My $0.02 on this, and my personal experience.
I was doing my 3rd year at my first school during the time prior to the instigation of the rules. I did general surgery as a student the way the residents did: q3 call, 2am lectures on the call night, with operating days being the post-call day. Days not on call, I was in the hospital with the interns at 430-5am, then out at the earliest 8pm. 5 days off in six weeks, with two days to travel back to the school for the shelf exam.
Medicine was even worse: 5am to 9pm on average, with call days going from 5am to whenever the next day, usually 9pm+. The lectures in the morning, noon, and in the late afternoon made the Marquis de Sade envious at the torture. It seems every time the teams got into the groove of getting work done, there was another lecture. For basic knowledge, I learn better from a book than a lecture by someone who drones. No days where we didn't go into the hospital.
My condition manifested during this time, and I had to leave USU and the service soon after.
Flash forward to 2004: when I transferred into school at the 3rd year level.
Surgery: Not allowed to go into the hospital before 6am, then we were usually done by 6pm. Call for the students was until 11pm due to mandatory lectures. While the attendings teased the interns and residents about having to be out at the 30-hour mark, I heard them being heart attack serious about it in reality. They knew they were under the microscope by pretty much everyone, as surgery supposedly is the specialty that crushed the soul with the hours. I got one day off in six (actually 36 hours, as we came in one weekend day until noon.) Never saw someone break the rules clinically. The only rule-breaker I know was the chief resident I had cloak me in my long-coat ceremony (started this school with surgery, and he was the first one I worked with.) He stayed in the hospital beyond hours to do it for me, and I got him out ASAP.
Medicine: Did time at two hospitals. While they were smiling on the floors (my first reaction: "Wait, am I on internal medicine wards? Aren't we all supposed to be miserable, frowning dregs?") There were still rules violation; I saw one resident stay well past the 30 hours on paperwork alone. Students didn't stay in the hospital overnight, as they had mandatory lectures every day. Same setup as surgery for students on the weekends; 36 hours off. The second hospital was much better. Despite me wanting to be in the thick of things, the interns and the resident of my team pretty much got me out at 5pm, and unless on call, stay home on the weekend, under the half joking threat of beatings. (my reaction: "WTF?!") I obeyed Rule #6 of surgery, (when told to go home, get the f*** out of the hospital.) This hospital was consistent, and *almost* had me thinking a medicine internship wouldn't be bad. No violations that I saw at this hospital.
Flash forward to surgery prelim 1 and 2 years: I scrambled to this program, and I was shocked at how well the program treated. Q4 call on average, with NY requiring you to be out by 27 hours, not 30. All lectures aside from journal club were scheduled to accommodate this (you were excused from journal club post-call.) Hours were usually 6am to 5-6pm. Residents made the call schedule, were accommodating to times as needed, and schedule at least 2 golden weekends a month Call was usually Friday and Sunday or Saturday 1 weekend, and either Thursday call (off for 3 days,) or work until Friday, then weekend off. Possibly one of the friendliest surgery programs I have yet to encounter. Our program director and our vice director (my mentor,) were almost fanatical about getting us out at the appointed time. We even had transitionals do electives in surgery for the hours.
Medicine/transistionals at this hospital were different. In at 6am (like we were,) but would work way later than I thought they should have. When I was on call, I would see medicine teams not on call still roaming the hospital until 9pm+. Their one day off was 24 hours precisely. Compared to us, they were beaten badly. Even as an intern, when transitionals that chose surgery as an elective, I would force them out of the hospital post-call at the appointed time, as I confided in my chiefs that these guys were lying through their teeth about hours. In my second year, *every* transitional chose surgery as an elective at *least* once, because we would enforce the hours.
The only time a surgery resident ever broke the hour limitations was during my second year; an intern who was doing the random timecards on the mandatory medicine ICU rotation (required by our program.) He logged 85-90hrs a week for most of the rotation. Man, was my PD and my mentor were honked at the medicine service for that. But they didn't admonish nor punish the intern for being honest. In fact, our PD, being a medical officer in the service for a few years, adhered to the Officer code: "I will not lie, cheat, or steal, or tolerate those who do."
As for academics: I will admit that my ABSITEs weren't the best, but the categoricals were pretty good. Every graduating senior got the fellowship of their choice; one got hearts at Cleveland, one got vascular at Strong in Rochester, NY, and the rest got minimal invasive fellowships anywhere from Virginia to California.
I think I had a unique experience, and I know I have seen most of this from a student's point of view. However, I could see improvement in morale, teamwork, cross coverage, and interpersonal skills from the point the hour limits hit. I know the limits go away when you become an attending, as everyone should be aware of. But I think the time limit force people to give high quality, to the point education.
I believe that sometimes rules present a challenge. The time rule challenges teachers to give the same quality or better education within the limited time they have. I have heard of programs clocking out to attend lectures "off the time rules." I fortunately have never been in one.
/end my $0.02
