clinical and educational activities during clinical clerkships.

Students are also asked to respond to a question about duty hours on the PCE log at the mid-point and the end of each clerkship, as indicated below. Responses will be reviewed by the clerkship director and PCE mentor to insure that students are not exceeding the 80-hour limit and to remedy the situation if the limit is being exceeded. Students who continue to exceed the 80-hour limit will be cited for unprofessional behavior in their clerkship evaluation.

Please follow the guidelines below in responding to the duty-hours survey:

During a typical week in this clerkship, do you spend more than 80 hours on duty, physically present at the hospital/clinic?

Response options: Yes or No

Guidelines:

• DO INCLUDE all clinical and academic activities during which you were physically present in the hospital or clinic—hours of scheduled clerkship activities (rounding, seeing patients, completing medical records, ordering and reviewing lab tests, etc.), time spent sleeping in the hospital when you are on-call (but not when you are not on-call), time in scheduled didactic sessions, and time in the Primary Care Clerkship, PCE tutorials, and Patient Doctor-III.
• DO NOT INCLUDE time spent commuting; reading, studying, or preparing academically at home or away from the patient care unit, such as preparing for presentations or conferences and studying for exams; or on hospital premises for activities that are not scheduled as part of your clerkship.

*Harvard University Policy on Religious Holidays (Section 7.01)

In accordance with Massachusetts State law, any student in an educational institution who is unable, because of his or her religious beliefs, to attend classes or to participate in any examination, study, or work requirement on a particular day shall be excused from any such examination, study, or work requirement. The student shall be provided with an opportunity to make up such examination, study or work requirement, which he or she may have missed because of such absence on any particular day, provided that such makeup examination or work does not create an unreasonable burden upon the School. No fees of any kind shall be charged by the institution for making available to the said student such opportunity. No adverse or prejudicial effects shall result to any student because of his/her availing himself or herself of the provisions of this section.