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

ACGME Clinical and Educational Work Hour Standards: Perspectives and Recommendations from Emergency Medicine Educators

Introduction

The American College of Emergency Physicians (ACEP) and the Council of Emergency Medicine Residency Directors (CORD) were invited to contribute to the 2016 Accreditation Council for Graduate Medical Education’s (ACGME) Second Resident Duty Hours in the Learning and Working Environment Congress. We describe the joint process used by ACEP and CORD to capture the opinions of emergency medicine (EM) educators on the ACGME clinical and educational work hour standards, formulate recommendations, and inform subsequent congressional testimony.

Methods

In 2016 our joint working group of experts in EM medical education conducted a consensus-based, mixed-methods process using survey data from medical education stakeholders in EM and expert iterative discussions to create organizational position statements and recommendations for revisions of work hour standards. A 19-item survey was administered to a convenience sample of 199 EM residency training programs using a national EM educational listserv.

Results

A total of 157 educational leaders responded to the survey; 92 of 157 could be linked to specific programs, yielding a targeted response rate of 46.2% (92/199) of programs. Respondents commented on the impact of clinical and educational work-hour standards on patient safety, programmatic and personnel costs, resident caseload, and educational experience. Using survey results, comments, and iterative discussions, organizational recommendations were crafted and submitted to the ACGME.

Conclusion

EM educators believe that ACGME clinical and educational work hour standards negatively impact the learning environment and are not optimal for promoting patient safety or the development of resident professional citizenship.

Students' educational experiences and interaction with residents on night shifts

BACKGROUND

The purpose of this mixed-methods study was to investigate whether increased night shifts for students on paediatric rotations had any negative impact on their overall quality of educational experiences in light of the implementation of duty-hour restrictions.

METHODS

Both quantitative and qualitative data were collected from 30 students on paediatric rotations during the academic year 2011/12. Students completed two questionnaires, one in response to their experiences during the day shifts and another in response to their experiences during the night shifts. Only 25 cases were retained for the final analyses. The non-parametric Wilcoxon signed-rank test was used to analyse the quantitative data, and constant comparative thematic analyses, as described by Creswell, were used to analyse the qualitative data. [Do] increased nights shifts for students … [have] any negative impact on their overall quality of educational experiences[?] RESULTS: The results indicated that students' perceived quality of experiences during the night shifts was greater, compared with their day shifts. Students reported having more time to socialise during the night shifts. They further reported that informal ways of learning, such as impromptu teaching and spontaneous discussions on clinical problems, were more beneficial, and these often occurred in abundance during the night shifts as opposed to the scheduled didactic teaching sessions that occur during the day shifts.

DISCUSSION

This study documented many unanticipated benefits of night shifts. The feeling of cohesiveness of the night team deserves further exploration, as this can be linked to better performance outcomes. More consideration should be given to implementing night shifts as a regular feature of clerkships.

The Internal Medicine Subinternship--Now More Important than Ever: A Joint CDIM-APDIM Position Paper

For decades, the internal medicine (IM) subinternship has served as a critical interface between undergraduate and graduate medical education. As such, the vast majority of U.S. medical schools offer this rotation to help students prepare for post-graduate training. Historically an experiential rotation, a formal curriculum with specific learning objectives was eventually developed for this course in 2002. Since then, graduate medical education (GME) has changed significantly with the regulation of duty hours, adoption of competency-based education, and development of training milestones and entrustable professional activities. In response to these and many other changes to residency training and medical practice, in 2010, the Association of Program Directors in Internal Medicine (APDIM) surveyed its members-with input from the Clerkship Directors in Internal Medicine (CDIM) Subinternship Task Force-to determine which core skills program directors expected from new medical school graduates. The results of that survey helped to inform a joint CDIM-APDIM committee's decision to re-evaluate the goals of the IM subinternship in an effort to enhance the transition from medical school to residency. This joint committee defined the minimum expectations of what constitutes an IM subinternship rotation, proposed recommended skills for IM subinterns, and discussed challenges and future directions for this crucial course.

A typology of teaching roles and relationships for medical education

BACKGROUND

Educational programs involve interactions between the instructors and the learners. In these interactions, instructors may play various roles. However, a nomenclature for relationships with learners appropriate to those roles has not been developed for medical education.

AIMS

This article presents a typology of instructor's roles to facilitate the connection of outcomes with instructional methods and to inform training sessions for instructors.

METHOD

Published articles in general education and medical education were searched for examples of terms used for instructor's roles in developmental interactions. Examples were grouped and classified to develop a two-dimensional typology.

RESULTS

The typology has eight categories on two dimensions. One dimension is the purpose for interaction: (1) knowledge transmission, (2) professional identity formation, (3) negotiating the institutional milieu, and (4) relationship building. The other dimension is dichotomous on whether the instructor is a member of the profession to which the learners aspire. Twelve terms were categorized: Advisor, Advocate, Buddy, Coach, Counselor, Facilitator, Guru, Master, Mentor, Role model, Teacher and Tutor.

CONCLUSIONS

Faculty instructors in medical education are often pressed for time, so clarifying role expectations is a low-cost scheme to enhance results. Using the typology can align instructor behavior with the desired learner outcomes and enhance efficient use of instructional time.

Barriers and Facilitators to Effective Feedback: A Qualitative Analysis of Data From Multispecialty Resident Focus Groups

BACKGROUND

Despite the importance of feedback, the literature suggests that there is inadequate feedback in graduate medical education.

OBJECTIVE

We explored barriers and facilitators that residents in anesthesiology, emergency medicine, obstetrics and gynecology, and surgery experience with giving and receiving feedback during their clinical training.

METHODS

Residents from 3 geographically diverse teaching institutions were recruited to participate in focus groups in 2012. Open-ended questions prompted residents to describe their experiences with giving and receiving feedback, and discuss facilitators and barriers. Data were transcribed and analyzed using the constant comparative method associated with a grounded theory approach.

RESULTS

A total of 19 residents participated in 1 of 3 focus groups. Five major themes related to feedback were identified: teacher factors, learner factors, feedback process, feedback content, and educational context. Unapproachable attendings, time pressures due to clinical work, and discomfort with giving negative feedback were cited as major barriers in the feedback process. Learner engagement in the process was a major facilitator in the feedback process.

CONCLUSIONS

Residents provided insights for improving the feedback process based on their dual roles as teachers and learners. Time pressures in the learning environment may be mitigated by efforts to improve the quality of teacher-learner relationships. Forms for collecting written feedback should be augmented by faculty development to ensure meaningful use. Efforts to improve residents' comfort with giving feedback and encouraging learners to engage in the feedback process may foster an environment conducive to increasing feedback.

The effect of resident duty-hours restrictions on internal medicine clerkship experiences: surveys of medical students and clerkship directors

PHENOMENON: Medical students receive much of their inpatient teaching from residents who now experience restructured teaching services to accommodate the 2011 duty-hour regulations (DHR). The effect of DHR on medical student educational experiences is unknown. We examined medical students' and clerkship directors' perceptions of the effects of the 2011 DHR on internal medicine clerkship students' experiences with teaching, feedback and evaluation, and patient care.

APPROACH

Students at 14 institutions responded to surveys after their medicine clerkship or subinternship. Students who completed their clerkship (n = 839) and subinternship (n = 228) March to June 2011 (pre-DHR historical controls) were compared to clerkship students (n = 895) and subinterns (n = 377) completing these rotations March to June 2012 (post-DHR). Z tests for proportions correcting for multiple comparisons were performed to assess attitude changes. The Clerkship Directors in Internal Medicine annual survey queried institutional members about the 2011 DHR just after implementation.

FINDINGS

Survey response rates were 64% and 50% for clerkship students and 60% and 48% for subinterns in 2011 and 2012 respectively, and 82% (99/121) for clerkship directors. Post-DHR, more clerkship students agreed that attendings (p =.011) and interns (p =.044) provided effective teaching. Clerkship students (p =.013) and subinterns (p =.001) believed patient care became more fragmented. The percentage of holdover patients clerkship students (p =.001) and subinterns (p =.012) admitted increased. Clerkship directors perceived negative effects of DHR for students on all survey items. Most disagreed that interns (63.1%), residents (67.8%), or attendings (71.1%) had more time to teach. Most disagreed that students received more feedback from interns (56.0%) or residents (58.2%). Fifty-nine percent felt that students participated in more patient handoffs. INSIGHTS: Students perceive few adverse consequences of the 2011 DHR on their internal medicine experiences, whereas their clerkship director educators have negative perceptions. Future research should explore the impact of fragmented patient care on the student-patient relationship and students' clinical skills acquisition.

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.

Faculty development for hospitalists: structured peer observation of teaching

BACKGROUND

Hospitalists provide much of the clinical teaching in internal medicine, yet formative feedback to improve their teaching is rare.

METHODS

We developed a peer observation, assessment, and feedback program to improve attending hospitalist teaching. Participants were trained to identify 10 optimal teaching behaviors using a structured observation tool that was developed from the validated Stanford Faculty Development Program clinical teaching framework. Participants joined year-long feedback dyads and engaged in peer observation and feedback on teaching. Pre- and post-program surveys assessed confidence in teaching, performance of teaching behaviors, confidence in giving and receiving feedback, attitudes toward peer observation, and overall satisfaction with the program.

RESULTS

Twenty-two attending hospitalists participated, averaging 2.2 years (± 2.1 years standard deviation [SD]) experience; 15 (68%) completed pre- and post-program surveys. Confidence in giving feedback, receiving feedback, and teaching efficacy increased (1 = strongly disagree, 5 = strongly agree, mean ± SD): "I can accurately assess my colleagues' teaching skills," (pre = 3.2 ± 0.9 vs post = 4.1 ± 0.6, P < 0.01), "I can give accurate feedback to my colleagues" (pre = 3.4 ± 0.6 vs post = 4.2 ± 0.6, P < 0.01), and "I am confident in my ability to teach students and residents" (pre = 3.2 ± 0.9 vs post = 3.7 ± 0.8, P = 0.026).

CONCLUSIONS

Peer observation and feedback of teaching increases hospitalist confidence in several domains that are essential for optimizing teaching. Further studies are needed to examine if educational outcomes are improved by this program.

Implementation of an interactive virtual-world simulation for structured surgeon assessment of clinical scenarios

BACKGROUND

A novel simulation technology has emerged through the use of online 3-dimensional virtual worlds in which it is feasible to create virtual patients. This study establishes the face, content and construct validity of online 3-dimensional virtual patients in Second Life (a 3-dimensional virtual world accessible via the Internet).

STUDY DESIGN

Sixty-three surgeons of the following grades participated in this study: intern (n = 20); junior resident (n = 15); senior resident (n = 18), and attending (n = 10). All subjects assessed a series of 3 virtual patients (level 1) with different surgical presentations, such as lower gastrointestinal bleeding, acute pancreatitis, and small bowel obstruction. The junior resident group managed an additional 3 cases (level 2) with the same presentation but of increasing complexity. The senior resident and attending groups completed a total of 9 cases (level 1 to 3). The primary outcomes measures were the face and content validity rated on a 7-point Likert scale and a performance score based on a performance rating.

RESULTS

The simulation demonstrated high face and content validity ratings. Eight of 9 cases, with the exception of the level 3 small bowel obstruction, demonstrated significant differences in performance among the user groups (p < 0.01). Additional subset analysis demonstrated that the attending group performed best for performance ratings.

CONCLUSIONS

This novel form of simulation demonstrated high face and content validity. Performance assessed in managing a series of virtual patients varies with different levels of surgical training. This simulation can be used to differentiate among these levels and can be implemented as a unique form of assessment.

The Computer Book of the Internal Medicine Resident: competence acquisition and achievement of learning objectives

BACKGROUND

The Computer Book of the Internal Medicine resident (CBIMR) is a computer program that was validated to analyze the acquisition of competences in teams of Internal Medicine residents.

OBJECTIVES

To analyze the characteristics of the rotations during the Internal Medicine residency and to identify the variables associated with the acquisition of clinical and communication skills, the achievement of learning objectives and resident satisfaction.

METHODS

All residents of our service (n=20) participated in the study during a period of 40 months. The CBIMR consisted of 22 self-assessment questionnaires specific for each rotation, with items on services (clinical workload, disease protocolization, resident responsibilities, learning environment, service organization and teamwork) and items on educational outcomes (acquisition of clinical and communication skills, achievement of learning objectives, overall satisfaction). Associations between services features and learning outcomes were analyzed using bivariate and multivariate analysis.

RESULTS

An intense clinical workload, high resident responsibilities and disease protocolization were associated with the acquisition of clinical skills. High clinical competence and teamwork were both associated with better communication skills. Finally, an adequate learning environment was associated with increased clinical competence, the achievement of educational goals and resident satisfaction.

CONCLUSIONS

Potentially modifiable variables related with the operation of clinical services had a significant impact on the acquisition of clinical and communication skills, the achievement of educational goals, and resident satisfaction during the specialized training in Internal Medicine.

Can incorporating inpatient overnight work hours into a pediatric clerkship improve the clerkship experience for students?

PURPOSE

After incorporating medical students into pediatric resident night-float teams, the authors studied the effects of the new schedule on (1) cognitive performance, (2) number of new admissions, (3) clerkship satisfaction, and (4) amount and quality of resident teaching.

METHOD

Part 1 was a retrospective historical controls study. The intervention was a schedule change that eliminated inpatient call. The historical control group had a four-week inpatient schedule of daytime hours plus five calls (DT+C). The comparison group had a schedule of three weeks of daytime hours plus five consecutive overnight shifts (DT+OS). National Board of Medical Examiners (NBME) Pediatrics Subject Exam scores, number of admission history and physicals (HPEs), and clerkship satisfaction data from both groups were compared. Part 2 was a two-item survey with open-ended comments that measured perceptions of resident teaching time and quality of resident teaching (QRT) from students on the DT+OS schedule.

RESULTS

DT+OS students had a significantly increased number of HPEs (t=2.17; P=.03) compared with the DT+C group (mean=7.49, standard deviation [SD]=3.34 in DT+OS versus mean=6.11, SD=2.95 in DT+C). The paired samples t test showed that students rated QRT significantly higher when on overnights than when they were on daytime hours (t=2.47; P=.02). There were no differences in satisfaction or NBME scores.

CONCLUSION

Overnight work hours for medical students increased clerkship capacity while maintaining student satisfaction and cognitive performance. Added benefits included increased clinical experience and improved QRT.

Medical education in the United States of America

This article was written to provide a brief history of the medical educational system in the USA, the current educational structure, and the current topics and challenges facing USA medical educators today. The USA is fortunate to have a robust educational system, with over 150 medical schools, thousands of graduate medical education programs, well-accepted standardized examinations throughout training, and many educational research programs. All levels of medical education, from curriculum reform in medical schools and the integration of competencies in graduate medical education, to the maintenance of certification in continuing medical education, have undergone rapid changes since the turn of the millennium. The intent of the changes has been to involve the patient sooner in the educational process, use better educational strategies, link educational processes more closely with educational outcomes, and focus on other skills besides knowledge. However, with the litany of changes have come increased regulation without (as of yet) clear evidence as to which of the changes will result in better physicians. In addition, the USA governmental debt crisis threatens the current educational structure. The next wave of changes in the USA medical system needs to focus on what particular educational strategies result in the best physicians and how to fund the system over the long term.

Effects of varying inpatient attending physician rotation length on medical students' and attending physicians' perceptions of teaching quality

BACKGROUND

Patient care needs and work hour restrictions have altered inpatient internal medicine educational experiences.

PURPOSE

The goal is to compare different attending physician rotation lengths on medical students' and attending physicians' experiences.

METHODS

We studied clerkship students' evaluations (N= 86) and internal medicine attending surveys (N=21). We divided attending experiences into 2-week and 4-week rotations. We assessed exam scores and evaluations with 5-point Likert questions (5=strongly agree). Means were compared with t tests, Wilcoxon Ranked Sums, and logistic regression.

RESULTS

More than 90% of students and attending physicians responded. Students and attending physicians generally evaluated their 2- and 4-week experiences similarly. Attending physicians favored 4 weeks for evaluating students' performance (3.30 vs. 4.36, p<.01). Exam scores were similar in the 2- and 4-week student groups (M=78.2, SD=5.0 vs. 76.5, SD=8.5, p=.43).

CONCLUSIONS

Shorter rotations do not negatively impact students' experiences. Obtaining quality evaluations may be difficult for shorter rotations.

Duty hours in emergency medicine: balancing patient safety, resident wellness, and the resident training experience: a consensus response to the 2008 institute of medicine resident duty hours recommendations

Representatives of emergency medicine (EM) were asked to develop a consensus report that provided a review of the past and potential future effects of duty hour requirements for EM residency training. In addition to the restrictions made in 2003 by the Accreditation Council for Graduate Medical Education (ACGME), the potential effects of the 2008 Institute of Medicine (IOM) report on resident duty hours were postulated. The elements highlighted include patient safety, resident wellness, and the resident training experience. Many of the changes and recommendations did not affect EM as significantly as other specialties. Current training standards in EM have already emphasized patient safety by requiring continuous on-site supervision of residents. Resident fatigue has been addressed with restrictions of shift lengths and limitation of consecutive days worked. One recommendation from the IOM was a required 5-hour rest period for residents on call. Emergency department (ED) patient safety becomes an important concern with the decrease in the availability and in the patient load of a resident consultant that may result from this recommendation. Of greater concern is the already observed slower throughput time for admitted patients waiting for resident care, which will increase ED crowding and decrease patient safety in academic institutions. A balance between being overly prescriptive with duty hour restrictions and trying to improve resident wellness was recommended. Discussion is included regarding the appropriate length of EM training programs if clinical experiences were limited by new duty hour regulations. Finally, this report presents a review of the financing issues associated with any changes.

Improving education under work-hour restrictions: comparing learning and teaching preferences of faculty, residents, and students

BACKGROUND

Faced with work-hour restrictions, educators are mandated to improve the efficiency of resident and medical student education. Few studies have assessed learning styles in medicine; none have compared teaching and learning preferences. Validated tools exist to study these deficiencies. Kolb describes 4 learning styles: converging (practical), diverging (imaginative), assimilating (inductive), and accommodating (active). Grasha Teaching Styles are categorized into "clusters": 1 (teacher-centered, knowledge acquisition), 2 (teacher-centered, role modeling), 3 (student-centered, problem-solving), and 4 (student-centered, facilitative).

STUDY DESIGN

Kolb's Learning Style Inventory (HayGroup, Philadelphia, Pennsylvania) and Grasha-Riechmann's TSS were administered to surgical faculty (n = 61), residents (n = 96), and medical students (n = 183) at a tertiary academic medical center, after informed consent was obtained (IRB # 06-0612). Statistical analysis was performed using χ(2) and Fisher exact tests.

RESULTS

Surgical residents preferred active learning (p = 0.053), whereas faculty preferred reflective learning (p < 0.01). As a result of a comparison of teaching preferences, although both groups preferred student-centered, facilitative teaching, faculty preferred teacher-centered, role-modeling instruction (p = 0.02) more often. Residents had no dominant teaching style more often than surgical faculty (p = 0.01). Medical students preferred converging learning (42%) and cluster 4 teaching (35%). Statistical significance was unchanged when corrected for gender, resident training level, and subspecialization.

CONCLUSIONS

Significant differences exist between faculty and residents in both learning and teaching preferences; this finding suggests inefficiency in resident education, as previous research suggests that learning styles parallel teaching styles. Absence of a predominant teaching style in residents suggests these individuals are learning to be teachers. The adaptation of faculty teaching methods to account for variations in resident learning styles may promote a better learning environment and more efficient faculty-resident interaction. Additional, multi-institutional studies using these tools are needed to elucidate these findings fully.

Medical student patient experiences before and after duty hour regulation and hospitalist support

BACKGROUND/OBJECTIVE

With the growth of hospitalist services and the reduction in residency work hours, medical education has changed dramatically. The objective of this study was to examine changes in junior medical student-patient encounters after initiation of residency work hours and implementation of a large hospitalist practice at our academic medical center.

DESIGN

Medicine clerkship students from 2002-2007 recorded the number of hospital patients and their principal diagnoses cared for during a 6-week block rotation. Comparisons were made between clerkship experiences among students in 2002-2004 and 2005-2007 for number of patients and diversity of patient diagnoses seen. Data from the 2004-2005 transition period, when teams fluctuated during implementation of the hospitalist service, were excluded.

MEASUREMENTS AND MAIN RESULTS

A total of 4,697 patients were seen by students during the two periods, and patient logs for 154 students (3,253 patients in 2002-2004) and 120 students (1,444 patients in 2005-2007) were compared. The mean number of patients directly cared for by students on their junior medicine clerkship dropped from 21 patients (2002-2004) to 12 patients (2005-2007) per student (p < 0.001). Compared to 2002-2004, fewer students from 2005-2007 helped manage patients with chest pain (85.7% vs. 74.2%, p = 0.016), pancreatitis (66.9% vs. 23.3%, p < 0.001), pneumonia (69.5% vs. 54.2%, p = 0.009), gastroenteritis (45.5% vs. 20.8%, p < 0.001), or cellulitis (46.8% vs. 19.2%, p < 0.001). Alternatively, students from 2005-2007 saw more patients with abdominal pain (64.9% vs. 79.2%, p = 0.010), anemia (44.8% vs. 70.8%, p < 0.001), mental status changes (32.5% vs. 51.7%, p = 0.001), failure to thrive (16.2% vs. 53.3%, p < 0.001), and endocrine disorders (including diabetes, thyroid disorders, Addison's, 51.3% vs. 74.2%, p < 0.001).

CONCLUSIONS

With institutional and residency changes, junior medicine clerkship students had fewer opportunities for direct care of patients and encountered a different mix of patient diagnoses. Increasingly during their junior medicine clerkship, students may not have exposure to basic medical conditions, which may affect their ability to care for future patients.

Medicine clerkships and portable computing: a national survey of internal medicine clerkship directors

BACKGROUND

Portable computers are widely used by medical trainees, but there is a lack of data on how these devices are used in clinical education programs.

PURPOSES

The objective is to define the current use of portable computing in internal medicine clerkships and to determine medicine clerkship directors' perceptions of the current value and future importance of portable computing.

METHODS

A 2006 national survey of institutional members of the Clerkship Directors in Internal Medicine.

RESULTS

Eighty-three of 110 (75%) of institutional members responded. An institutional requirement for portable computing was reported by 32 schools (39%), whereas only 13 (16%) provided students with a portable computer. Between 10 and 31 institutions (12-37%) reported student use for patient care activities (i.e. order entry, writing patient notes) and only 2 to 4 institutions (2-5%) required such use. The majority of respondents (59-95%) reported portable computer use for educational activities (i.e., tracking patient problems, knowledge resource), however, only in 5 to 19 (6-23%) were such educational uses required. Fifty-six respondents (68%) reported that portable computer's "added value" for teaching and 61 (73%) reported that portable computers would be important in meeting clerkship objectives in the next 3 years. Of interest, even among the institutions requiring portable computers, only 50% recommended or required specific software.

CONCLUSIONS

Portable computing is required at 39% of allopathic medical schools in the United States. However required portable computing for specific patient care or educational tasks is uncommon. In addition, guidance on specific software exists in only one half of school requiring portable computers, suggesting informal or unstructured uses of required portable computer's in the remaining half. The educational impact of formal institutional requirements for software versus informal "user-defined" applications is unknown.

Impact of duty-hour restriction on resident inpatient teaching

BACKGROUND

Education and patient care are essential to academic hospitalists, and residents are key partners in these goals. The Accreditation Council for Graduate Medical Education (ACGME) duty-hour restrictions (DHR) likely impacted aspects of resident teaching, well-being, and patient care practices that affect the duties of academic hospitalists.

OBJECTIVE

To determine the impact of DHR on resident teaching time and the factors associated with, and impacts of, time spent teaching.

DESIGN

Cross-sectional survey. SETTING AND MEASUREMENTS: A total of 164 internal medicine residents at University of California, San Francisco (UCSF), San Francisco, CA were queried regarding their time spent teaching, completion of administrative tasks, number of hours worked, frequency of emotional exhaustion, and satisfaction with quality of patient care provided after DHR. Regression analyses identified factors associated with decreased teaching time and determined that there were associations between time spent teaching, emotional exhaustion, and satisfaction with quality of patient care.

RESULTS

A total of 125 residents (76%) responded; 24% reported spending less time teaching. Less time teaching was associated with being a postgraduate year (PGY)-2 (odds ratio [OR], 7.14; 95% confidence interval [CI], 1.56-32.79) or PGY-3 (OR, 8.23; 95% CI, 1.44-47.09), reporting working <80 hours/week (OR, 5.99; 95% CI, 1.11-32.48) and spending a greater percentage of time on administrative tasks (OR, 1.03; 95% CI, 1.00-1.06). Those residents who spent less time teaching also reported less frequent emotional exhaustion (P = 0.003) and more satisfaction with quality of care (P = 0.006).

CONCLUSIONS

DHR has decreased teaching time for some residents, and those residents are more likely to be less emotionally exhausted and deliver self-perceived higher quality of care. Academic hospitalists should consider these impacts of DHR and make adjustments such as educational and work-life innovations to account for these shifts.

Association between hand-off patients and subject exam performance in medicine clerkship students

BACKGROUND

Teaching hospitals increasingly rely on transfers of patient care to another physician (hand-offs) to comply with duty hour restrictions. Little is known about the impact of hand-offs on medical students.

OBJECTIVE

To evaluate the impact of hand-offs on the types of patients students see and the association with their subsequent Medicine Subject Exam performance.

DESIGN

Observational study over 1 year.

PARTICIPANTS

Third-year medical students in an Inpatient Medicine Clerkship at five hospitals with night float systems.

PRIMARY OUTCOME

Medicine Subject Exam at the end of the clerkship; explanatory variables: number of fresh (without prior evaluation) and hand-off patients, diagnoses, subspecialty patients, and full evaluations performed during the clerkship, and United Stated Medical Licensing Examination (USMLE) Step I scores.

MAIN RESULTS

Of the 2,288 patients followed by 89 students, 990 (43.3%) were hand-offs. In a linear regression model, the only variables significantly associated with students' Subject Exam percentile rankings were USMLE Step I scores (B = 0.26, P < 0.001) and the number of full evaluations completed on fresh patients (B =0.20, P = 0.048; model r (2) = 0.58). In other words, for each additional fresh patient evaluated, Subject Exam percentile rankings increased 0.2 points. For students in the highest quartile of Subject Exam percentile rankings, only Step I scores showed a significant association (B = 0.22, P = 0.002; r (2) = 0.5). For students in the lowest quartile, only fresh patient evaluations demonstrated a significant association (B = 0.27, P = 0.03; r (2) = 0.34).

CONCLUSIONS

Hand-offs constitute a substantial portion of students' patients and may have less educational value than "fresh" patients, especially for lower performing students.

Teaching about racial/ethnic health disparities: a national survey of clerkship directors in internal medicine

BACKGROUND

The Institute of Medicine and the Liaison Committee on Medical Education (LCME) have both identified the importance of integrating teaching regarding health disparities into medical education. Thus far most of the limited teaching in this area occurs in the first two years of medical school.

PURPOSE

The purpose of this study is to evaluate education in internal medicine clerkships about health disparities and understand barriers to including this content.

METHOD

In 2005, the Clerkship Directors in Internal Medicine (CDIM) conducted their annual, confidential survey. The authors asked about clerkship content addressing ethnic/racial health disparities, means for implementing curricula, and barriers to covering disparities content. For each, there were yes/no statements, multiple-choice questions, and free text responses.

RESULTS

The survey response rate was 81% (88/109). Forty-one percent indicated that they cover ethnic/racial health disparities in their clerkship. Of these 36 respondents, 50% covered prevalence of disease. Fewer clerkships addressed differences in presentation of disease (33%), health outcomes (24%), and quality of care (19%). Barriers to including health disparities content: limited time in the curriculum (34%), clerkship director lack of expertise (12%), concerns regarding sensitive material (11%), and the opinion that evidence remains controversial (7%). Sixty-one percent of all respondents did feel that the "internal medicine clerkship should explicitly address ethnic/racial differences in common medical illnesses"; there was no correlation between clerkship director gender or age and response to this question (chi-square and Mann-Whitney U, respectively; p >.05).

CONCLUSIONS

Although most internal medicine clerkships do not currently have explicit content about racial/ethnic health disparities, many regard this as essential content. National organizations, such as CDIM, can take leadership through modification of published guides on curriculum objectives and creating opportunities for dissemination of appropriate curriculum.

Letters of recommendation: rating, writing, and reading by clerkship directors of internal medicine

BACKGROUND

Letters of Recommendations (LORs) are used for applications to medical school and graduate medical education, but how they are used by current internal medicine educators is unknown.

DESCRIPTION

In 2006, the Clerkship Directors of Internal Medicine conducted its annual, voluntary survey, and one section pertained to LORs. Survey items were categorized into questions regarding rating, writing, and reading LORs with answers on 3- to 5-point scales.

EVALUATION

The response rate for the 110 institution members was 75%. When rating LORs, the most important factor was depth of understanding of the trainee (98% essential or important), followed by a numerical comparison to other students (94%), grade distribution (92%), and summary statement (91%). Although most (78%) agreed that reading LORs in general were important for trainee selection, few agreed that this was because of the ability to discern marginal performance (31%) or predict future performance (25%).

CONCLUSIONS

LORs remain an important part of the application process for medical school and internal medicine residency. Letter writers should convey a great depth of understanding of the applicant, provide a numerical comparison with other students (including a denominator), and give a specific summary statement.

Paediatric experiences with work-hour limitations

OBJECTIVES

To evaluate the perceived impact of work-hour limitations on paediatric residency training programmes and to determine the various strategies used to accommodate these restrictions.

METHODS

A three-page pre-tested survey was administered to programme directors at the 2004 Association of Paediatric Programme Directors meeting. The impact of work-hours was evaluated with Likert-type questions and the methods used to meet work-hour requirements were compared between large programmes (>or=30 residents) and small programmes.

RESULTS

Surveys were received from 53 programme directors. The majority responded that work-hour limitations negatively impacted inpatient continuity, time for education, schedule flexibility and attending staff satisfaction. Supervision by attending staff was the only aspect to significantly improve. Perceived resident satisfaction was neutral. To accommodate work-hour limitations, 64% of programmes increased clinical responsibility to existing non-resident staff, 36% hired more non-resident staff and 17% increased the number of residents. Only one programme hired additional non-clinical staff. Large programmes were more likely to use more total methods on the inpatient wards (P < 0.01) and in the intensive care units (P < 0.05) to accommodate work-hour limitations.

CONCLUSIONS

Programme directors perceived a negative impact of work-hours on most aspects of training without a perceived difference in resident satisfaction. While a variety of methods are used to accommodate work-hour limitations, programmes are not widely utilizing non-clinical staff to alleviate clerical burdens.

Impact of duty hour regulations on medical students' education: views of key clinical faculty

BACKGROUND

Teaching faculty have valuable perspectives on the impact of residency duty hour regulations on medical students.

OBJECTIVE

The objective of this study was to elicit faculty views on the impact of residency duty hour regulations on medical students' educational experience on inpatient medicine rotations.

DESIGN AND PARTICIPANTS

We conducted a National Survey of Key Clinical Faculty (KCF) at 40 internal medicine residency programs affiliated with U.S. medical schools using a random sample stratified by National Institutes of Health funding and program size.

MEASUREMENTS

This study measures KCF opinions on the effect of duty hour regulations on students' education.

RESULTS

Of 154 KCF targeted, 111 responded (72%). Fifty-two percent of KCF reported worsening in the overall quality of students' education compared to just 2.7% reporting improvement (p < 0.001). In multivariate analysis adjusted for gender, academic rank, specialty, and years of teaching experience, faculty who spent >/=15 hours per week teaching were more likely to report worsening in medical students' level of responsibility on inpatient teams [odds ratio (OR) 3.1; 95% confidence interval (CI) 1.3-7.6], ability to follow patients throughout hospitalization (OR 3.2; 95% CI 1.3-7.9), ability to develop working relationships with residents (OR 2.3; 95% CI 1.0-5.2), and the overall quality of students' education (OR 3.3; 95% CI 1.4-8.1) compared to faculty who spent less time teaching.

CONCLUSION

Key clincal faculty report concerns about the impact of duty hour regulations on aspects of medical students' education in internal medicine. Medical schools and residency programs should identify ways to ensure optimal educational experiences for students within duty hour requirements.

Clinician educators' experiences with institutional review boards: results of a national survey

PURPOSE

To explore clinician educators' perceptions and experiences in obtaining institutional review board (IRB) approval to conduct medical education research (MER).

METHOD

Institutional members of the Clerkship Directors in Internal Medicine (CDIM; n = 110) were surveyed in 2006. The survey included questions about familiarity with and clarity of IRB policies, satisfaction with review of education research protocols, and how MER might be facilitated.

RESULTS

Of 83 respondents (response rate 76%), 50 had submitted a MER protocol to an IRB. Nearly all were deemed exempt (74/154) or minimal risk (71/154). No protocols were rejected or not approved. Nearly a fourth of respondents were unfamiliar with specific IRB policies directly applicable to MER. Among those respondents who had some familiarity with the IRB policies specified, 47% to 52% considered the IRB policies clear. Eighteen of 30 (60%) respondents with recent experience in multiinstitutional MER agreed there were notable differences in the expectations of various institutional IRBs; only two reported that multiple IRB reviews resulted in improvements to the protocol. Half (37/73) indicated they would be more likely to conduct MER if they had a better understanding of the IRB's role and requirements in MER. Sixty-six of 73 (90%) agreed they would benefit from a national consensus statement regarding the IRB's role in MER.

CONCLUSIONS

A high percentage of clinician educators in CDIM are conducting IRB-approved MER. They report several challenges with working with IRBs, and they agree that IRBs and clinician educators would benefit from a national consensus on the IRB's role in MER.

Resident duty hours reform: are we there yet?

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented resident duty hours restrictions to address growing concerns about medical errors and resident well-being. Many anticipated that resident duty hours restrictions would improve the quality and safety of care by minimizing the detrimental effects of fatigue on resident performance. Others were concerned that the fundamental clinical and educational principle of continuity of care would be lost or at least eroded, and that more frequent "hand-offs" might result in more clinical errors. Some lamented the loss of the total-emersion residency experience that serves as a forging process to temper the mind and body to create a finely honed clinician. The author draws from the literature to examine the effects of the ACGME resident duty hours restrictions three years after their implementation. From the perspectives of resident perceptions, attending perceptions, organizational approaches, and unintended consequences, the author concludes that far more than simple control of duty hours will be required to achieve the goals of clinical excellence, educational excellence, resident well-being, and professionalism.