Shifting Indirect Patient Care Duties to After Hours in the Era of Work Hours Restrictions.
Acad Med. 2011 Mar 23;
Authors: Mourad M, Vidyarthi AR, Hollander H, Ranji SR
PURPOSE: Few data describe how often residents d…

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Lost in Transition: The Experience and Impact of Frequent Changes in the Inpatient Learning Environment.
Acad Med. 2011 Mar 23;
Authors: Bernabeo EC, Holtman MC, Ginsburg S, Rosenbaum JR, Holmboe ES
PURPOSE: The tradit…

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Use of simulated pages to prepare medical students for internship and improve patient safety.
Acad Med. 2011 Jan;86(1):77-84
Authors: Schwind CJ, Boehler ML, Markwell SJ, Williams RG, Brenner MJ
During the transition f…

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Perspective: Malpractice in an Academic Medical Center: A Frequently Overlooked Aspect of Professionalism Education.

Acad Med. 2011 Jan 18;

Authors: Hochberg MS, Seib CD, Berman RS, Kalet AL, Zabar SR, Pachter HL

Understanding how medical malpractice occurs and is resolved is important to improving patient safety and preserving the viability of a physician’s career in academic medicine. Every physician is likely to be sued by a patient, and how the physician responds can change his or her professional life. However, the principles of medical malpractice are rarely taught or addressed during residency training. In fact, many faculty at academic medical centers know little about malpractice.In this article, the authors propose that information about the inciting causes of malpractice claims and their resolution should be incorporated into residency professionalism curricula both to improve patient safety and to decrease physician anxiety about a crucial aspect of medicine that is not well understood. The authors provide information on national trends in malpractice litigation and residents’ understanding of malpractice, then share the results of their in-depth review of surgical malpractice claims filed during 2001-2008 against their academic medical center. The authors incorporated those data into an evidence-driven curriculum for residents, which they propose as a model for helping residents better understand the events that lead to malpractice litigation, as well as its process and prevention.

PMID: 21248606 [PubMed - as supplied by publisher]

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Checklists to Reduce Diagnostic Errors.

Acad Med. 2011 Jan 18;

Authors: Ely JW, Graber ML, Croskerry P

Diagnostic errors are common and can often be traced to physicians’ cognitive biases and failed heuristics (mental shortcuts). A great deal is known about how these faulty thinking processes lead to error, but little is known about how to prevent them. Faulty thinking plagues other high-risk, high-reliability professions, such as airline pilots and nuclear plant operators, but these professions have reduced errors by using checklists. Recently, checklists have gained acceptance in medical settings, such as operating rooms and intensive care units. This article extends the checklist concept to diagnosis and describes three types of checklists: (1) a general checklist that prompts physicians to optimize their cognitive approach, (2) a differential diagnosis checklist to help physicians avoid the most common cause of diagnostic error-failure to consider the correct diagnosis as a possibility, and (3) a checklist of common pitfalls and cognitive forcing functions to improve evaluation of selected diseases. These checklists were developed informally and have not been subjected to rigorous evaluation. The purpose of this article is to argue for the further investigation and revision of these initial attempts to apply checklists to the diagnostic process. The basic idea behind checklists is to provide an alternative to reliance on intuition and memory in clinical problem solving. This kind of solution is demanded by the complexity of diagnostic reasoning, which often involves sense-making under conditions of great uncertainty and limited time.

PMID: 21248608 [PubMed - as supplied by publisher]

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Commentary: lowly interns, more is merrier, and the casablanca strategy.

Acad Med. 2011 Jan;86(1):8-10

Authors: Croskerry P

Test ordering is an integral part of clinical decision making. Variation in test-ordering behavior appears to reflect uncertainty in the clinical reasoning and decision-making process. Among decision makers, novices function mostly in the analytic mode of reasoning, experiencing high levels of uncertainty and, therefore, account for the most variance. While less discriminate test ordering has both economical and clinical downsides, it nevertheless remains a rite of passage along the road toward expertise.In response to the article by Iwashyna and colleagues, the author of this commentary reflects on the implications of test-ordering behavior in the academic medicine setting. The process of ordering tests can serve purposes other than the obvious, not the least of which allows the decision maker additional time for reflection in the decision-making process, perhaps leading to a less mindless and more mindful approach.The author observes that test-ordering behavior of novitiates might be optimized through a variety of strategies that improve both active and passive learning in the clinical environment. In addition to specific education around costs, as well as Bayesian considerations, active learning importantly requires exposure to those processes that may subvert clinical reasoning, notably cognitive biases. Passive learning is enhanced in supportive environments. Throughout, those who supervise and teach should provide effective models.

PMID: 21191201 [PubMed - in process]

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Almost Internists: Analysis of Students Who Considered Internal Medicine but Chose Other Fields.

Acad Med. 2010 Dec 16;

Authors: Durning SJ, Elnicki DM, Cruess DF, Reddy S, Kernan WN, Harrell HE, Schwartz MD, Fagan MJ, Battistone M, Hauer KE

PURPOSE: Medical students’ career choices affect health care. To understand how to increase the number of students who choose careers in internal medicine (IM), students who seriously considered IM but chose another field (“Switchers”) and those who rejected IM (“Never Considered”) were compared with those who chose IM (“Choosers”). METHOD: Fourth-year medical students from 11 U.S. institutions were surveyed about demographics, medical school educational experiences, and aspects of the specialty of IM. Univariate analysis and multivariate logistic regression models examined associations between student characteristics and classification as Switchers, Choosers, and Never Considered. RESULTS: A total of 1,177 students completed the survey (82% response rate). There were 274 (23%) Choosers, 398 (34%) Switchers, and 499 (43%) Never Considered. The authors’ models explained over 80% of variance in these three career choice classification groups. For most responses, an increasingly favorable gradient from Never Considered to Choosers was observed. Multivariate analysis revealed six items that were associated with higher probability of choosing IM: types of patients internists see, timing of career decision, interest groups, intellectual challenge, satisfaction among internists, and the core IM clerkship. CONCLUSIONS: Several potentially modifiable educational experiences and aspects of IM distinguished Switchers from the other two groups. The percentage of variance explained by group suggests that these findings identify important underpinnings of career decisions. These items also suggest ways that educational experiences and aspects of the specialty could be redesigned by academicians and policy makers to improve the attractiveness of IM careers.

PMID: 21169784 [PubMed - as supplied by publisher]

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Regulation of Medical Student Work Hours: A National Survey of Deans.

Acad Med. 2010 Nov 18;

Authors: Friedman E, Karani R, Fallar R

PURPOSE: Because of the impact of resident duty hours on resident and medical student education, it is important to determine curriculum deans' opinions toward and current status of student work hours regulations. METHOD: In 2008, the authors electronically surveyed the curriculum deans at the 126 U.S. medical schools accredited by the Liaison Committee on Medical Education (LCME) regarding student work hours at their schools. RESULTS: Sixty-six respondents (82%) had a written policy restricting their students' work hours, and in 63% of these, the policy also extended to students visiting their institution. Policies applied to mandatory and elective (84%) or only mandatory (16%) rotations. About half the respondents supported a universal policy across medical schools, but of those who supported a policy, there was an equal split between whether individual schools or the LCME should create the policy. Deans felt strongly (>80%) that student well-being would be improved by work hours regulation, yet 48% noted that it would negatively affect scheduling required clerkship activities. Fifty-four percent supported the Accreditation Council for Graduate Medical Education work hours policy for students, and most (82%) felt that students should work no more than 80 hours/week. Students are always supervised, yet extended work hours can affect learning and patient and team interactions. CONCLUSIONS: Without a mandate, many schools have created policies to restrict student work hours. This study describes the current status and offers an opportunity for consensus building around this important issue.

PMID: 21099393 [PubMed - as supplied by publisher]

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The Third Year in the First Person: Medical Students Report on Their Principal Clinical Year.

Acad Med. 2010 Nov 18;

Authors: Krupat E, Pelletier SR, Chernicky DW

PURPOSE: To obtain an accurate and detailed portrait of medical students’ principal clinical year using firsthand accounts of their experiences over the course of the year. METHOD: All 45 Harvard Medical School students at four clinical sites who were training in 2005-2006 under three different pedagogical models provided open-ended responses to a monthly check-in asking them for brief descriptions of any interesting or memorable experiences associated with their clerkships. Associations with gender, time of year, rotation, and clerkship model were also studied. RESULTS: A total of 770 incidents were collected, and these were coded for positivity-negativity and content. Five broad theme areas were identified: stories about physicians (e.g., physicians giving instruction, acting as role models), medical students and their behavior (feelings of uncertainty or being useful, of workload), patients and patient care (e.g., learning by doing or observing, forming bonds with patients, memorable patients, treating patients over time), groups and group climate (e.g., effectiveness of teams, informal groups, comparison of services), and content themes (e.g., birth, death, cancer, bad news). Two-thirds of all stories were coded as positive. CONCLUSIONS: These third-year medical students often framed their experiences positively, finding learning lessons even in stressful or unpleasant events. Their stories also reflect relatively consistent orientations toward patients and patient care (e.g., biomedical versus patient-centered). The authors believe these incidents reflect the emerging professional identities of medical students; educators can use these to help students reflect on the kind of physician they aspire to become.

PMID: 21099394 [PubMed - as supplied by publisher]

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Effect of the ACGME Duty Hours Restrictions on Surgical Residents and Faculty: A Systematic Review.

Acad Med. 2010 Nov 19;

Authors: Jamal MH, Rousseau MC, Hanna WC, Doi SA, Meterissian S, Snell L

PURPOSE: Educators in surgical training programs are concerned that the Accreditation Council for Graduate Medical Education (ACGME) duty hours limitations may adversely affect surgical residents’ education, especially their operative experience, so the authors aimed to evaluate the impact of duty hours reductions on surgical residency. METHOD: The authors searched English- and French-language literature (2000-2008) for articles about the impact of duty hours restrictions on surgical residents’ education and well-being and on faculty educators. They used the following databases: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and ERIC. The authors included every report that examined the effects of duty hours limits on surgical training, excluding opinion papers and editorials. Two reviewers independently performed data extraction and quality assessment for all reports and resolved disagreements by consensus. RESULTS: The authors retrieved 1,146 reports and included 56 in the study. They compiled positive and negative outcomes on (1) residents’ education, (2) resident lifestyle, and (3) surgical faculty. Overall, the effects of duty hours reductions on residents’ education and lifestyle were positive or neutral, but the effects on surgical faculty were negative. The 16 articles with the highest-quality scores had 27 positive themes and 11 negative themes. CONCLUSIONS: This is the largest and most current review of the literature addressing the effect of the ACGME duty hours limitations on surgical training. Limitations had a positive effect on residents but a negative effect on surgical faculty. Importantly, duty hours limitations did not adversely affect surgical residents’ operating-room experience.

PMID: 21099662 [PubMed - as supplied by publisher]

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Conceptual Frameworks in the Study of Duty Hours Changes in Graduate Medical Education: A Review.

Acad Med. 2010 Nov 19;

Authors: Schwartz A, Pappas C, Bashook PG, Bordage G, Edison M, Prasad B, Swiatkowski V

PURPOSE: Conceptual frameworks are approaches to a research problem that specify key entities and their relationships. The 2009 Institute of Medicine (IOM) report on resident duty hours, subsequent studies, and published responses to the report present a variety of conceptual frameworks for the study of the impact of duty hours regulations. The authors sought to identify and describe these conceptual frameworks and their implications. METHOD: The authors reviewed the IOM report and articles in both peer-reviewed and non-peer-reviewed literature for the period January 2008 through April 2010, identified using multiple electronic databases including PubMed, EMBASE, CINAHL, BEME, and PsycInfo. Studies that explicitly described or argued for the effect of resident duty hours on any other outcome, as judged by consensus of multiple reviewers, were included. The authors selected 239 of 858 studies reviewed. Several of the authors reviewed articles to identify conceptual frameworks used implicitly or explicitly to describe the relationship between duty hours (or duty hours regulations) and outcomes. Identification was by consensus. RESULTS: Twenty-three conceptual frameworks were identified. Several made contradictory predictions about the impact of duty hours regulations on patient outcomes, resident education, and other key outcomes. CONCLUSIONS: The concept of duty hours itself is contested, and little attention has been paid to the nature and intensity of the activities that occupy residents’ hours. Much research focuses on isolated outcomes of duty hours changes without considering mediation or moderation. More studies are needed to define trade-offs between outcomes and the value society places on these trade-offs.

PMID: 21099663 [PubMed - as supplied by publisher]

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The Impact of Residents, Interns, and Attendings on Inpatient Laboratory Ordering Patterns: A Report From One University’s Hospitalist Service.

Acad Med. 2010 Oct 8;

Authors: Iwashyna TJ, Fuld A, Asch DA, Bellini LM

PURPOSE: To examine the laboratory test ordering patterns of interns in order to determine the effects of more senior residents’ and attendings’ supervision on trainees’ patterns and residents’ perceptions of control in test ordering. METHOD: In a 2007 cohort study of 2,066 patients cared for by 85 interns, 56 residents, and 27 attendings on the University of Pennsylvania general medical hospitalist service, the authors studied variation in laboratory test utilization and costs in 10,908 patient-days. Ordinary least squares regression was used to partition variance among supervised and supervising physicians. Interns and residents were surveyed about their perceived control over lab test ordering. RESULTS: Forty-five percent (95% confidence interval [CI]: 39-53) of the variation in laboratory test utilization was attributable to interns’ ordering, 26% (95% CI: 21-34) to residents, and 9% (95% CI: 7-16) to attendings; 20% (95% CI: 6-25) could not be uniquely attributed to a particular level of the care team. Similar results were obtained for variation in laboratory costs. Interns underestimated their control over laboratory test utilization, residents overestimated their control, and both groups had inaccurate assessments of their own utilization relative to peers. CONCLUSIONS: Attending faculty had relatively little impact on laboratory ordering patterns. This may reflect a consistent baseline impact of attending physicians on laboratory use, but it may also represent a missed opportunity to reduce practice variation and improve patient care. Observing variation in trainee practice patterns in the face of different supervisors represents a new approach to measuring the supervision in clinical settings.

PMID: 20938318 [PubMed - as supplied by publisher]

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Long-term retention of central venous catheter insertion skills after simulation-based mastery learning.

Acad Med. 2010 Oct;85(10 Suppl):S9-S12

Authors: Barsuk JH, Cohen ER, McGaghie WC, Wayne DB

BACKGROUND: Simulation-based mastery learning (SBML) of central venous catheter (CVC) insertion improves trainee skill and patient care. How long skills are retained is unknown. METHOD: This is a prospective cohort study. Subjects completed SBML and were required to meet or exceed a minimum passing score (MPS) for CVC insertion on a posttest. Skills were retested 6 and 12 months later and compared with posttest results to assess skill retention. RESULTS: Forty-nine of 61 (80.3%) subjects completed follow-up testing. Although performance declined from posttest where 100% met the MPS for CVC insertion, 82.4% to 87.1% of trainees passed the exam and maintained their high performance up to one year after training. CONCLUSIONS: Skills acquired from SBML were substantially retained during one year. Individual performance cannot be predicted, so programs should use periodic testing and refresher training to ensure competence.

PMID: 20881713 [PubMed - in process]

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Changes in perception of and participation in unprofessional behaviors during internship.

Acad Med. 2010 Oct;85(10 Suppl):S76-80

Authors: Arora VM, Wayne DB, Anderson RA, Didwania A, Farnan JM, Reddy ST, Humphrey HJ

BACKGROUND: Do perceptions of and participation in unprofessional behaviors change during internship? METHOD: Interns at three Chicago medicine residencies anonymously reported participation in unprofessional behaviors before and after internship. On the basis of a prior survey, interns rated 28 unprofessional behaviors from 1 (unprofessional) to 5 (professional). Site-adjusted regression examined changes in participation rates and perception scores. RESULTS: Response rates were 93% (105) before and 88% (99) after internship. Participation in on-call unprofessional behaviors increased ("blocking" admissions [12% versus 41%, P < .001], disparaging the ER [27% versus 45%, P = .005], misrepresenting tests as urgent to expedite care [40% versus 60%; P = .003], and signing out by phone [20% versus 42%, P < .001]). Participation in egregious behaviors (fraud, disrespect, misrepresentation) and perceptions of most behaviors remained unchanged. CONCLUSIONS: Although participation in egregious unprofessional behavior remained unchanged during internship, participation in on-call unprofessional behaviors increased.

PMID: 20881710 [PubMed - in process]

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A new professionalism? Surgical residents, duty hours restrictions, and shift transitions.

Acad Med. 2010 Oct;85(10 Suppl):S72-5

Authors: Coverdill JE, Carbonell AM, Fryer J, Fuhrman GM, Harold KL, Hiatt JR, Jarman BT, Moore RA, Nakayama DK, Nelson MT, Schlatter M, Sidwell RA, Tarpley JL, Termuhlen PM, Wohltmann C, Mellinger JD

BACKGROUND: Some anticipated that the Accreditation Council for Graduate Medical Education duty hours restrictions would foster a team-focused “new professionalism” among residents. This study explores the prevalence and challenges of a new professionalism and whether they vary by program size. METHOD: Questionnaires distributed in 15 general surgery programs produced an 82% response rate (N = 306); 52 semistructured follow-up interviews were completed. Results include means, percentage who “agree or strongly agree,” significance tests, and main themes from the interviews. RESULTS: A new professionalism is limited by residents’ reluctance to pass work from day to night teams, unclear guidance regarding stay-or-go decisions during shift transitions, little educational emphasis on sign-outs, and the practice of long hours in the name of professionalism. Program size is largely unassociated with these beliefs and behaviors. CONCLUSIONS: A new professionalism represents a stalled revolution among surgical residents. The new professionalism’s emphasis on teamwork requires additional attention to staffing and workload management.

PMID: 20881709 [PubMed - in process]

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