Resident duty hours: a survey of internal medicine program directors

The Impact of Orthopaedic Surgical Training on Body Composition

BACKGROUND

Residency is known to consist of rigorous training that has contributed to increased rates of resident burn out, depression, and suicide. There have been recent efforts to attempt to combat and solve the rising levels of mental health concerns amongst physicians and physicians in training. While studies have examined the adverse effects of medical training on mental health, few have examined the associated changes in physical health. This study aimed to identify and compare baseline body composition and hand grip strength of orthopaedic surgery residents. The second aim was to identify and compare changes that may occur over the course of the training program.

METHODS

First year orthopaedic surgery residents ("interns") were recruited to undergo body composition measurements via bioimpedance analysis (BIA) during their first, third, and twelfth month of post-graduate training. At each interval, three hand-grip-strength measurements per hand were captured. Additionally, orthopaedic surgery residents who had already completed their first year ("non-interns") were recruited to undergo baseline and 12-month BIA for comparison.

RESULTS

Six interns and six non-interns were recruited. The interns lost 2.88 ± 4.26 kg (-3.31% ± 4.75%) of their initial body mass with most of the loss being body fat mass (1.97 ± 2.62 kg) by three months. Interns recovered a fair amount of mass loss by 12 months with a net change of -0.78 ± 3.14 kg (-1.09% ± 3.90%). Non-interns experienced an overall net weight gain (1.20 ± 3.64 kg; 1.68% ± 5.55%) over the same period. Intern HGS changed by -1.92 ± 2.49 kg and 3.39 ± 2.34 kg at 3- (n=6) and 12-months (n=3), respectively.

CONCLUSION

This study demonstrates that there is an appreciable decrease in overall body mass, lean tissue mass, and body fat throughout the orthopaedic resident's intern year. The results demonstrate an initial fall in each body metric and strength by 3-months followed by partial recovery by 12-months. This pattern contrasts the average gain of body mass in each measured metric by non-interns. This study is limited by population sizes and by incompleteness of HGS data. Level of Evidence: II.

Simulator training improves ultrasound scanning performance on patients: a randomized controlled trial

BACKGROUND

Simulation-based mastery training may improve clinical performance. The aim of this study was to determine the effect of simulation-based mastery training on clinical performance in abdominal diagnostic ultrasound for radiology residents.

METHOD

This study was a multicenter randomized controlled trial registered at clinicaltrials.gov (identifier: NCT02921867) and reported using the Consolidated Standards of Reporting Trials (CONSORT) statement. Twenty radiology residents from 10 different hospitals were included in the study. Participants were randomized into two groups: (1) simulator-based training until passing a validated test scored by a blinded reviewer or (2) no intervention prior to standard clinical ultrasound training on patients. All scans performed during the first 6 weeks of clinical ultrasound training were scored. The primary outcome was performance scores assessed using Objective Structured Assessment of Ultrasound Skills (OSAUS). An exponential learning curve was fitted for the OSAUS score for the two groups using non-linear regression with random variation. Confidence intervals were calculated based on the variation between individual learning curves.

RESULTS

After randomization, eleven residents completed the simulation intervention and nine received standard clinical training. The simulation group participants attended two to seven training sessions using between 6 and 17 h of simulation-based training. The performance score for the simulation group was significantly higher for the first 29 scans compared to that for the non-simulation group, such that scores reached approximately the same level after 49 and 77 scans, respectively.

CONCLUSION

We showed improved performance in diagnostic ultrasound scanning on patients after simulation-based mastery learning for radiology residents.

TRIAL REGISTRATION

NCT02921867 KEY POINTS: • Improvement in scanning performance on patients is seen after simulation-based mastery learning in diagnostic abdominal ultrasound. • Simulation-based mastery learning can prevent patients from bearing the burden of the initial steep part of trainees' learning curve.

Education Outcomes in a Duty-Hour Flexibility Trial in Internal Medicine

BACKGROUND

Concern persists that inflexible duty-hour rules in medical residency programs may adversely affect the training of physicians.

METHODS

We randomly assigned 63 internal medicine residency programs in the United States to be governed by standard duty-hour policies of the 2011 Accreditation Council for Graduate Medical Education (ACGME) or by more flexible policies that did not specify limits on shift length or mandatory time off between shifts. Measures of educational experience included observations of the activities of interns (first-year residents), surveys of trainees (both interns and residents) and faculty, and intern examination scores.

RESULTS

There were no significant between-group differences in the mean percentages of time that interns spent in direct patient care and education nor in trainees' perceptions of an appropriate balance between clinical demands and education (primary outcome for trainee satisfaction with education; response rate, 91%) or in the assessments by program directors and faculty of whether trainees' workload exceeded their capacity (primary outcome for faculty satisfaction with education; response rate, 90%). Another survey of interns (response rate, 49%) revealed that those in flexible programs were more likely to report dissatisfaction with multiple aspects of training, including educational quality (odds ratio, 1.67; 95% confidence interval [CI], 1.02 to 2.73) and overall well-being (odds ratio, 2.47; 95% CI, 1.67 to 3.65). In contrast, directors of flexible programs were less likely to report dissatisfaction with multiple educational processes, including time for bedside teaching (response rate, 98%; odds ratio, 0.13; 95% CI, 0.03 to 0.49). Average scores (percent correct answers) on in-training examinations were 68.9% in flexible programs and 69.4% in standard programs; the difference did not meet the noninferiority margin of 2 percentage points (difference, -0.43; 95% CI, -2.38 to 1.52; P=0.06 for noninferiority). od Institute and the ACGME; iCOMPARE ClinicalTrials.gov number, NCT02274818 .).

CONCLUSIONS

There was no significant difference in the proportion of time that medical interns spent on direct patient care and education between programs with standard duty-hour policies and programs with more flexible policies. Interns in flexible programs were less satisfied with their educational experience than were their peers in standard programs, but program directors were more satisfied. (Funded by the National Heart, Lung, and Blo

The relationship between long working hours and depression among first-year residents in Japan

BACKGROUND

In Japan, some residents develop mental health problems. In previous studies, it was reported that long working hours might be a cause of stress reaction such as depression. There were some reports that compared residents with 80 or more working hours with those with less than 80 working hours. However, many residents are practically detained for extra-long time, designated as 100 h or more per week, for medical practice, training, self-study, etc. There have been few reports on extra-long hours of work. This study evaluated the working environment and the amount of stress experienced by first-year residents, and examined the relationship between long working hours and depression, especially in the group of extra-long working hours.

METHODS

The study included 1241 first-year residents employed at 250 training hospitals in 2011. A self-report questionnaire was administered at the beginning of the residency and 3 months later to collect data on demographics, depressive symptoms, and training conditions (e.g., duration of work, sleep, disposable time, and night shift). Depressive symptoms were rated using the Center for Epidemiologic Studies Depression Scale.

RESULTS

The mean duration of work per week was 79.4 h, with 97 residents (7.8%) working 100 h or more. At 3 months, clinically significant depressive symptoms were reported by 45.5% of residents working 100 or more h per week, which proportion was significantly greater than that for respondents working less than 60 h (P < 0.001). Multivariate logistic regression analysis showed that a working week of 80 to 99.9 h was associated with a 2.83 fold higher risk and 100 h or more was associated with a 6.96-fold higher risk of developing depressive symptoms compared with a working week of less than 60 h.

CONCLUSION

Working excessively long hours was significantly associated with development of depressive symptoms. Proper management of resident physicians' working hours is critical to maintaining their physical and mental health and to improve the quality of care they provide.

Development of a reliable simulation-based test for diagnostic abdominal ultrasound with a pass/fail standard usable for mastery learning

BACKGROUND

This study aimed to develop a test with validity evidence for abdominal diagnostic ultrasound with a pass/fail-standard to facilitate mastery learning.

METHOD

The simulator had 150 real-life patient abdominal scans of which 15 cases with 44 findings were selected, representing level 1 from The European Federation of Societies for Ultrasound in Medicine and Biology. Four groups of experience levels were constructed: Novices (medical students), trainees (first-year radiology residents), intermediates (third- to fourth-year radiology residents) and advanced (physicians with ultrasound fellowship). Participants were tested in a standardized setup and scored by two blinded reviewers prior to an item analysis.

RESULTS

The item analysis excluded 14 diagnoses. Both internal consistency (Cronbach's alpha 0.96) and inter-rater reliability (0.99) were good and there were statistically significant differences (p < 0.001) between all four groups, except the intermediate and advanced groups (p = 1.0). There was a statistically significant correlation between experience and test scores (Pearson's r = 0.82, p < 0.001). The pass/fail-standard failed all novices (no false positives) and passed all advanced (no false negatives). All intermediate participants and six out of 14 trainees passed.

CONCLUSION

We developed a test for diagnostic abdominal ultrasound with solid validity evidence and a pass/fail-standard without any false-positive or false-negative scores.

KEY POINTS

• Ultrasound training can benefit from competency-based education based on reliable tests. • This simulation-based test can differentiate between competency levels of ultrasound examiners. • This test is suitable for competency-based education, e.g. mastery learning. • We provide a pass/fail standard without false-negative or false-positive scores.

Implementation of 2011 Duty Hours Regulations through a Workload Reduction Strategy and Impact on Residency Training

BACKGROUND

Training programs have implemented the 2011 ACGME duty hour regulations (DHR) using "workload compression" (WLC) strategies, attempting to fit similar clinical responsibilities into fewer working hours, or workload reduction (WLR) approaches, reducing the number of patient encounters per trainee. Many have expressed concern that these strategies could negatively impact patient care and learner outcomes.

OBJECTIVE

This study evaluates the medical knowledge and clinical impact of a WLR intervention in a single institution.

DESIGN & PARTICIPANTS

Nonrandomized intervention study with comparison to a historical control study among 58 PGY-1 internal medicine trainees in the 2 years after duty hour implementation [exposure cohort (EC), 7/1/2011-6/30/2013], compared to 2 years before implementation [comparison cohort (CC), 7/1/2009-6/30/2011].

MAIN MEASURES

Process outcomes were average inpatient encounters, average new inpatient admissions, and average scheduled outpatient encounters per PGY-1 year. Performance outcomes included trainee inpatient and outpatient days on service, In-Training Examination (ITE) scores as an objective surrogate of medical knowledge, Case-Mix Index (CMI), and quality of care measures (30-day readmission rate, 30-day mortality rate, and average length of stay).

KEY RESULTS

Baseline characteristics and average numbers of inpatient encounters per PGY-1 class were similar between the EC and CC. However, the EC experienced fewer new inpatient admissions (157.47 ± 40.47 vs. 181.72 ± 25.45; p < 0.01), more outpatient encounters (64.80 ± 10.85 vs. 56.98 ± 6.59; p < 0.01), and had similar ITE percentiles (p = 0.58). Patients of similar complexity cared for by the EC also had a greater reduction in readmissions (21.21 % to 19.08 %; p < 0.01) than the hospital baseline (12.07 to 11.14 %; p < 0.01).

CONCLUSIONS

Our WLR resulted in a small decrease in the average number of new inpatient admissions and an increase in outpatient encounters. ITE and care quality outcomes were maintained or improved. While there is theoretical concern that reducing PGY-1 inpatient admissions volumes may negatively impact education and clinical care measures, this study found no evidence of such a trade-off.