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Luther VP, Paras ML, Schultz S, Aziz M, Balba G, McCarty TP, Razonable RR, Reece R, Shnekendorf R, Sundareshan V, Chirch LM. High-Volume, High-Acuity, and High-Impact Learning: Tips and Tricks for Infectious Diseases Training Programs. Open Forum Infect Dis 2024; 11:ofae016. [PMID: 38434609 PMCID: PMC10906700 DOI: 10.1093/ofid/ofae016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 12/18/2023] [Indexed: 03/05/2024] Open
Abstract
The Infectious Diseases Society of America Training Program Directors Committee met in October 2022 and discussed an observed increase in clinical volume and acuity on infectious diseases (ID) services, and its impact on fellow education. Committee members sought to develop specific goals and strategies related to improving training program culture, preserving quality education on inpatient consult services and in the clinic, and negotiating change at the annual IDWeek Training Program Director meeting. This paper outlines a presentation of ideas brought forth at the meeting and is meant to serve as a reference document for infectious diseases training program directors seeking guidance in this area.
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Affiliation(s)
- Vera P Luther
- Section on Infectious Diseases, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Molly L Paras
- Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sara Schultz
- Section of Infectious Diseases, Temple University Hospital, Lewis Katz School of Medicine, Philadelphia, Pennsylvania, USA
| | - Mariam Aziz
- Division of Infectious Diseases, Rush University Medical Center, Chicago, Illinois, USA
| | - Gayle Balba
- Division of Infectious Diseases, Medstar Georgetown University Hospital, Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Todd P McCarty
- Division of Infectious Diseases, University of Alabama at Birmingham, and Birmingham Veterans Affairs Medical Center, Birmingham, Alabama, USA
| | - Raymund R Razonable
- Division of Infectious Diseases, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Rebecca Reece
- Division of Infectious Diseases, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | | | - Vidya Sundareshan
- Division of Infectious Diseases, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Lisa M Chirch
- Division of Infectious Diseases, University of Connecticut School of Medicine, Farmington, Connecticut, USA
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Shepherd L, Chilton S, Cristancho SM. Residents, Responsibility, and Error: How Residents Learn to Navigate the Intersection. Acad Med 2023; 98:934-940. [PMID: 37146251 DOI: 10.1097/acm.0000000000005267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
PURPOSE As a competency of Canadian postgraduate education, residents are expected to be able to promptly disclose medical errors and assume responsibility for and take steps to remedy these errors. How residents, vulnerable through their inexperience and hierarchical team position, navigate the highly emotional event of medical error is underexplored. This study examined how residents experience medical error and learn to become responsible for patients who have faced a medical error. METHOD Nineteen residents from a breadth of specialties and years of training at a large Canadian university residency program were recruited to participate in semistructured interviews between July 2021 and May 2022. The interviews probed their experience of caring for patients who had experienced a medical error. Data collection and analysis were conducted iteratively using a constructivist grounded theory method with themes identified through constant comparative analysis. RESULTS Participants described their process of conceptualizing error that evolved throughout residency. Overall, the participants described a framework for how they experienced error and learned to care for both their patients and themselves following a medical error. They outlined their personal development of understanding error, how role modeling influenced their thinking about error, their recognition of the challenge of navigating a workplace environment full of opportunities for error, and how they sought emotional support in the aftermath. CONCLUSIONS Teaching residents to avoid making errors is important, but it cannot replace the critical task of supporting them both clinically and emotionally when errors inevitably occur. A better understanding of how residents learn to manage and become responsible for medical error exposes the need for formal training as well as timely, explicit discussion and emotional support both during and after the event. As in clinical management, graded independence in error management is important and should not be avoided because of faculty discomfort.
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Affiliation(s)
- Lisa Shepherd
- L. Shepherd is professor, Division of Emergency Medicine, Department of Medicine, Centre for Education Research and Innovation, Western University, London, Ontario, Canada
| | - Stephanie Chilton
- S. Chilton is a senior resident, Division of Emergency Medicine, Department of Medicine, Western University, London, Ontario, Canada
| | - Sayra M Cristancho
- S.M. Cristancho is associate professor, Department of Surgery and Faculty of Education, Centre for Education Research and Innovation, Western University, London, Ontario, Canada
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Steffey MA, Griffon DJ, Risselada M, Scharf VF, Buote NJ, Zamprogno H, Winter AL. Veterinarian burnout demographics and organizational impacts: a narrative review. Front Vet Sci 2023; 10:1184526. [PMID: 37470072 PMCID: PMC10352684 DOI: 10.3389/fvets.2023.1184526] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 06/19/2023] [Indexed: 07/21/2023] Open
Abstract
Burnout is a work-related syndrome of physical and emotional exhaustion secondary to prolonged, unresolvable occupational stress. Individuals of different demographic cohorts may have disparate experiences of workplace stressors and burnout impacts. Healthcare organizations are adversely affected by burnt out workers through decreased productivity, low morale, suboptimal teamwork, and potential impacts on the quality of patient care. In this second of two companion reviews, the demographics of veterinary burnout and the impacts of burnout on affected individuals and work environments are summarized, before discussing mitigation concepts and their extrapolation for targeted strategies within the veterinary workplace and profession.
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Affiliation(s)
- Michele A. Steffey
- Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, Davis, CA, United States
| | - Dominique J. Griffon
- Western University of Health Sciences, College of Veterinary Medicine, Pomona, CA, United States
| | - Marije Risselada
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Purdue University, West-Lafayette, IN, United States
| | - Valery F. Scharf
- Department of Clinical Sciences, North Carolina State University College of Veterinary Medicine, Raleigh, NC, United States
| | - Nicole J. Buote
- Department of Clinical Sciences, Cornell University College of Veterinary Medicine, Ithaca, NY, United States
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Coakley N, O'Leary P, Bennett D. Endured and prevailed: a phenomenological study of doctors' first year of clinical practice. BMC Med Educ 2023; 23:109. [PMID: 36782187 PMCID: PMC9923928 DOI: 10.1186/s12909-023-04059-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 01/24/2023] [Indexed: 06/18/2023]
Abstract
CONTEXT The challenging nature of the transition from medical student to doctor is highlighted by the associated negative consequences to new doctors' mental health and wellbeing. Enhanced understanding of the lived experience of recent medical graduates as they move through the stages of transition over the first year of practice can inform interventions to ease the difficulties encountered. METHODS Using interpretative phenomenological analysis (IPA), a novel approach to this topic, we explored the lived experience of transition from student to doctor over the first year of practice after graduation. Twelve new graduates were purposively recruited. We conducted semi-structured interviews at the end of their first year of practice with respect to their experience over the first year. RESULTS The experience of transition was characterised by overlapping temporal stages. Participants' initial adjustment period was characterised by shock, coping and stabilisation. A phase of development followed, with growth in confidence and a focus on self-care. Adversity was experienced in the form of interprofessional tensions, overwork, isolation and mistreatment. Finally, a period of reflection and rationalisation marked the end of the first year. DISCUSSION Following initial anxiety regarding competence and performance, participants' experience of transition was predominantly influenced by cultural, relational and contextual aspects of clinical practice. Solutions to ease this challenging time include stage-specific transitional interventions, curricular change at both undergraduate and postgraduate levels and a re-evaluation of the clinical learning environment to mitigate the difficulties endured.
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Affiliation(s)
- Niamh Coakley
- Department of Medicine, University College Cork, National University of Ireland, Cork, Ireland.
| | - Paula O'Leary
- School of Medicine, University College Cork, National University of Ireland, Cork, Ireland
| | - Deirdre Bennett
- Medical Education Unit, University College Cork, National University of Ireland, Cork, Ireland
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Mirabella AC, McAmis NE, Kiassat C, Feinn R, Singh G. Preferences to improve rounding efficiency amongst hospitalists: a survey analysis. J Community Hosp Intern Med Perspect 2021; 11:501-506. [PMID: 34211657 PMCID: PMC8221154 DOI: 10.1080/20009666.2021.1929047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background: There is no ‘gold standard’ method of rounding for hospitalists. This study investigates hospitalist rounding preferences to improve efficiency based on resources categorized under work assignment and communication. Methods: An anonymous survey containing demographics and questions on preferences for rounding efficiently by hospitalists were widely distributed online. Res6ponses were presented using descriptive statistics and SPSS v26. Results: There were 143 respondents, majority male (60%) with (40%) female. Most (80%) expect higher patient volumes when working with an advanced practitioner (AP). Half (50%) preferred rounding independently, (34%) with an AP, and majority (62%) with a resident. Geographic rounding was most efficient at 85%. Text messaging for paging was preferred (70.1%) to pagers (23.4%). Respondents preferred calling a consultant (52%) or text messaging (40%). Majority have not used a WOW yet (74%) believe WOWs could improve efficiency. Majority prefer dictation via Dragon (47%) to the phone application (23%). Only 29% believe their EMR is too complex to navigate. Preference difference due to age was insignificant. Discussion and Conclusion: In this study, 143 hospitalists provided preferences for improving rounding efficiency based on elements from work assignment and communication. This analysis can provide insights on designing best practices for hospitalists rounding efficiently.
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Affiliation(s)
- Angela C Mirabella
- Frank H. Netter MD School of Medicine, Quinnipiac University, North Haven, CT, USA
| | - Nicole E McAmis
- Frank H. Netter MD School of Medicine, Quinnipiac University, North Haven, CT, USA
| | - Corey Kiassat
- School of Engineering, Quinnipiac University, Hamden, CT, USA
| | - Richard Feinn
- Frank H. Netter MD School of Medicine, Quinnipiac University, North Haven, CT, USA
| | - Gagan Singh
- Department of Hospital Medicine , Hartford Hospital, Hartford, CT, USA
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Kohn R, Harhay MO, Weissman GE, Anesi GL, Bayes B, Song H, Halpern SD, Greysen SR, Kerlin MP. The Association of Geographic Dispersion with Outcomes among Hospitalized Pulmonary Service Patients. Ann Am Thorac Soc 2020; 17:249-52. [PMID: 31618603 DOI: 10.1513/AnnalsATS.201906-471RL] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Berger S, Nassetta LB, Hofto ME, Scalici P, Pass RF. Drip System for Admissions to Resident Teams: Impact on Workload and Education. South Med J 2020; 113:635-639. [PMID: 33263133 DOI: 10.14423/smj.0000000000001183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Assigning patients to a call team every fourth day (bolus system) caused the maldistribution of patients among resident teams and required additional faculty effort for overflow patient care. We changed to a continuous daily rotation (drip system) and examined the effect on clinical workload among resident teams, resident education, and faculty utilization. METHODS This is a retrospective study based on the daily records of 7 am team census, the attending physician schedules for a pediatric hospital medicine service with 5 teams, and the measures of resident education, including noon conference attendance, scores on in-service examinations, and duty hour violations. Data from the bolus system (May 2014-June 2015) were compared with the drip system (May 2016-June 2017). RESULTS Data from 348 bolus days and 338 drip days were analyzed. There was a decrease in interteam variation from 6.2 to 3.9 patients (P < 0.001). There were fewer days with the following: large interteam variation (143 to 25, P < 0.001), days with resident teams at or above capacity (26 to 11, P = 0.01), resident teams below a minimum 7 am census (133 to 18, P < 0.001), and days when additional faculty were pulled for clinical care (61 to 9, P < 0.001). Resident noon conference attendance was unchanged and there was no adverse effect on examination scores or duty hour violations. CONCLUSIONS Changing from a bolus to a drip model for admissions to inpatient teams resulted in a more even distribution of the workload and a more efficient use of physician resources without negatively affecting resident education.
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Affiliation(s)
- Stephanie Berger
- From the Department of Pediatrics, University of Alabama at Birmingham School of Medicine and Children's of Alabama, Birmingham
| | - Lauren B Nassetta
- From the Department of Pediatrics, University of Alabama at Birmingham School of Medicine and Children's of Alabama, Birmingham
| | - Meghan E Hofto
- From the Department of Pediatrics, University of Alabama at Birmingham School of Medicine and Children's of Alabama, Birmingham
| | - Paul Scalici
- From the Department of Pediatrics, University of Alabama at Birmingham School of Medicine and Children's of Alabama, Birmingham
| | - Robert F Pass
- From the Department of Pediatrics, University of Alabama at Birmingham School of Medicine and Children's of Alabama, Birmingham
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Fajardo R, Vaporciyan A, Starnes S, Erkmen CP. Implementation of wellness into a cardiothoracic training program: A checklist for a wellness policy. J Thorac Cardiovasc Surg 2020; 161:1979-1986. [PMID: 32868064 DOI: 10.1016/j.jtcvs.2020.04.186] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 04/21/2020] [Accepted: 04/23/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Romulo Fajardo
- Department of General Surgery, Temple University Hospital, Philadelphia, Pa.
| | - Ara Vaporciyan
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Sandra Starnes
- Division of Thoracic Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Cherie P Erkmen
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pa
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Wieler J, Lehman E, Khalid M, Hennrikus E. A Day in the Life of an Internal Medicine Resident - A Time Study: What Is Changed from First to Third Year? Adv Med Educ Pract 2020; 11:253-258. [PMID: 32280293 PMCID: PMC7125302 DOI: 10.2147/amep.s247974] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 03/15/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND In the past decade, internal medicine residencies have undergone major changes in competency-based assessments, work-hour restrictions and the implementation of the electronic medical record. The aim of this study is to compare a typical day of a first year post-graduate (PGY1) to that of a third year post-graduate (PGY3) internal medicine resident and examine if the differences in their days demonstrate the American Board of Internal Medicine's (ABIM) desired progression towards competency-based milestones and unsupervised practice. METHODS We conducted an observational time study documenting 14,103 minutes, 9 major categories, and 17 subcategories while shadowing 10 internal medicine PGY1s and 10 PGY3s during inpatient, non-call days. The following day, house staff completed surveys of their perceived time allocation of the previous 24 hours. RESULTS PGY1s spent an average of 12.5 hours managing an average of 6 patients. Thirty-eight percent of their time was spent on the computer, 21% discussing patients and 18% directly with patients. PGY3s, overseeing an average of 12 patients, worked 1.5 hours less per day (p<0.001), had 1.5 hours less computer time (p=0.001), 24 minutes less direct patient contact (p=0.045), and 36 minutes more patient care discussions (p=0.011). CONCLUSION The difference between PGY1s' and PGY3s' daily time allocations is minimal. Whereas a PGY3 spends 1.5 hours less than a PGY1 on writing computer notes and discharges, they also work 1.5 hours less per day. The additional 36 minutes of patient care discussions was the only significant time quantity difference that would be considered a higher level of practice for the PGY3 compared to the PGY1. With residents now caring for fewer patients, there has been a marked increase in computer time per patient for both PGY1s and PGY3s.
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Affiliation(s)
- Jane Wieler
- Department of Emergency Medicine, Jefferson University Medical Center, Philadelphia, PA, USA
| | - Erik Lehman
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Muhammad Khalid
- Department of Internal Medicine, Pennsylvania State University College of Medicine and Hershey Medical Center, Hershey, PA, USA
| | - Eileen Hennrikus
- Department of Internal Medicine, Pennsylvania State University College of Medicine and Hershey Medical Center, Hershey, PA, USA
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Abstract
BACKGROUND Gastroenterology training in Canada is guided by the Royal College of Physicians and Surgeons of Canada. Resident perspectives on training and the degree of heterogeneity across training programs have not been previously surveyed. AIM This study aims to evaluate the current Canadian adult gastroenterology training experience from a resident perspective and provide insight into the heterogeneity among training programs. METHOD A survey designed by three current gastroenterology residents was distributed to trainees attending the Gastroenterology Residents-in-Training course at Canadian Digestive Diseases Week 2018. Categorical data from the survey was analyzed in table format. Other continuous data was converted to dichotomous data and analyzed in groups of small and large programs, the large program defined as greater than six trainees. RESULTS The overall response rate was 45 of 56 (80%), representing 13 of 14 accredited training sites. Mandatory rotations and core procedures varied widely across respondents, with only inpatient training consistent across all sites. Small programs had a higher call burden (P=0.039), but staff were more likely to be available to cover call if the resident coverage was unavailable (P=0.002). There were nonsignificant trends in small programs in the inability to take a post-call day (P=0.07) and a resident perception of being well trained (P=0.07). CONCLUSIONS There is heterogeneity across programs in mandatory rotations and core procedures. With the upcoming shift to competency-based medical education, it is an opportune time to re-evaluate and perhaps standardize how gastroenterology training is delivered in Canada.
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Affiliation(s)
- Brian P H Chan
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Michael Fine
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Seth Shaffer
- Section of Gastroenterology, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Khurram J Khan
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Rousseau M, Könings KD, Touchie C. Overcoming the barriers of teaching physical examination at the bedside: more than just curriculum design. BMC Med Educ 2018; 18:302. [PMID: 30537960 PMCID: PMC6288852 DOI: 10.1186/s12909-018-1403-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 11/23/2018] [Indexed: 05/21/2023]
Abstract
BACKGROUND Physicians in training must achieve a high degree of proficiency in performing physical examinations and must strive to become experts in the field. Concerns are emerging about physicians' abilities to perform these basic skills, essential for clinical decision making. Learning at the bedside has the potential to support skill acquisition through deliberate practice. Previous skills improvement programs, targeted at teaching physical examinations, have been successful at increasing the frequency of performing and teaching physical examinations. It remains unclear what barriers might persist after such program implementation. This study explores residents' and physicians' perceptions of physical examinations teaching at the bedside following the implementation of a new structured bedside curriculum: What are the potentially persisting barriers and proposed solutions for improvement? METHODS The study used a constructivist approach using a qualitative inductive thematic analysis that was oriented to construct an understanding of the barriers and facilitators of physical examination teaching in the context of a new bedside curriculum. Participants took part in individual interviews and subsequently focus groups. Transcripts were coded and themes were identified. RESULTS Data analyses yielded three main themes: (1) the culture of teaching physical examination at the bedside is shaped and threatened by the lack of hospital support, physicians' motivation and expertise, residents' attitudes and dependence on technology, (2) the hospital environment makes bedside teaching difficult because of its chaotic nature, time constraints and conflicting responsibilities, and finally (3) structured physical examination curricula create missed opportunities in being restrictive and pose difficulties in identifying patients with findings. CONCLUSIONS Despite the implementation of a structured bedside curriculum for physical examination teaching, our study suggests that cultural, environmental and curriculum-related barriers remain important issues to be addressed. Institutions wishing to develop and implement similar bedside curricula should prioritize recruitment of expert clinical teachers, recognizing their time and efforts. Teaching should be delivered in a protected environment, away from clinical duties, and with patients with real findings. Physicians must value teaching and learning of physical examination skills, with multiple hands-on opportunities for direct role modeling, coaching, observation and deliberate practice. Ideally, clinical teachers should master the art of combining both patient care and educational activities.
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Affiliation(s)
- Melissa Rousseau
- Department of Medicine, The Ottawa Hospital, University of Ottawa, 501 Smyth Road CPCR L2135, Box 209, Ontario, Ottawa K1H 8L6 Canada
| | - Karen D. Könings
- Department of Educational Development and Research, Faculty of Health, Medicine and Life Sciences, Maastricht University, the Netherlands, Universiteitssingel 60, Room M 5.08, 6229 ER Maastricht, The Netherlands
| | - Claire Touchie
- Department of Medicine, The Ottawa Hospital, University of Ottawa and the Ottawa Hospital Research Institute, 501 Smyth Road CPCR L2135, Box 209, Ontario, Ottawa K1H 8L6 Canada
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Moore NH, Fondahn ED, Baty JD, Blanchard MS. Impact of a hospital bounceback policy to reduce readmissions. Healthcare (Basel) 2018; 6:41-45. [DOI: 10.1016/j.hjdsi.2017.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 10/23/2017] [Accepted: 10/25/2017] [Indexed: 10/18/2022] Open
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Burchiel KJ, Zetterman RK, Ludmerer KM, Philibert I, Brigham TP, Malloy K, Arrighi JA, Ashley SW, Bienstock JL, Carek PJ, Correa R, Forstein DA, Gaiser RR, Gold JP, Keepers GA, Kennedy BC, Kirk LM, Kothari A, Langdale LA, Shayne PH, Stain SC, Woods SK, Wyatt-Johnson C, Nasca TJ. The 2017 ACGME Common Work Hour Standards: Promoting Physician Learning and Professional Development in a Safe, Humane Environment. J Grad Med Educ 2017; 9:692-696. [PMID: 29270256 PMCID: PMC5734321 DOI: 10.4300/jgme-d-17-00317.1] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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14
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Blair T, Wiener Z, Seroussi A, Tang L, O'Hora J, Cheung E. Resident Workflow and Psychiatric Emergency Consultation: Identifying Factors for Quality Improvement in a Training Environment. Acad Psychiatry 2017; 41:377-380. [PMID: 27928767 DOI: 10.1007/s40596-016-0646-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 11/22/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE Quality improvement to optimize workflow has the potential to mitigate resident burnout and enhance patient care. This study applied mixed methods to identify factors that enhance or impede workflow for residents performing emergency psychiatric consultations. METHODS The study population consisted of all psychiatry program residents (55 eligible, 42 participating) at the Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles. The authors developed a survey through iterative piloting, surveyed all residents, and then conducted a focus group. The survey included elements hypothesized to enhance or impede workflow, and measures pertaining to self-rated efficiency and stress. Distributional and bivariate analyses were performed. Survey findings were clarified in focus group discussion. RESULTS This study identified several factors subjectively associated with enhanced or impeded workflow, including difficulty with documentation, the value of personal organization systems, and struggles to communicate with patients' families. CONCLUSION Implications for resident education are discussed.
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Affiliation(s)
| | - Zev Wiener
- University of California, Los Angeles, CA, USA
| | | | - Lingqi Tang
- University of California, Los Angeles, CA, USA
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15
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Jurkovich GJ, Davis KA, Burlew CC, Dente CJ, Galante JM, Goodwin JS, Joseph B, de Moya M, Becher RD, Pandit V. Acute care surgery: An evolving paradigm. Curr Probl Surg 2017; 54:364-395. [PMID: 28756821 DOI: 10.1067/j.cpsurg.2017.05.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
| | - Kimberly A Davis
- Department of Surgery, Yale School of Medicine, New Haven, CT; Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Clay Cothren Burlew
- Department of Surgery, Denver Health Medical Center, University of Colorado, Denver, CO
| | - Christopher J Dente
- Department of Surgery, Emory University at Grady Memorial Hospital, Atlanta, GA
| | | | | | - Bellal Joseph
- Department of Surgery, University of Arizona, Tucson, AZ
| | - Marc de Moya
- Chief of the Division of Trauma, Critical Care, and Acute Care Surgery, Medical College of Wisconsin, Milwaukee
| | - Robert D Becher
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Viraj Pandit
- Department of Surgery, The University of Arizona, Tucson, AZ
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Abstract
Interest in nephrology has been declining in recent years. Long work hours and a poor work/life balance may be partially responsible, and may also affect a fellowship's educational mission. We surveyed nephrology program directors using a web-based survey in order to define current clinical and educational practice patterns and identify areas for improvement. Our survey explored fellowship program demographics, fellows' workload, call structure, and education. Program directors were asked to estimate the average and maximum number of patients on each of their inpatient services, the number of patients seen by fellows in clinic, and to provide details regarding their overnight and weekend call. In addition, we asked about number of and composition of didactic conferences. Sixty-eight out of 148 program directors responded to the survey (46%). The average number of fellows per program was approximately seven. The busiest inpatient services had a mean of 21.5±5.9 patients on average and 33.8±10.7 at their maximum. The second busiest services had an average and maximum of 15.6±6.0 and 24.5±10.8 patients, respectively. Transplant-only services had fewer patients than other service compositions. A minority of services (14.5%) employed physician extenders. Fellows most commonly see patients during a single weekly continuity clinic, with a typical fellow-to-faculty ratio of 2:1. The majority of programs do not alter outpatient responsibilities during inpatient service time. Most programs (approximately 75%) divided overnight and weekend call responsibilities equally between first year and more senior fellows. Educational practices varied widely between programs. Our survey underscores the large variety in workload, practice patterns, and didactics at different institutions and provides a framework to help improve the service/education balance in nephrology fellowships.
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Affiliation(s)
- Scott E Liebman
- Department of Medicine, Division of Nephrology, University of Rochester Medical Center, Rochester, New York
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Fang M, Linson E, Suneja M, Kuperman EF. Impact of adding additional providers to resident workload and the resident experience on a medical consultation rotation. BMC Med Educ 2017; 17:44. [PMID: 28228099 PMCID: PMC5322644 DOI: 10.1186/s12909-017-0874-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 01/31/2017] [Indexed: 05/24/2023]
Abstract
BACKGROUND Excellence in Graduate Medical Education requires the right clinical environment with an appropriate workload where residents have enough patients to gain proficiency in medicine with optimal time for reflection. The Accreditation Council for Graduate Medical Education (ACGME) has focused more on work hours rather than workload; however, high resident workload has been associated with lower resident participation in education and fatigue-related errors. Recognizing the potential risks associated with high resident workload and being mindful of the costs of reducing resident workload, we sought to reduce residents' workload by adding an advanced practice provider (APP) to the surgical comanagement service (SCM) and study its effect on resident satisfaction and perceived educational value of the rotation. METHODS In Fiscal Year (FY) 2014 and 2015, an additional faculty member was added to the SCM rotation. In FY 2014, the faculty member was a staff physician, and in FY 2015, the faculty member was an APP.. Resident workload was assessed using billing data. We measured residents' perceptions of the rotation using an anonymous electronic survey tool. We compared FY2014-2015 data to the baseline FY2013. RESULTS The number of patients seen per resident per day decreased from 8.0(SD 3.3) in FY2013 to 5.0(SD 1.9) in FY2014 (p < 0.001) and 5.7(SD 2.0) in FY2015 (p < 0.001). A higher proportion of residents reported "just right" patient volume (64.4%, 91.7%, 96.7% in FY2013, 2014, 2015 respectively p < 0.001), meeting curricular goals (79.9%, 95.0%, 97.2%, in FY2013, 2014 and 2015 respectively p < 0.001), and overall educational value of the rotation (40.0%, 72.2%, 72.6% in FY2013, 2014, 2015 respectively, p < 0.001). CONCLUSIONS Decreasing resident workload through adding clinical faculty (both staff physician and APPs) was associated with improvements on resident perceived educational value and clinical experience of a medical consultation rotation.
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Affiliation(s)
- Michele Fang
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA USA
- Department of Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
- Section of Hospital Medicine, Hospital of the University of Pennsylvania, Department of Medicine, Section of Hospital Medicine, 3400 Spruce Street, Maloney Building, 5th floor, Suite 5033, Philadelphia, PA 19104 USA
| | - Eric Linson
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA USA
| | - Manish Suneja
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA USA
| | - Ethan F. Kuperman
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA USA
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Thorp J, Dattalo M, Ghanem KG, Christmas C. Implementation of 2011 Duty Hours Regulations through a Workload Reduction Strategy and Impact on Residency Training. J Gen Intern Med 2016; 31:1475-81. [PMID: 27514539 DOI: 10.1007/s11606-016-3840-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 05/19/2016] [Accepted: 07/27/2016] [Indexed: 10/21/2022]
Abstract
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.
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Abstract
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.
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Garrison GM, Pecina JL. Using the M/G/∞ queueing model to predict inpatient family medicine service census and resident workload. Health Informatics J 2016; 22:429-39. [DOI: 10.1177/1460458214565949] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The number and timing of unplanned admissions to inpatient teaching services vary. Recent changes to resident duty hours make it essential to maximize learning experiences and balance workload on these services. Queueing theory provides a mechanism for understanding and planning for the variations in admissions and daily census. Daily admissions, length of stay, and daily census were modeled for a teaching inpatient family medicine service over 46 months using an M/G/∞ queueing model. Q–Q plots and a Kolmogorov–Smirnov test were used to check the fit of actual data to the model. Admissions and daily census followed a Poisson distribution (λ = 3.28 and λ = 8.28, respectively), while length-of-stay followed a lognormal distribution (µ = 0.49, σ2 = 0.83). The M/G/∞ queueing model proved useful for predicting overflow admission frequency, defining expected resident workload in terms of patient-days, and determining hospital unit size requirements.
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Johnson-Martinez K, Wheeler R, Clevenger C, Tomolo A. Geographic Localization: The Need for Better Reporting and Outcome Selection. Am J Med Qual 2016; 31:489-90. [PMID: 27048702 DOI: 10.1177/1062860616640352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | - Carolyn Clevenger
- Atlanta VA Medical Center, Decatur, GA Emory University, Atlanta, GA
| | - Anne Tomolo
- Atlanta VA Medical Center, Decatur, GA Emory University, Atlanta, GA
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Wingo MT, Halvorsen AJ, Beckman TJ, Johnson MG, Reed DA. Associations between attending physician workload, teaching effectiveness, and patient safety. J Hosp Med 2016; 11:169-73. [PMID: 26741703 DOI: 10.1002/jhm.2540] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 10/30/2015] [Accepted: 11/08/2015] [Indexed: 11/11/2022]
Abstract
BACKGROUND Prior studies suggest that high workload among attending physicians may be associated with reduced teaching effectiveness and poor patient outcomes, but these relationships have not been investigated using objective measures of workload and safety. OBJECTIVE To examine associations between attending workload, teaching effectiveness, and patient safety, hypothesizing that higher workload would be associated with lower teaching effectiveness and negative patient outcomes. DESIGN, SETTING, AND PARTICIPANTS We conducted a retrospective study of 69,386 teaching evaluation items submitted by 543 internal medicine residents for 107 attending physicians who supervised inpatient teaching services from July 2, 2005 to July 1, 2011. MEASUREMENTS Attending workload measures included hospital service census, patient length of stay, daily admissions, daily discharges, and concurrent outpatient duties. Teaching effectiveness was measured using residents' evaluations of attendings. Patient outcomes considered were applicable patient safety indicators (PSIs), intensive care unit transfers, cardiopulmonary resuscitation/rapid response team calls, and patient deaths. Mixed linear models and generalized linear regression models were used for statistical analysis. RESULTS Workload measures of midnight census and daily discharges were associated with lower teaching evaluation scores (both β = -0.026, P < 0.0001). The number of daily admissions was associated with higher teaching scores (β = 0.021, P = 0.001) and increased PSIs (odds ratio = 1.81, P = 0.0001). CONCLUSION Several measures of attending physician workload were associated with slightly lower teaching effectiveness, and patient safety may be compromised when teams are managing new admissions. Ongoing efforts by residency programs to optimize the learning environment should include strategies to manage the workload of supervising attendings.
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Affiliation(s)
- Majken T Wingo
- Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Andrew J Halvorsen
- Internal Medicine Residency Program, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Thomas J Beckman
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Matthew G Johnson
- Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Darcy A Reed
- Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
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Abstract
PURPOSE To summarize current high-quality studies evaluating the effect and efficacy of resident duty hours reforms (DHRs) on patient safety and resident education and well-being. METHOD The authors searched PubMed and Medline in August 2012 and again in May 2013 for literature (1987-2013) about the effects of DHRs. They assessed the quality of articles using the Medical Education Research Study Quality Instrument (MERSQI) scoring system. They considered randomized controlled trials (RCTs), partial RCTs, and all studies with a MERSQI score ≥ 14 to be "high-quality" methodology studies. RESULTS A total of 72 high-quality studies met inclusion criteria. Most studies showed no change or slight improvement in mortality and complication rates after DHRs. Resident well-being was generally improved, but there was a perceived negative impact on education (knowledge acquisition, skills, and cognitive performance) following DHRs. Eleven high-quality studies assessed the impact of DHR interventions; all reported a neutral to positive impact. Seven high-quality studies assessed costs associated with DHRs and demonstrated an increase in hospital costs. CONCLUSIONS The results of most studies that allow enough time for DHR interventions to take effect suggest a benefit to patient safety and resident well-being, but the effect on the quality of training remains unknown. Additional methodologically sound studies on the impact of DHRs are necessary. Priorities for future research include approaches to optimizing education and clinical proficiency and studies on the effect of intervention strategies on both education and patient safety. Such studies will provide additional information to help improve duty hours policies.
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Affiliation(s)
- Henry Lin
- H. Lin is a pediatric gastroenterologist, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. E. Lin is a gastroenterology fellow, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin. S. Auditore is market segment development manager, American Medical Association, Chicago, Illinois. J. Fanning is chief of membership and resident fellow member-early career psychiatrist officer, American Psychiatric Association, Arlington, Virginia
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Ratelle JT, Kelm DJ, Halvorsen AJ, West CP, Oxentenko AS. Predicting and communicating risk of clinical deterioration: an observational cohort study of internal medicine residents. J Gen Intern Med 2015; 30:448-53. [PMID: 25451991 DOI: 10.1007/s11606-014-3114-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 10/13/2014] [Accepted: 11/03/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Despite its importance, little is known about internal medicine (IM) residents' ability to assess and communicate a patient's overnight risk during the resident-to-resident handoff. OBJECTIVE To evaluate IM residents' ability to identify patients at risk for clinical deterioration using the Patient Acuity Rating (PAR) tool (scored on a 1-7 symmetric scale; 1="Extremely unlikely", 7="Extremely likely"), and to measure how well IM residents conveyed a patient's potential for clinical deterioration during day-to-night handoff. DESIGN AND PARTICIPANTS Observational cohort study of 46 postgraduate year 1 (PGY-1) and 32 postgraduate year 3 (PGY-3) internal medicine residents rotating on one of four general medicine services from October 2013 through January 2014. MAIN MEASURES Primary outcomes were (1) level of agreement between resident handoff giver and receiver regarding patients' clinical risk and (2) accuracy of resident-assigned PAR score in predicting a patient's risk of clinical deterioration over the subsequent 24 hours. KEY RESULTS Analysis of PGY-1 giver-receiver handoff agreement revealed an intraclass correlation coefficient (ICC) (95 % CI) of 0.51 (0.45-0.56), while PGY-3 giver-receiver agreement yielded an ICC (95 % CI) of 0.42 (0.36-0.47). Based on 865 ratings of 378 patients, PGY-1 handoff giver PAR scores of 5 and 6+ were significantly associated with increased odds of clinical deterioration within 24 hours (aOR = 6.5 and 12.4; P = 0.03 and 0.005, respectively). For the 1,170 PAR ratings of 438 patients assigned by PGY-3 handoff givers, PAR scores of 4, 5, and 6+ were significantly associated with increased odds of an event within 24 hours (aORs = 6.0, 9.6, and 18.1; P = 0.03, 0.01, and 0.0008, respectively). CONCLUSIONS The PAR is a useful tool to quantify IM residents' judgment of patient stability, and may be particularly valuable during resident handoff, given that the level of agreement between giver and receiver regarding patient risk is only fair.
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Vucicevic D, Mookadam F, Webb BJ, Labonte HR, Cha SS, Blair JE. The impact of 2011 ACGME duty hour restrictions on internal medicine resident workload and education. Adv Health Sci Educ Theory Pract 2015; 20:193-203. [PMID: 24916955 DOI: 10.1007/s10459-014-9525-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Accepted: 05/28/2014] [Indexed: 06/03/2023]
Abstract
The Accreditation Council for Graduate Medical Education (ACGME) implemented work hour restrictions for physicians in training in 2003 that were revised July 1, 2011. Current published data are insufficient to assess whether such work hour restrictions will have long-term impact on residents' education. We searched computer-generated reports of hospital in-patient census, continuity clinic census, in-training exam scores and first-year resident attendance at educational conferences for the academic years 2010-2011 (August 1, 2010-May 31, 2011) and 2011-2013 (August 1, 2011-May 31, 2013). During the first year of the study period, the residents' inpatient internal medicine services admitted 1,754 patients; during this same period for academic years 2011-2012 and 2012-2013, the teaching services admitted 1,539 and 1,428 patients respectively, yielding a decrease of 16.4%. Monthly, these services cared for a mean of 27.1 (27.1/175.4 [15.4%]) fewer patients and 9.7 (9.7/34.4 [28.2%]) fewer patients per intern than in the previous year. No statistical difference was observed regarding continuity clinic attendance and in-training exam scores. Residents in the years following work hours restrictions attended more educational conferences. Implementation of 2011 ACGME work hour regulations resulted in fewer patients seen by first-year residents in hospital, but did not affect in-training exam scores. Whether these findings will translate into differences in patient outcomes, and quality of care remains to be seen.
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Affiliation(s)
- Darko Vucicevic
- Division of Cardiovascular Diseases, Mayo Clinic Hospital, Mayo Clinic Arizona, 13400 East Shea Blvd, Scottsdale, AZ, 85259, USA,
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Abstract
Patient safety in hospital is dependent on a multitude of factors. Recent reports into the failings of healthcare organisations in the UK have highlighted low staffing levels as a significant factor. There is research into the impact of nurse-to-patient ratios on patient safety, but our literature search found little published data that would allow healthcare providers to define a minimum number of physician staff and skills mix that would assure safety in the largest hospital specialty: unscheduled (acute) medicine. Future work should focus on the evaluation of existing data on hospital mortality rates and physician staffing levels as well as on empirical time and motion studies to ascertain the resources required to undertake safe medical care at times of peak demand.
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Affiliation(s)
- Jodie Sabin
- Department of Medicine, Ysbyty Gwynedd, Bangor, UK
| | | | - Louella Vaughan
- Department of Medicine, Northwest London Collaboration for Leadership in Applied Health Research and Care, London, UK
| | - Rhid Dowdle
- Department of Medicine, Royal Glamorgan Hospital, Llantrisant, UK
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Campbell S, Campbell M, Shah C, Djuricich AM. Educational Conference Scheduling, Patient Discharge Time, and Resident Satisfaction. J Grad Med Educ 2014; 6:574-6. [PMID: 26279788 PMCID: PMC4535227 DOI: 10.4300/jgme-d-13-00400.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Revised: 03/31/2014] [Accepted: 04/07/2014] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Limits on resident duty hours instituted in 2003 and 2011 have compressed medical resident daily workload. Despite this compression, residents must gain competence to practice medicine without supervision. OBJECTIVE We sought to determine whether moving the time our educational conference is scheduled affects the time when patient discharges are completed on an internal medicine teaching service. METHODS The study was conducted at a county hospital within a large internal medicine residency program. During the 4-month study period, the morning report conference for internal medicine residents was shifted from 8:30 am to 2 pm. Patient discharge times, defined as the time the discharge order set was signed, were obtained for the service via the electronic health record. The outcomes measured were patient discharge time variation and internal medicine resident preference for conference time. RESULTS Survey response rate was 82% (42 of 51). Of the residents who responded, 64% (27 of 42) preferred the 8:30 am report time, and 74% (31 of 42) felt the 8:30 am time was also better for education and timing of teaching rounds. There was no difference in discharge times for 2999 patients on the medicine teaching service, whether educational case conference morning report occurred at 8:30 am or at 2 pm. CONCLUSIONS Medical patient average discharge time was not influenced by time of educational conference. Factors other than the timing of educational conference appear to influence hospital discharge times on an inpatient internal medicine service.
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Fanucchi L, Unterbrink M, Logio LS. (Re)turning the pages of residency: the impact of localizing resident physicians to hospital units on paging frequency. J Hosp Med 2014; 9:120-2. [PMID: 24382808 DOI: 10.1002/jhm.2143] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Revised: 11/27/2013] [Accepted: 12/09/2013] [Indexed: 11/12/2022]
Abstract
BACKGROUND Geographic localization of physicians to patient care units may improve communication, decrease interruptions, and reduce resident workload. This study examines whether interns on geographically localized patient care units receive fewer pages than those on teams that are not. METHODS The study is a retrospective analysis of the number of pages received by interns on 5 internal medicine teams: 2 in a geographically localized model (GLM), 2 in a partial localization model (PLM), and 1 in a standard model (SM) over 1 month at New York-Presbyterian Hospital/Weill Cornell. Multivariate linear regression techniques were used to analyze the relationship between the number of pages received per intern and the type of team. RESULTS The number of pages received per intern per hour, adjusted for team census and number of admissions, was 2.2 (95% confidence interval [CI]: 2.0-2.4) in the GLM, 2.8 (95% CI: 2.6-3.0) in the PLM, and 3.9 (95% CI: 3.6-4.2) in the SM; all differences were statistically significant (P < 0.001). CONCLUSION Geographic localization of resident teams to patient care units was associated with significantly fewer pages received by interns during the day. Such patient care models may improve resident workload in part by decreasing pages, and consequently has important implications for patient safety and medical education.
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Affiliation(s)
- Laura Fanucchi
- Department of Medicine, University of Kentucky College of Medicine, Lexington, Kentucky
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Roshetsky LM, Coltri A, Flores A, Vekhter B, Humphrey HJ, Meltzer DO, Arora VM. No time for teaching? Inpatient attending physicians' workload and teaching before and after the implementation of the 2003 duty hours regulations. Acad Med 2013; 88:1293-1298. [PMID: 23887003 DOI: 10.1097/acm.0b013e31829eb795] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
PURPOSE Understanding the association between attending physicians' workload and teaching is critical to preserving residents' learning experience. The authors tested the association between attending physicians' self-reported workload and perceptions of time for teaching before and after the 2003 resident duty hours regulations. METHOD From 2001 to 2008, the authors surveyed all inpatient general medicine attending physicians at a teaching hospital. To measure workload, they used a conceptual framework to create a composite score from six domains (mental demand, physical demand, temporal demand, effort, performance, frustration). They measured time for teaching using (1) open-ended responses to hours per week spent doing didactic teaching and (2) responses (agree, strongly agree) to the statement "I had enough time for teaching." They conducted multivariate logistic regression analyses, controlling for month, year, and clustering by attending physicians, to test the association between workload scores and time for teaching. RESULTS Of 738 eligible attending physicians, 482 (65%) completed surveys. Respondents spent a median of three hours per week dedicated to teaching. Less than half (198; 43%) reporting enough time for teaching. The composite workload scores were normally distributed (median score of 15) and demonstrated a weak positive correlation with actual patient volume (r = 0.25). The odds of an attending physician reporting enough time for teaching declined by 21% for each point increase in composite workload score (odds ratio = 0.79 [95% confidence interval 0.69-0.91]; P = .001). CONCLUSIONS The authors found that attending physicians' greater self-perceived workload was associated with decreased time for teaching.
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Affiliation(s)
- Lisa M Roshetsky
- Department of Medicine, Georgetown University School of Medicine, Washington, DC, USA
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Philibert I, Nasca T, Brigham T, Shapiro J. Duty-hour limits and patient care and resident outcomes: can high-quality studies offer insight into complex relationships? Annu Rev Med 2012; 64:467-83. [PMID: 23121182 DOI: 10.1146/annurev-med-120711-135717] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Long hours are an accepted component of resident education, yet data suggest they contribute to fatigue that may compromise patient safety. A systematic review confirms that limiting duty hours increases residents' hours of sleep and improves objective measures of alertness. Most studies of operative experience for surgical residents found no effect, and there is evidence of a limited positive effect on residents' mood. We find a mixed effect on patient safety, although problems with supervision, rather than the limits, may be responsible or contibute; evidence of reduced continuity of care and reduced continuity in residents' clinical education; and evidence that increased workload under the limits has a negative effect on patient and resident outcomes. We highlight specific areas for research and offer recommendations for national policy.
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Affiliation(s)
- Ingrid Philibert
- Accreditation Council for Graduate Medical Education, Chicago, Illinois 60654, USA.
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Averbukh Y, Southern W. The impact of the number of admissions to the inpatient medical teaching team on patient safety outcomes. J Grad Med Educ 2012; 4:307-11. [PMID: 23997873 PMCID: PMC3444182 DOI: 10.4300/jgme-d-11-00190.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2011] [Revised: 11/10/2011] [Accepted: 12/18/2011] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION The clinical work in academic internal medicine inpatient units is done by teaching teams. To date, few studies have investigated how team workload affects patient safety outcomes. OBJECTIVE We examined the association between the number of patients seen by a teaching team, 30-day readmission, and 60-day mortality. METHODS In this retrospective observational study we defined each team as "less busy" (total monthly admissions ≤49, the median for all teams) or "more busy" (total monthly admissions >49). We compared patients in both groups' demographic characteristics, comorbidities (Charlson score), severity of illness (the Laboratory-based Acute Physiology Score [LAPS]), and length of stay using t tests, χ(2) tests, and rank sum tests, as appropriate. Logistic regression models were constructed to determine whether there was an association between assignment to a busy team and readmission and mortality. RESULTS Of 12 119 admissions examined, 6398 (52.8%) were assigned to the less busy teams and 5721 (47.2%) were assigned to busy teams. Mean length of stay was not statistically different between the groups (5.2 vs 5.3 days; P = .08). After adjustment for demographic and clinical characteristics (LAPS and Charlson score), care by a busy team was associated with greater 30-day readmission rate (odds ratio, 1.21; 95% confidence interval [CI], 1.10-1.34) but not with increased risk of mortality (odds ratio, 1.05; 95% CI, 0.88-1.27). There was a significant linear association between the number of monthly admissions to teams and the readmission rate. CONCLUSIONS Admission to a busier teaching team is associated with a 21% increase in the odds of 30-day readmission. Sixty-day mortality was not affected by the number of monthly admissions to the teaching team.
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Philibert I. Education and patient care effects of resident workload restrictions: tackling a largely unexplored subject. Mayo Clin Proc 2012; 87:311-3. [PMID: 22469342 PMCID: PMC3498393 DOI: 10.1016/j.mayocp.2012.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Accepted: 03/06/2012] [Indexed: 11/23/2022]
Affiliation(s)
- Ingrid Philibert
- Correspondence: Address to Ingrid Philibert, PhD, MBA, Senior Vice President, Field Activities, and Executive Managing Editor, JGME, Accreditation Council for Graduate Medical Education, 515 N State St, Ste 2000, Chicago, IL 60654
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