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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What Drives Faculty Ratings of Residents’ Clinical Skills? The Impact of Faculty’s Own Clinical Skills.

Acad Med. 2010 Oct;85(10 Suppl):S25-8

Authors: Kogan JR, Hess BJ, Conforti LN, Holmboe ES

BACKGROUND: Factors explaining faculty variability in performance appraisals of trainees' clinical skills are poorly understood. This study sought to identify whether faculty characteristics and clinical skills performance impacted their ratings of residents' clinical skills. METHOD: Forty-four internal medicine faculty completed a demographic questionnaire, eight standardized patient (SP) encounters, and rated four videotaped scenarios of standardized residents with SPs using the mini-CEX. Faculty characteristics, their SP exam content, and process performance scores were correlated with their mini-CEX ratings of residents. RESULTS: Faculty demographics, including experience, were not associated with mini-CEX ratings. Higher history-taking performance scores were associated with rater stringency in interviewing (r = -0.55, P < .01) and organization (r = -0.35, P < .05). Higher faculty process performance scores were associated with rater stringency in interviewing and physical exam (r = -0.41 and r = -0.42, P < .01, respectively) and organization (r = -0.36, P < .05). CONCLUSIONS: Faculty's own clinical skills may be associated with their ratings of trainees.

PMID: 20881697 [PubMed - in process]

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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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Simulation training in central venous catheter insertion: improved performance in clinical practice.

Acad Med. 2010 Sep;85(9):1462-9

Authors: Evans LV, Dodge KL, Shah TD, Kaplan LJ, Siegel MD, Moore CL, Hamann CJ, Lin Z, D’Onofrio G

PURPOSE: To determine whether simulation training of ultrasound (US)-guided central venous catheter (CVC) insertion skills on a partial task trainer improves cannulation and insertion success rates in clinical practice. METHOD: This prospective, randomized, controlled, single-blind study of first- and second-year residents occurred at a tertiary care teaching hospital from January 2007 to September 2008. The intervention group (n = 90) received a didactic and hands-on, competency-based simulation training course in US-guided CVC insertion, whereas the control group (n = 95) received training through a traditional, bedside apprenticeship model. Success at first cannulation and successful CVC insertion served as the primary outcomes. Secondary outcomes included reduction in technical errors and decreased mechanical complications. RESULTS: Blinded independent raters observed 495 CVC insertions by 115 residents over a 21-month period. Successful first cannulation occurred in 51% of the intervention group versus 37% of the control group (P = .03). CVC insertion success occurred for 78% of the intervention group versus 67% of the control group (P = .02). Simulation training was independently and significantly associated with success at first cannulation (odds ratio: 1.7; 95% confidence interval: 1.1-2.8) and with successful CVC insertion (odds ratio: 1.7; 95% confidence interval: 1.1-2.8)–both independent of US use, patient comorbidities, or resident specialty. No significant differences related to technical errors or mechanical complications existed between the two groups. CONCLUSIONS: Simulation training was associated with improved in-hospital performance of CVC insertion. Procedural simulation was associated with improved residents’ skills and was more effective than traditional training.

PMID: 20736674 [PubMed - indexed for MEDLINE]

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Slowing Down to Stay Out of Trouble in the Operating Room: Remaining Attentive in Automaticity.

Acad Med. 2010 Oct;85(10):1571-1577

Authors: Moulton CA, Regehr G, Lingard L, Merritt C, Macrae H

PURPOSE: Automaticity is integral to expert performance, but experts must be able to transition from an automatic mode into a more effortful state when required. In this study, the authors identified and characterized the manifestations of the phenomenon of “slowing down when you should” to stay out of trouble in operative practice. METHOD: The authors interviewed 28 surgeons (60-minute, semistructured format) from various specialties at four academic medical centers and observed 5 hepatopancreatobiliary surgeons in the operating room (29 cases, 147 hours) during 2007-2009. Using a grounded theory qualitative methodology, they conducted a thematic analysis of transcripts and field notes in an iterative manner. Data collection continued until saturation. They adopted a reflexive approach throughout. RESULTS: Surgeons described and the authors observed four phenomenological manifestations of the transition to a more effortful state. In the most extreme manifestation, “stopping,” surgeons actually stopped the procedure, whereas in the most subtle manifestation, “fine-tuning,” surgeons were able to continue the procedure and focus on minor events simultaneously. A separate phenomenon of “drifting” represented surgeons’ failure to transition out of the automatic mode when appropriate, resulting in surgical errors or near misses. CONCLUSIONS: The manifestations of the slowing down phenomenon represent acts of cognitive refocusing during the potentially more-critical moments of operative practice. Further, the authors challenge the conception of automaticity as effortless, arguing that automatic behavior can be attentive (fine-tuning) as well as inattentive (drifting).

PMID: 20881677 [PubMed - as supplied by publisher]

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Does Simulator-Based Clinical Performance Correlate With Actual Hospital Behavior? The Effect of Extended Work Hours on Patient Care Provided by Medical Interns.

Acad Med. 2010 Oct;85(10):1583-1588

Authors: Gordon JA, Alexander EK, Lockley SW, Flynn-Evans E, Venkatan SK, Landrigan CP, Czeisler CA,

PURPOSE: The correlation between simulator-based medical performance and real-world behavior remains unclear. This study explored whether the effects of extended work hours on clinical performance, as reported in prior hospital-based studies, could be observed in a simulator-based testing environment. METHOD: Intern volunteers reported to the simulator laboratory in a rested state and again in a sleep-deprived state (after a traditional 24- to 30-hour overnight shift [n=17]). A subset also presented after a shortened overnight shift (16 scheduled hours [n=8]). During each laboratory visit, participants managed two critically ill patients. An on-site physician scored each case, as did a blinded rater later watching videotapes of the performances (score=1 [worst] to 8 [best]; average of both cases=session score). RESULTS: Among all participants, the average simulator session score was 6.0 (95% CI: 5.6-6.4) in the rested state and declined to 5.0 (95% CI: 4.6-5.4) after the traditional overnight shift (P<.001). Among those who completed the shortened overnight shift, the average postshift simulator session score was 5.8 (95% CI: 5.0-6.6) compared with 4.3 (95% CI: 3.8-4.9) after a traditional extended shift (P<.001). CONCLUSIONS: In a clinical simulation test, medical interns performed significantly better after working a shortened overnight shift compared with a traditional extended shift. These findings are consistent with real-time hospital studies using the same shift schedule. Such an independent correlation not only confirms the detrimental impact of extended work hours on medical performance but also supports the validity of simulation as a clinical performance assessment tool.

PMID: 20881679 [PubMed - as supplied by publisher]

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Predictors of Persistent Burnout in Internal Medicine Residents: A Prospective Cohort Study.

Acad Med. 2010 Oct;85(10):1630-1634

Authors: Campbell J, Prochazka AV, Yamashita T, Gopal R

PURPOSE: Resident burnout continues to be a major problem despite work hours restrictions. The authors conducted a longitudinal study to determine whether burnout in internal medicine residents is persistent and what factors predispose residents to persistent burnout. METHOD: The authors mailed a survey to internal medicine residents at the University of Colorado Denver Health Science Center each May, from 2003 through 2008. The survey measures included the Maslach Burnout Inventory organized into three subscales: emotional exhaustion (EE), depersonalization (DP), and personal accomplishment. The authors defined burned-out residents as having a high EE or DP score and persistent burnout as being burned out during all three years of residency. RESULTS: Of the 179 eligible residents, 86 (48%) responded to the survey during all three years of their residency. Sixty-seven residents (78%) were burned out at least once: 58 residents (67%) were burned out during their internship, 58 (67%) during their second year, and 50 (58%) during their third year (P < .08). Of the 58 burned-out interns, 42 (72%) continued to be burned out through their three years of training. Persistent burnout was more likely to occur in men (OR = 3.31, P < .01) and was associated with screening positive for depression as an intern (OR = 4.4, P < .002). CONCLUSIONS: Once present, burnout tends to persist through residency. Men and residents who screened positive for depression as interns are at the highest risk for persistent burnout. Interventions to prevent burnout during internship may significantly decrease burnout throughout residency.

PMID: 20881685 [PubMed - as supplied by publisher]

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Evaluation of Medical Student Performance on Objective Structured Clinical Exams With Standardized Patients With and Without Disabilities.

Acad Med. 2010 Sep 28;

Authors: Brown RS, Graham CL, Richeson N, Wu J, McDermott S

PURPOSE: To investigate whether medical students’ performance on a family medicine clerkship objective structured clinical exam (OSCE) differed when the standardized patient (SP) had a disability versus when the SP did not have a disability. METHOD: SPs with spinal cord injury (SP-SCI), SPs with intellectual disability (SP-ID), and SPs without a disability participated separately in two OSCE scenarios that were administered by the University of South Carolina School of Medicine’s Department of Family and Preventive Medicine from 2007 to 2009. OSCE scores were determined based on the number of critical actions completed by the student, and scores were analyzed to determine differences among scenarios. RESULTS: Students scored lower in history, physical exam, lab tests, and interpersonal skills with an SP-SCI, and lower in history, physical exam, and lab tests with an SP-ID than did students interacting with SPs without a disability. The odds ratio for ordering a hemoglobin A1c in one scenario was 4.16 times higher in cases when the SP did not have a disability (95% confidence interval [CI] 1.78-9.17, P = .001). In the second scenario, the odds ratio was 3.08 times higher for ordering a urinalysis (95% CI 1.34-7.08, P = .006) and was 2.15 times higher for providing lifestyle counseling (95% CI 1.04-4.44, P = .038) in students interacting with SPs without a disability. CONCLUSIONS: Students performed better when the SP did not have a disability. This suggests that greater emphasis should be placed on teaching appropriate care of patients with a disability.

PMID: 20881817 [PubMed - as supplied by publisher]

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