A qualitative assessment of internal medicine resident perceptions of graduate medical education following implementation of the 2011 ACGME duty hour standards

Urology Residents’ Perspectives on the In-House On-Call Systems: A Study in an Accredited Academic Center

Introduction: Medical education and training are crucial in maintaining patients’ safety and improving patient care quality. Multiple studies have evaluated the effects of restrictive policies on the resident's quality of life and education. Due to the compiling data and the fact that these trials evaluated programs with a substantial number of residents, it remains uncertain whether these conclusions can be extended to urology programs with a small number of residents. Multiple on-call systems have been adopted in residency programs across the world. This study evaluated the residents’ quality of life, clinical experience, and education upon transitioning from 24-hour to 12-hour in-house on-call systems.

Methods and materials: In this observational and questionnaire-based study, the effect of the transition from 24-hour to 12-hour in-house on-call systems was compared in terms of the resident's quality of life and education, surgical case volume, and working hours’ rules compliance.

Quality of life and education: We adopted a validated survey based on a 5-point Likert scale to assess the residents’ perception of the transition to a 12-hour on-call system on their quality of life and education.

Surgical case volume: We extracted the number of cases the residents operated on from the operating theater database at our institution.

Working hours: compliance and violations: The weekly working hours, compliance, and violations per ACGME-I rules were collected from the MedHub platform.

Results: Quality of life and education: Residents rated the 12-hour on-call system superior in terms of quality of life, education, and surgical case volume.

Surgical case volume: There was a 45% increment in the surgical case volume (p = 0.04) with the 12-hour on-call system.

Working hours: compliance and violations

There was no significant difference in the mean weekly working hours (p = 0.1). However, the total number of duty hours violations decreased in the 12-hour on-call system.

Conclusion: The 12-hour system is a better alternative to the 24-hour system in terms of the resident's quality of life, education, surgical case volume, and compliance with duty hour rules.

Japanese International Medical Graduates and the United States clinical training experience: Challenges abroad and methods to overcome them

INTRODUCTION

Due to the large language and cultural distances between Japan and the US compared to many countries, Japanese International Medical Graduates (IMGs) may have a different US training experience, including more stress, than many IMGs. We examined the US clinical training experience for Japanese IMGs, including the challenges encountered, how those challenges are overcome, and the benefits of US training.

METHODS

We performed individual semistructured interviews with 35 purposively sampled Japanese IMGs who had completed US clinical training. Exploratory thematic analysis was conducted using iterative data collection and constant comparison.

RESULTS

All participants reported high personal growth and that US clinical training was worth the sacrifices. Commonly fatigue was lower than during Japanese residency. Participants explained medical practice and local culture associated challenges that aligned with literature on US graduates and other IMGs. By contrast, nearly all participants reported that English communication was very challenging, and described specific language related struggles and methods to help overcome them. Communication struggles were contextualized within an American training culture that values verbal assertiveness. Self-esteem varied among participants and, for some participants, improved with confidence in communication. Several participants reported depression and other mental illness. The training environment varied among residency programs.

CONCLUSIONS

Japanese IMGs who completed US training report that it was worth it, but describe significant language and culture related struggles and effects on mental health. Further research should address which Japanese IMGs are most likely to struggle, how this will transpire, and how to optimize the US clinical training experience.

Patients of Our Own: Defining "Ownership" of Clinical Care in Graduate Medical Education

Phenomenon: Learning to assume ownership of patient care is a critical objective of medical training. However, little is known about how ownership is best defined and measured or about its value to trainees. The authors aimed to define ownership and elucidate the significance of developing ownership skills over the course of pediatric residency training. Approach: Focus groups and phone interviews were held with pediatric residency program directors (N = 18) and pediatric residents (N = 14). Focus groups and interviews were audio-recorded, transcribed verbatim, and qualitatively analyzed using thematic analysis. Findings: Program directors and residents characterized ownership as essential to good patient care. Ownership was defined as including personal responsibility, a connection to patients/families, and follow-up and follow-through. For many, ownership was most conspicuous in its absence. Respondents found meaning in their work when exerting ownership and lack of ownership was linked to burnout and frustration. Ownership was recognized as a critical skill that requires development during training to form a professional identity, avoid burnout, become an independent practitioner and function as an integral member of medical teams. Insights: Pediatric residents and faculty considered ownership a cornerstone of patient care and critical to forming a professional identity. The defining characteristics of patient care ownership-personal responsibility, connections with patients and families, and continuity of care-can be used to develop an instrument to assess trainee development of ownership. These findings reinforce the value of ownership in graduate medical education and support creating curricular interventions to foster ownership.

Contrasting Residency Training in Japan and the United States From Perspectives of Japanese Physicians Trained in Both Systems

BACKGROUND

International medical graduates (IMGs) have significant exposure to clinical training in their home country, which provides opportunity for international comparison of training experiences. One relevant IMG population is Japanese physicians who have completed some training before entering residency programs in the United States and desire to improve medical education in Japan.

OBJECTIVE

We examined Japanese IMGs' perceptions of the respective attributes of residency in the United States and Japan.

METHODS

Individual semistructured interviews were conducted with 33 purposively sampled Japanese IMGs who had completed training. We used exploratory thematic analysis, iterative data collection, and thematic analyses with constant comparison.

RESULTS

Comments were organized into 3 categories: (1) attributes of US residency preferable to Japanese residency; (2) attributes of residency training with no clear preference for the US or Japanese systems; and (3) attributes of Japanese residency preferable to US residency. Within each category, we matched themes to residency program requirements or culture of medical training. Main themes include high regard for Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements, with emphasis on efficient achievement of clinical competency through graded responsibility, contrasted with preference expressed for a Japanese training culture of increased professional commitment facilitated by a lack of work hour limits and development of broad clinician skills, including bedside procedures and radiology interpretation.

CONCLUSIONS

Japanese training culture contrasts with a US model that is increasingly focused on work-life balance and associated compartmentalization of patient care. These findings enhance our understanding of the global medical education landscape and challenges to international standardization of training.

The ophthalmology postgraduate training programme in South Africa: The registrars’ perspective

Background: In South Africa, to become an ophthalmologist, one must successfully complete a 4-year postgraduate training programme as a registrar. This training has been offered at different institutions around the country for many years without ever being scrutinised.Aim: The aim of this study was to evaluate the training methods and platforms, overall satisfaction levels, problems and solutions pertaining to postgraduate ophthalmology training as identified by ophthalmology registrars.Setting: The study was conducted in all the institutions across South Africa offering ophthalmology postgraduate training.Methods: This was an educational evaluation study. The data collection instrument used was a questionnaire created using SurveyMonkey.com and sent via email to all ophthalmology registrars, including supernumerary candidates. Ethical approval was granted by the university’s Biomedical Research Ethics Committee.Results: There was a 48% response rate to the survey. Registrars were satisfied that they had received adequate teaching and support, although there was room for improvement. The common problems that impacted the quality of training, as cited by the registrars, were staff shortages, large patient numbers as well as old and broken-down infrastructure or equipment. Despite 86% of the registrars spending at least 5–10 h a week in theatre, 13.3% indicated that they had no supervision during that time. Access to teaching materials (journals, library and Internet) was not available to 34% of the respondents.Conclusion: Registrars were generally satisfied with their training, but major problems that negatively affect their time as trainees were highlighted. Cooperation between registrars, universities, heads of departments and the department of health will be important to remedy this situation.

A 3-Year Study of Resident Reaction to 2011 ACGME Work Hour Rules in a Family Medicine Residency

INTRODUCTION

2011 Accreditation Council for Graduate Medical Education (ACGME) work hour rules prompted concerns regarding potential negative impacts on patient care and resident education. We were interested in resident reaction to call restructuring and night oat (NF) in a family medicine residency over 3 years following implementation of the 2011 rules.

METHODS

We conducted structured interviews of residents from 2011-2012 through 2013-2014. Interviews were recorded, transcribed, and analyzed for themes.

RESULTS

Fifty-eight interviews were conducted, including 18/18 residents in 2011-2012 (100%), 18/20 residents in 2012-2013 (90%), and 22/22 residents in 2013-2014 (100%). Following introduction of the 24-hour work limit, upper year residents reported significantly less fatigue and improved personal lives, patient care, and educational experience. Reactions to NF varied with length and intensity of the NF rotation; most PGY-1 residents reported increased fatigue, more burnout, and worse personal lives on NF. Most residents felt patient care quality on NF did not differ from non-NF rotations because improved inpatient nighttime continuity mitigated effects of fatigue and increased care transitions. Reactions regarding educational experience on NF were initially negative, but improved over time.

CONCLUSIONS

Residents' reactions to 2011 ACGME work hour rules suggest the rules improved resident well-being, except on NF. Negative effects of NF may be minimized by limiting NF rotations to 5 nights/week for 2 consecutive weeks, and 1 month total per academic year.

The Importance of Fostering Ownership During Medical Training

There is a need to consider the impact of the new resident-hours regulations on the variety of aspects of medical education and patient care. Most existing literature about this subject has focused on the role of fatigue in resident performance, education, and health care delivery. However, there are other possible consequences of these new regulations, including a negative impact on decision ownership. Our main assumption of is that increased shift work in medicine can decrease ownership of treatment decisions and impact negatively on quality of care. We review some potential components of decision ownership in treatment context and suggest possible ways in which the absence of decision ownership may decrease the quality of medical decision making. The article opens with the definition of decision ownership and the overview of some contextual factors that may contribute to the development of ownership in medical residency. The following section discusses decision ownership in medical care from the perspective of "diffusion of responsibility." We question the quality of choices made within narrow decisional frames. We also compare isolated and interrelated choices, assuming that residents make more isolated decisions during their shifts. Lastly, we discuss the consequences of decreased decision ownership impacting the delivery of health care.

Preferences and Outcomes for Chemotherapy Teaching in a Postgraduate Obstetrics and Gynecology Training Program

PURPOSE

To determine whether chemotherapy teaching is a desired component of postgraduate training programs in obstetrics and gynecology and assess its effect on practicing clinicians.

METHOD

After obtaining institutional review board approval, 99 individuals who completed postgraduate training at a single academic medical center between 2005 and 2013 were invited to complete an online survey. Descriptive statistics were used to summarize responses.

RESULTS

Of the 99 individuals, 68 (68%) completed the survey. Respondents included physicians currently practicing in both academic medicine (n = 36, 52.9%) and private practice (n = 24, 35.2%). Most respondents (n = 60, 88.2%) indicated that chemotherapy teaching was a desired feature of their training and expressed a preference for both formal didactics and direct clinical involvement (n = 55, 80.2%). Benefits identified by respondents included improved insight into the management of symptoms commonly associated with chemotherapy (n = 55, 82.1%) and an enhanced ability to counsel patients referred for oncology care (n = 48, 70.5%). All respondents who pursued training in gynecologic oncology following residency (n = 6) indicated that chemotherapy teaching favorably affected their fellowship experience. Of the 6 gynecologic oncologists, 3 (50%) who responded also indicated that chemotherapy teaching during residency improved their performance in fellowship interviews.

CONCLUSION

Chemotherapy teaching was a desired feature of postgraduate training in general obstetrics and gynecology at the institution studied. Consideration should be given to creating curricula that incorporate the principles and practice of chemotherapy and address the needs of obstetrics and gynecology trainees who intend to pursue both general and subspecialty practice.

Gamification as a tool for enhancing graduate medical education

Introduction

The last decade has seen many changes in graduate medical education training in the USA, most notably the implementation of duty hour standards for residents by the Accreditation Council of Graduate Medical Education. As educators are left to balance more limited time available between patient care and resident education, new methods to augment traditional graduate medical education are needed.

Objectives

To assess acceptance and use of a novel gamification-based medical knowledge software among internal medicine residents and to determine retention of information presented to participants by this medical knowledge software.

Methods

We designed and developed software using principles of gamification to deliver a web-based medical knowledge competition among internal medicine residents at the University of Alabama (UA) at Birmingham and UA at Huntsville in 2012–2013. Residents participated individually and in teams. Participants accessed daily questions and tracked their online leaderboard competition scores through any internet-enabled device. We completed focus groups to assess participant acceptance and analysed software use, retention of knowledge and factors associated with loss of participants (attrition).

Results

Acceptance: In focus groups, residents (n=17) reported leaderboards were the most important motivator of participation. Use: 16 427 questions were completed: 28.8% on Saturdays/Sundays, 53.1% between 17:00 and 08:00. Retention of knowledge: 1046 paired responses (for repeated questions) were collected. Correct responses increased by 11.9% (p<0.0001) on retest. Differences per time since question introduction, trainee level and style of play were observed. Attrition: In ordinal regression analyses, completing more questions (0.80 per 10% increase; 0.70 to 0.93) decreased, while postgraduate year 3 class (4.25; 1.44 to 12.55) and non-daily play (4.51; 1.50 to 13.58) increased odds of attrition.

Conclusions

Our software-enabled, gamification-based educational intervention was well accepted among our millennial learners. Coupling software with gamification and analysis of trainee use and engagement data can be used to develop strategies to augment learning in time-constrained educational settings.