Teaching and learning in an 80-hour work week: a novel day-float rotation for medical residents

Effect of Process Changes in Surgical Training on Quantitative Outcomes From Surgery Residency Programs

OBJECTIVES

The purpose of this article is to review the literature on process changes in surgical training programs and to evaluate their effect on the Accreditation Council of Graduate Medical Education (ACGME) Core Competencies, American Board of Surgery In-Training Examination (ABSITE) scores, and American Board of Surgery (ABS) certification.

DESIGN

A literature search was obtained from MEDLINE via PubMed.gov, ScienceDirect.com, Google Scholar on all peer-reviewed studies published since 2003 using the following search queries: surgery residency training, surgical education, competency-based surgical education, ACGME core competencies, ABSITE scores, and ABS pass rate.

RESULTS

Our initial search list included 990 articles on surgery residency training models, 539 on competency-based surgical education, 78 on ABSITE scores, and 33 on ABS pass rate. Overall, 31 articles met inclusion criteria based on their effect on ACGME Core Competencies, ABSITE scores, and ABS certification. Systematic review showed that 5/31, 19/31, and 6/31 articles on process changes in surgical training programs had a positive effect on patient care, medical knowledge, and ABSITE scores, respectively. ABS certification was not analyzed. The other ACGME core competencies were addressed in only 6 studies.

CONCLUSIONS

Several publications on process changes in surgical training programs have shown a positive effect on patient care, medical knowledge, and ABSITE scores. However, the effect on ABS certification, and other quantitative outcomes from residency programs, have not been addressed. Studies on education strategies showing evidence that residency program objectives are being achieved are still needed. This article addresses the 6 ACGME Core Competencies.

Peer Teaching to Foster Learning in Physiology

INTRODUCTION

Peer teaching is an effective tool to promote learning and retention of knowledge. By preparing to teach, students are encouraged to construct their own learning program, so that they can explain effectively to fellow learners. Peer teaching is introduced in present study to foster learning and pedagogical skills amongst first year medical under-graduates in physiology with a Hypothesis that teaching is linked to learning on part of the teacher.

MATERIALS AND METHODS

Non-randomized, Interventional study, with mixed methods design. Cases experienced peer teaching whereas controls underwent tutorials for four consecutive classes. Quantitative Evaluation was done through pre/post test score analysis for Class average normalized gain and tests of significance, difference in average score in surprise class test after one month and percentage of responses in closed ended items of feedback questionnaire. Qualitative Evaluation was done through categorization of open ended items and coding of reflective statements.

RESULTS

The average pre and post test score was statistically significant within cases (p = 0.01) and controls (p = 0.023). The average post test scores was more for cases though not statistically significant. The class average normalized gain (g) for Tutorials was 49% and for peer teaching 53%. Surprise test had average scoring of 36 marks (out of 50) for controls and 41 marks for cases. Analysed section wise, the average score was better for Long answer question (LAQ) in cases. Section wise analysis suggested that through peer teaching, retention was better for descriptive answers as LAQ has better average score in cases. Feedback responses were predominantly positive for efficacy of peer teaching as a learning method. The reflective statements were sorted into reflection in action, reflection on action, claiming evidence, describing experience, and recognizing discrepancies.

CONCLUSION

Teaching can stimulate further learning as it involves interplay of three processes: metacognitive awareness; deliberate practice, and self-explanation. Coupled with immediate feedback and reflective exercises, learning can be measurably enhanced along with improved teaching skills.

Scheduling in the context of resident duty hour reform

Fuelled by concerns about resident health and patient safety, there is a general trend in many jurisdictions toward limiting the maximum duration of consecutive work to between 14 and 16 hours. The goal of this article is to assist institutions and residency programs to make a smooth transition from the previous 24- to 36-hour call system to this new model. We will first give an overview of the main types of coverage systems and their relative merits when considering various aspects of patient care and resident pedagogy. We will then suggest a practical step-by-step approach to designing, implementing, and monitoring a scheduling system centred on clinical and educational needs in the context of resident duty hour reform. The importance of understanding the impetus for change and of assessing the need for overall workflow restructuring will be explored throughout this process. Finally, as a practical example, we will describe a large, university-based teaching hospital network's transition from a traditional call-based system to a novel schedule that incorporates the new 16-hour duty limit.

The effect of reducing maximum shift lengths to 16 hours on internal medicine interns' educational opportunities

PURPOSE

To evaluate educational experiences of internal medicine interns before and after maximum shift lengths were decreased from 30 hours to 16 hours.

METHOD

The authors compared educational experiences of internal medicine interns at Vanderbilt University Medical Center before (2010; 47 interns) and after (2011; 50 interns) duty hours restrictions were implemented in July 2011. The authors compared number of inpatient encounters, breadth of concepts in notes, exposure to five common presenting problems, procedural experience, and attendance at teaching conferences.

RESULTS

Following the duty hours restrictions, interns cared for more unique patients (mean 118 versus 140 patients per intern, P = .005) and wrote more history and physicals (mean 73 versus 88, P = .005). Documentation included more total concepts after the 16-hour maximum shift implementation, with a 14% increase for history and physicals (338 versus 387, P < .001) and a 10% increase for progress notes (316 versus 349, P < .001). There was no difference in the median number of selected procedures performed (6 versus 6, P = 0.94). Attendance was higher at the weekly chief resident conference (60% versus 68% of expected attendees, P < .001) but unchanged at morning report conferences (79% versus 78%, P = .49).

CONCLUSIONS

Intern clinical exposure did not decrease after implementation of the 16-hour shift length restriction. In fact, interns saw more patients, produced more detailed notes, and attended more conferences following duty hours restrictions.

A dedicated general competencies curriculum for radiology residents development and implementation

RATIONALE AND OBJECTIVES

The Accreditation Council on Graduate Medical Education (ACGME) through its Outcome Project requires training programs in all medical specialties to integrate six general competencies into residency training: patient care, medical knowledge, professionalism, interpersonal and communication skills, practice-based learning and improvement, and systems-based practice. In response, a required, or dedicated general competencies rotation for diagnostic radiology residents was instituted.

MATERIALS AND METHODS

We describe the development and implementation of this rotation. The rotation augments the core curriculum, with primary emphasis placed on resident-initiated quality improvement (QI) and quality assurance (QA) projects.

RESULTS

Between academic years 2003 and 2009 diagnostic radiology residents completed 38 QI/QA projects and performed clinical float coverage for the department. Residents met requirements of the systems-based practice and practice-based learning competency domains. In this process, residents improved their medical knowledge, interpersonal communication skills, professionalism, and provided patient care.

CONCLUSIONS

A dedicated general competencies rotation can be successfully implemented, and complement the requirements of the core curriculum. In combination with coverage for clinical services, the rotation makes a substantive contribution to resident education to further the goal of improved patient care.

Medical students-as-teachers: a systematic review of peer-assisted teaching during medical school

INTRODUCTION

International interest in peer-teaching and peer-assisted learning (PAL) during undergraduate medical programs has grown in recent years, reflected both in literature and in practice. There, remains however, a distinct lack of objective clarity and consensus on the true effectiveness of peer-teaching and its short- and long-term impacts on learning outcomes and clinical practice.

OBJECTIVE

To summarize and critically appraise evidence presented on peer-teaching effectiveness and its impact on objective learning outcomes of medical students.

METHOD

A literature search was conducted in four electronic databases. Titles and abstracts were screened and selection was based on strict eligibility criteria after examining full-texts. Two reviewers used a standard review and analysis framework to independently extract data from each study. Discrepancies in opinions were resolved by discussion in consultation with other reviewers. Adapted models of "Kirkpatrick's Levels of Learning" were used to grade the impact size of study outcomes.

RESULTS

From 127 potential titles, 41 were obtained as full-texts, and 19 selected after close examination and group deliberation. Fifteen studies focused on student-learner outcomes and four on student-teacher learning outcomes. Ten studies utilized randomized allocation and the majority of study participants were self-selected volunteers. Written examinations and observed clinical evaluations were common study outcome assessments. Eleven studies provided student-teachers with formal teacher training. Overall, results suggest that peer-teaching, in highly selective contexts, achieves short-term learner outcomes that are comparable with those produced by faculty-based teaching. Furthermore, peer-teaching has beneficial effects on student-teacher learning outcomes.

CONCLUSIONS

Peer-teaching in undergraduate medical programs is comparable to conventional teaching when utilized in selected contexts. There is evidence to suggest that participating student-teachers benefit academically and professionally. Long-term effects of peer-teaching during medical school remain poorly understood and future research should aim to address this.

Residents' perceptions of a night float system

BACKGROUND

A Night Float (NF) system has been implemented by many institutions to address increasing concerns about residents' work hours. The purpose of our study was to examine the perceptions of residents towards a NF system.

METHODS

A 115-item questionnaire was developed to assess residents' perceptions of the NF rotation as compared with a regular call month. The categories included patient care, education, medical errors, and overall satisfaction. Internal Medicine housestaff (post-graduate years 1-3) from three hospital settings at the University of Pittsburgh completed the questionnaire.

RESULTS

The response rate was 90% (n = 149). Of these, 74 had completed the NF rotation. The housestaff felt that the quality of patient care was improved because of NF (41% agreed and 18% disagreed). A majority also felt that better care was provided by a rested physician in spite of being less familiar with the patient (46% agreed and 21% disagreed). Most felt that there was less emphasis on education (65%) and more emphasis on service (52%) during NF. Overall, the residents felt more rested during their call months (83%) and strongly supported the 80-hour workweek requirement (77%).

CONCLUSION

Housestaff felt that the overall quality of patient care was improved by a NF system. The perceived improved quality of care by a rested physician coupled with a perceived decrease in the emphasis on education may have significant implications in housestaff training.

Perspective: Competency-based medical education: a defense against the four horsemen of the medical education apocalypse

Medical education is facing a convergence of challenges that the authors characterize as the four horsemen of the medical education apocalypse: teaching patient shortages, teacher shortages, conflicting systems, and financial problems. Rapidly expanding class sizes and new medical schools are coming online as medical student access to teaching patients is becoming increasingly difficult because of the decreasing length and increasing intensity of hospital stays, concerns about patient safety, patients who are stressed for time, teaching physician shortages and needs for increasing productivity from those who remain, and increasing emphasis on translational research. Further, medical education is facing reductions in funding from all sources, just as it is mounting its first major expansion in 40 years. The authors contend that medical education is on the verge of crisis and that little outside assistance is forthcoming. If medical education is to avoid a catastrophic decline, it will need to take steps to reinvent itself and make optimum use of all available resources. Curriculum materials developed nationally, increased reliance on simulation and standardized patient experiences, and adoption of quality-control methods such as competency-based education are suggested as ways to keep medical education vital in an environment that is increasingly preoccupied with fending off the four horsemen. The authors conclude with a call for a national dialogue about how the medical education community can address the problems represented by the four horsemen, and they offer some potential ways to maintain the vitality of medical education in the face of such overwhelming problems.

Peer assisted learning: a planning and implementation framework: AMEE Guide no. 30

Much has been written about the benefits and applications of Peer Assisted Learning (PAL) in the literature. Curriculum developers increasingly consider PAL as a vehicle to help undergraduate healthcare students learn to teach; an outcome which has received more attention in the UK since the General Medical Council stated in Tomorrow's Doctors that medical graduates must 'Be able to demonstrate appropriate teaching skills'. This guide is primarily designed to assist curriculum developers, course organisers and educational researchers develop and implement their own PAL initiatives. It is structured around a PAL planning framework consisting of 24 questions. The questions are grouped in threes, around eight themes. Each question is discussed with reference to the PAL literature and other related subjects, and is exemplified by responses from a recent PAL project developed at The University of Edinburgh. Working through the 24 questions, particularly with discussion in a small planning group, will enable readers to efficiently develop their ideas for PAL into comprehensive and practical project plans cognisant of current educational theory, existing PAL literature and the local context. The framework is particularly suitable for those who want to develop healthcare undergraduate PAL initiatives yet have little or no experience of PAL, as it provides an introduction to the relevant literature field and a step-by-step process for the design and implementation of such projects. It will also be of interest to those with experience of PAL and those seeking a structured framework for planning non-PAL curriculum developments in undergraduate healthcare curricula.

Complying with ACGME resident duty hours restrictions: restructuring the 80-hour workweek to enhance education and patient safety at Texas A&M/Scott & White Memorial Hospital

Compliance with the Accreditation Council for Graduate Medical Education resident duty hours rules has created unique educational and patient-care challenges for the general medicine inpatient teaching (GMIT) teams at Texas A&M/Scott & White Memorial Hospital, including multiple patient hand-offs, multiple resident absences during teaching time, and loss of continuity of care for individual patients, all of which may have compromised patient safety. The Texas A&M/Scott & White Memorial Hospital internal medicine residency program initially complied with the duty hours rules by having residents take call every fourth night, followed by a six-hour post-call day. This system proved to be inefficient because it significantly disrupted patient care and resident education. Residents reported that this call system frequently caused them to approach the 80-hour limit and that they had difficulty leaving post-call because of unfulfilled responsibilities. They also reported sleep interruption and inadequate time to prepare for and attend educational conferences.After determining the peak admission times at the hospital, program leaders designed a call system during which the primary call team takes admissions from 12:00 pm to 8:00 pm each day, then leaves by 10:00 pm and returns after 10 hours for a full post-call day. After-hours admissions are managed by hospitalists. The solution did require hiring additional hospitalists for night-call coverage. The new structure has greatly improved the residents' experience on the GMIT teams. The entire team works together on call and post-call. Rounds and inpatient teaching continue normally on post-call days. Residents attend clinics and conferences post-call. Hand-offs are reduced greatly, and residents report that they are better rested. Residents also state that the new call system significantly enhances their education, patient care, and personal life.

The impact of resident duty hours reform on the internal medicine core clerkship: results from the clerkship directors in internal medicine survey

PURPOSE

In July 2003, resident duty hours regulations were implemented. The impact of these regulations on medical student education has received minimal attention. The objective of this study was to evaluate the perceptions of internal medicine clerkship directors about the impact of resident physician duty hours reform on medical student teaching, assessment, and clerkship structure.

METHOD

A survey was sent to 114 institutional members of Clerkship Directors in Internal Medicine in May 2004. The survey included 17 attitude items rated on a 5-point Likert scale, five items related to clerkship structure, and four open-ended questions. Descriptive statistics were performed on the responses.

RESULTS

Ninety-six surveys were returned (84%). The majority of respondents did not believe duty hours reform had a positive impact on clerkship students' educational experiences, whereas 48.3% agreed or strongly agreed that residents had more difficulty evaluating students' clinical skills. There was not a significant change in inpatient clerkship structure after duty hours implementation. Time for teaching students, concerns about a shift-work mentality, and student continuity with their teams were major challenges. Impact on ambulatory internal medicine rotations was minimal.

CONCLUSIONS

Internal medicine clerkship directors are concerned about the impact of resident duty hours reform on student education. Additional studies of this educational impact are needed.

Internal medicine residents' clinical and didactic experiences after work hour regulation: a survey of chief residents

BACKGROUND

Work hour regulations for house staff were intended in part to improve resident clinical and educational performance.

OBJECTIVE

To characterize the effect of work hour regulation on internal medicine resident inpatient clinical experience and didactic education.

DESIGN

Cross-sectional mail survey.

PARTICIPANTS

Chief residents at all accredited U.S. internal medicine residency programs outside New York.

MEASUREMENTS AND MAIN RESULTS

The response rate was 62% (202/324). Most programs (72%) reported no change in average patient load per intern after work hour regulation. Many programs (48%) redistributed house staff admissions through the call cycle. The number of admissions per intern on long call (the day interns have the most admitting responsibility) decreased in 31% of programs, and the number of admissions on other days increased in 21% of programs. Residents on outpatient rotations were given new ward responsibilities in 36% of programs. Third-year resident ward and float time increased in 34% of programs, while third-year elective time decreased in 22% of programs. The mean weekly hours allotted to educational activities did not change significantly (12.7 vs 12.4, P = .12), but 56% of programs reported a decrease in intern attendance at educational activities.

CONCLUSIONS

In response to work hour regulation, many internal medicine programs redistributed rather than reduced residents' inpatient clinical experience. Hours allotted to educational activities did not change; however, most programs saw a decrease in intern attendance at conferences, and many reduced third-year elective time.

Medical education and the ACGME duty hour requirements: assessing the effect of a day float system on educational activities

BACKGROUND

In July 2003, the Accreditation Council for Graduate Medical Education (ACGME) instituted new resident work hour mandates, which are being shown to improve resident well-being and patient safety. However, there are limited data on the impact these new mandates may have on educational activities.

PURPOSES

To assess the impact on educational activities of a day float system created to meet ACGME work hour mandates.

METHODS

The inpatient ward coverage was changed by adding a day float team responsible for new patient admissions in the morning, with the on-call teams starting later and being responsible for new patient admissions thereafter. I surveyed the residents to assess the impact of this new system on educational activities-resident autonomy, attending teaching, conference attendance, resident teaching, self-directed learning, and ability to complete patient care responsibilities.

RESULTS

There was no adverse effect of the day float system on educational activities. House staff reported increased autonomy, enhanced teaching from attending physicians, and improved ability to complete patient care responsibilities. Additionally, house staff demonstrated improved compliance with the ACGME mandates.

CONCLUSIONS

The implementation of a novel day float system for the inpatient medicine ward service improved compliance with ACGME work duty requirements and did not adversely impact educational activities of the residency training program.

A Survey of the Work Effort of Full-time Surgeons of the Southeastern Surgical Congress

This is a survey research project to determine the work hours of practicing surgeons and compare those hours with hours that have been mandated for graduate medical education programs by the Accreditation Council for Graduate Medical Education (ACGME). The survey conducted of the membership of the Southeastern Surgical Congress focused on the amount of time devoted to professional activity. Although several categories of membership were surveyed, those surgeons in full-time practice were used for this report. Five hundred ninety-two general surgeons and some surgical specialties from 17 states reported a total professional work effort of 65 hours per week averaged over a month. Twenty per cent reported working more than 80 hours per week. Statistically significant ( P < 0.05) factors that characterized these individuals included years in practice (1 to 10 years), more clinical hours per week, fewer administrative hours per week, fewer teaching hours per week, fewer continuing medical education (CME) hours per year, and an increase in recent clinical practice. Interestingly, there was no significant difference in CME over a 2- or 5-year period. Other factors such as type of practice did not have statistical significance. There was no difference between states and no difference in time commitment to political or community activities. This survey indicates that surgeons going into practice in the Southeast from general surgery graduate medical education programs can expect to have a mean work week of 65 hours, and 20 per cent can expect to exceed an 80-hour work week.

Effect of the 80-Hour Work Week on Cases Performed by General Surgery Residents

The Accreditation Council for Graduate Medical Education (ACGME) implemented mandatory work week hours restrictions in 2003. Due to the traditionally long hours in general surgery, the effect of restrictions on surgical training and case numbers was a matter of concern. Data was compiled retrospectively from ACGME logs and operating room (OR) records at a university hospital for 2002 and 2003. Work week restrictions began in January 2003. This data was reviewed to determine resident case numbers, both in whole and by postgraduate year (PGY). Mean case numbers per resident-month in 2002 were 8.8 ± 8.2 for PGY1s, 16.2 ± 15.7 for PGY2s, 31.4 ± 12.9 for PGY3s, 31.5 ± 17.6 for PGY4s, and 31.5 ± 17.6 for PGY5s. In 2003, they were 8.8 ± 5.2 for PGY1s, 16.6 ± 13.9 for PGY2s, 27.8 ± 12.5 for PGY3s, 38.2 ± 18.8 for PGY4s, and 26.1 ± 9.6 for PGY5s. PGY1s, PGY2s, PGY3s, PGY4s, or all classes were not statistically different. PGY5s did have statistically fewer cases in 2003 ( P = 0.03). PGY5s did have statistically fewer cases after the work-hours restriction, which likely represented shifting of postcall afternoon cases to other residents. Comparing other classes and all PGYs, case numbers were not statistically different. Operative training experience does not appear to be hindered by the 80-hour work week.