Pediatric Residents’ and Continuity Clinic Preceptors’ Perceptions of the Effects of Restricted Work Hours on Their Learning Relationship

Creating an educationally minded schedule: one approach to minimize the impact of duty hour standards on intern continuity clinic experience

To determine if implementing an educationally minded schedule utilizing consecutive night shifts can moderate the impact of the 2011 duty hour standards on education and patient continuity of care in longitudinal primary care experience (continuity clinic). A 14-month pre-post study was performed in continuity clinic with one supervising physician group and two intern groups. Surveys to assess attitudes and education were distributed to the supervising physicians and interns before and after the changes in duty hour standards. Intern groups' schedules were reviewed for the number of regular and alternative day clinic (i.e. primary care experience on a different weekday) sessions and patient continuity of care. Fifteen supervising physicians and 51 interns participated (25 in 2011, 26 in 2012). Intern groups' comfort when discussing patient issues, educational needs and teamwork perception did not differ. Supervising physicians' understanding of learning needs and provision of feedback did not differ between groups. Supervising physicians indicated a greater ability to provide feedback and understand learning needs during regular continuity clinic sessions compared with alternative day clinics (all p < 0.05). No significant difference was detected between intern groups in the number of regularly scheduled continuity clinics, alternative day clinics or patient continuity of care. The 2011 duty hour standards required significant alterations to intern schedules, but educationally minded scheduling limited impact on education and patient continuity in care.

Conceptual frameworks in the study of duty hours changes in graduate medical education: a review

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.

Continuity of care in fixed-day versus variable-day resident continuity clinics

OBJECTIVE

Since the introduction of resident work-hour standards, pediatric residency programs have struggled to preserve robust continuity clinic experiences. Many programs have resorted to more flexible approaches to resident scheduling. We know little regarding the impact of such changes. We compared 2 continuity clinic scheduling models: a traditional fixed-day clinic and a variable-day clinic in which resident clinic days vary each week to accommodate resident schedules.

METHODS

The setting for our study was a large university resident continuity clinic. We analyzed 111 resident schedules and 1113 visits by children aged younger than 1 year during 2 periods: July 2007 to December 2007, when residents were scheduled by using a variable-day clinic model, and July 2008 to December 2008, when a fixed-day model was used. We compared the number of clinic sessions per resident and continuity of care. We used the usual provider of care definition of continuity: the proportion of visits in which a patient is seen by his or her primary resident. A multivariable logistic regression was used to model the relationship between patient continuity of care and clinic structure (fixed-day vs variable-day), resident level, patient age, and appointment type.

RESULTS

The number of clinics per resident during a 6-month period was higher using variable-day scheduling (19.6 vs 16.2; P < .01), whereas continuity of care was lower (0.54 vs 0.61; P = .01) In the multivariate model, continuity of care was significantly higher under the fixed-day model (odds ratio 1.40; P < .01).

CONCLUSIONS

Scheduling residents for continuity clinic on variable days results in lower patient continuity of care despite increased resident time in clinic.

Toward a new paradigm in graduate medical education in the United States: elimination of the 24-hour call

BACKGROUND

Sleep deprivation negatively affects resident performance, education, and safety. Concerns over these effects have prompted efforts to reduce resident hours. This article describes the design and implementation of a scheduling system with no continuous 24-hour calls. Aims included meeting Accreditation Council for Graduate Medical Education work hour requirements without increasing resident complement, maximizing continuity of learning and patient care, maintaining patient care quality, and acceptance by residents, faculty, and administration.

METHODS

Various coverage options were formulated and discussed. The final schedule was the product of consensus. After re-engineering the master rotation schedule, service-specific conversion of on-call schedules was initiated in July 2003 and completed in July 2004. Annual in-training and certifying examination performance, length of stay, patient mortalities, resident motor vehicle accidents/near misses, and resident satisfaction with the new scheduling system were tracked.

RESULTS

Continuous 24-hour call has been eliminated from the program since July 2004, with the longest assigned shift being 14 hours. Residents have at least 1 free weekend per month, a 10-hour break between consecutive assigned duty hours, and a mandatory 4-hour "nap" break if assigned a night shift immediately following a day shift. Program-wide, duty hours average 66 hours per week for first-year residents, 63 hours per week for second-year residents, and 60 hours per week for third-year residents. Self-reported motor vehicle accidents and/or near misses of accidents significantly decreased (P < .001) and resident satisfaction increased (P  =  .42). The change was accomplished at no additional cost to the institution and with no adverse patient care or educational outcomes.

CONCLUSIONS

Pediatric residency training with restriction to 14 consecutive duty hours is effective and well accepted by stakeholders. Five years later, the re-engineered schedule has become the new "normal" for our program.

Understanding paediatric resident-continuity preceptor relationships through the lens of apprenticeship learning

CONTEXT

Apprenticeship learning is common in medical education, but is often situated in theoretical frameworks which highlight its cognitive but not its social dimension.

METHODS

We conducted an ethnographic case study of paediatric residents' learning relationships with their preceptors in a community-based paediatric continuity site. It included 5 months (100 hours) of direct observation, and semi-structured interviews with 10 residents (before and after observation) and 10 primary care paediatricians who served as their continuity preceptors (after observation). Interview transcripts and notes from observations were inductively coded and analysed for major themes.

RESULTS

Our observations and reports of resident learning trajectories fit well with the concept of legitimate peripheral participation. Residents learned the everyday practice of primary care as they worked alongside experienced paediatricians in the continuity clinic. Although the direction of learning was towards central participation in patient care, residents learned during transient shifts to the periphery of practice. As a function of residents' increased participation, preceptors moved into more supportive roles. Residents were not only learners; at times they were teachers who facilitated preceptors' learning.

CONCLUSIONS

Legitimate peripheral participation is a concept that helps to explain apprenticeship as a dynamic social relationship which shapes, and is shaped by, learning that takes place in clinical practice. Other concepts shed light on the bidirectional nature of apprenticeship learning.