Medical students' perceptions of resident teaching: have duty hours regulations had an impact?

Resident Physicians as Clinical Educators in Anesthesiology: A Narrative Review

The importance of resident physicians as clinical educators is widely acknowledged in many clinical specialties and by national accreditation organizations for medical education. Within anesthesiology training programs, there is growing attention to the role of trainees as clinical educators. This narrative review describes the theoretical and demonstrated benefits of clinical teaching by residents in anesthesiology and other medical fields, summarizes current efforts to support and promote residents as educators, and suggests ways in which anesthesiology training programs can further assess and develop the role of residents as clinical educators.

Efficacy of a resident-as-teacher program (RATP) for general surgery residents: An evaluation of 3 Years of implementation

BACKGROUND

Teaching is a responsibility of general surgery residents and formal teaching instruction is mandated. This study examines the efficacy of a formal RATP incorporated into our general surgery residency curriculum.

METHODS

The RATP was developed locally and delivered longitudinally over the course of the academic year, starting in 2017. Self-assessment surveys were distributed to residents before and after completion of the program each academic year. Medical students were surveyed regarding their impression of teaching on the surgical clerkship.

RESULTS

RATP data was collected annually. All sessions were highly rated. Residents reported improved teaching self-efficacy after participation. Medical student agreement with the statement 'Residents provided effective teaching during the [surgery] clerkship' increased from 68.6% prior to RATP implementation to 79.7% in the following years (p < 0.05).

CONCLUSIONS

Incorporation of a locally developed RATP improved residents' self-perceptions and medical student perception of residents as teachers. RATPs should be adopted widely.

Public Perceptions of General Surgery Residency Training

OBJECTIVE

Patients are integral to surgical training. Understanding our patients' perceptions of surgical training, resident involvement and autonomy is crucial to optimizing surgical education and thus patient care. In the modern, connected world many factors extrinsic to a patient's experience of healthcare may influence their opinion of our training systems (i.e., social media, television shows, and internet searches). The purpose of this article is to contextualize the literature investigating public perceptions of general surgery training to allow us to effect patient education initiatives to optimize both surgical training and patient safety.

DESIGN

This is a perspective including a literature review summarizing the current knowledge of public perceptions of general surgery training.

CONCLUSIONS

Little is published regarding patient and public perceptions of general surgery residency training and the role of residents within this. Current literature demonstrates that the majority of patients are willing to have residents participate in their care. Patients' attitude toward resident involvement in their operation is improved by utilizing educational materials and by ensuring a supervising attending is present within the operating room. These observations, coupled with future work to delve deeper into factors affecting public perceptions of surgical training and resident involvement within this, can guide strategies to improve surgical education.

Evaluation of a Preceptorship Model on Third-Year General Surgery Clerkship

BACKGROUND

Medical students increasingly report not feeling meaningfully involved during surgical clerkships. Preceptorship and mentorship through longitudinal experiences ameliorate this problem. A preceptorship model was introduced into the surgery clerkship at our institution to increase contact and improve relationships between students and faculty.

METHODS

The preceptorship model was introduced at select sites in 2017. In contrast to the standard structure in which students are assigned to cases and clinics as needed, preceptorship students are assigned to attending surgeons and follow the surgeons' schedules for the rotation. Student performance data, including final grades, clinical evaluations, and shelf examination scores, were collected for clerkship students from May 2017 to November 2018. Formative and summative evaluations for each student were collected. Qualitative content analysis was used to explore evaluations for themes.

RESULTS

Two hundred and seventy-four students completed the clerkship during the study period; 41 experienced a preceptorship model. There was no difference in student performance across clerkship structures. Summative and formative evaluations for preceptorship students were longer than for traditional students (137 words vs 78 words; p < 0.0001 and 46 words vs 16 words, p = 0.03 respectively). Preceptorship student evaluations contained higher-quality feedback relating to clerkship objectives than those of traditional students. Preceptorship comments also contained more frequent mentions of response to feedback.

CONCLUSIONS

A preceptorship model was successfully implemented on the third-year surgical clerkship at our institution. Although there was no difference between top performers on either clerkship structure, preceptorship students received written evaluations with better feedback as a result of their direct relationship with faculty. Strategies such as this, which improve student-faculty relationships, will be needed as programs find new ways to assess residency applicants.

Factors that Contribute to Resident Teaching Effectiveness

Background

One of the key components of residency training is to become an educator. Resident physicians teach students, advanced practice providers, nurses, and even faculty on a daily basis.

Objective

The goal of this study was to identify the objective characteristics of residents, which correlate with perceived overall teaching effectiveness.

Methods

We conducted a one-year, retrospective study to identify factors that were associated with higher resident teaching evaluations. Senior emergency medicine (EM) teaching residents are evaluated by medical students following clinical teaching shifts. Eighteen factors pertaining to resident teaching effectiveness were chosen. Two items from the medical students' evaluations were analyzed against each factor: teaching effectiveness was measured on a five-point Likert scale and an overall teaching score (1-75).

Results

A total of 46 EM residents and 843 medical student evaluations were analyzed. The ACGME milestones for systems-based practice (p = 0.02) and accountability (p = 0.05) showed a statistically significant association with a rating of “five” on the Likert scale for teaching effectiveness. Three other ACGME milestones, systems-based practice (p = 0.01), task switching (p = 0.04), and team management (p = 0.03) also showed a statically significant association of receiving a score of 70 or greater on the overall teaching score.

Conclusion

Residents with higher performance associated with system management and accountability were perceived as highly effective teachers. USMLE and in-service exams were not predictive of higher teaching evaluations. Our data also suggest that effective teachers are working in both academic and community settings, providing a potential resource to academic departments and institutions.

Are Surgeons Born or Made? A Comparison of Personality Traits and Learning Styles Between Surgical Trainees and Medical Students

OBJECTIVE

Medical students and surgical trainees differ considerably in both their preferential learning styles and personality traits. This study compares the personality profiles and learning styles of surgical trainees with a cohort of medical students specifically intent on pursuing a surgical career.

DESIGN

A cross-sectional study was conducted contrasting surgical trainees with medical students specifying surgical career intent. The 50-item International Personality Item Pool Big-Five Factor Marker (FFM) questionnaire was used to score 5 personality domains (extraversion, conscientiousness, agreeableness, openness to experience, and neuroticism). The 24-item Learning Style Inventory (LSI) Questionnaire was used to determine the preferential learning styles (visual, auditory, or tactile). χ(2) Analysis and independent samples t-test were used to compare LSI and FFM scores, respectively.

SETTING

Surgical trainees from several UK surgical centers were contrasted to undergraduate medical students.

PARTICIPANTS

A total of 53 medical students who had specifically declared desire to pursue a surgical career and were currently undertaking an undergraduate intercalated degree in surgical sciences were included and contrasted to 37 UK core surgical trainees (postgraduate years 3-4).

RESULTS

The LSI questionnaire was completed by 53 students and 37 trainees. FFM questionnaire was completed by 29 medical students and 34 trainees. No significant difference for learning styles preference was detected between the 2 groups (p = 0.139), with the visual modality being the preferred learning style for both students and trainees (69.8% and 54.1%, respectively). Neuroticism was the only personality trait to differ significantly between the 2 groups, with medical students scoring significantly higher than trainees (2.9 vs. 2.6, p = 0.03).

CONCLUSIONS

Medical students intent on pursuing a surgical career exhibit similar personality traits and learning styles to surgical trainees, with both groups preferring the visual learning modality. These findings facilitate future research into potential ways of improving both the training and selection of students and junior trainees onto residency programs.

Overnight Hospital Experiences for Medical Students: Results of the 2014 Clerkship Directors in Internal Medicine National Survey

BACKGROUND

Since the 2011 Accreditation Council of Graduate Medical Education (ACGME) work hour rules for residents were implemented, 24-30 h call for interns has been replaced by shift work, including night-float. The impact of these changes on undergraduate medical education experiences in internal medicine has not been described.

OBJECTIVE

We aimed to determine the current status of medical students' overnight experiences in Internal Medicine clerkships and sub-internships, and to assess internal medicine educators' perceptions of the importance of overnight work during internal medicine rotations.

DESIGN AND PARTICIPANTS

In May 2014, the Clerkship Directors in Internal Medicine (CDIM) conducted its annual survey. Twenty-eight questions about student participation in overnight work and perceptions of the importance of overnight work (rated on 1-5 Likert scale, 1 = very unimportant and 5 =  ery important) were included. Descriptive statistics were used to summarize responses. Free text results were analyzed qualitatively.

KEY RESULTS

The response rate was 78 %. A minority of respondents reported students having any overnight experience during the clerkship (38.7 %) or the sub-internship (40.7 %). Only 5 % of respondents reported having students assigned to night-float rotations outside of clerkships or sub-internships. Respondents agreed that overnight experiences were more important during the sub-internship than the clerkship, 4.0 ± 1.1 vs. 3.2 ± 1.2, p < 0.001. Admitting new patients, following their course and responding to emergencies were rated as important overnight tasks for both clerkship and sub-internship students.

CONCLUSIONS

Overnight experiences offer students additional educational opportunities. Clerkship directors felt that the overnight experience for the sub-intern in particular was an important chance to practice providing emergency cross coverage and other intern roles. In the era of ACGME duty hours, there is a need to further examine whether there is a role for increased overnight hospital experiences for medical students.

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.

Confounding factors in using upward feedback to assess the quality of medical training: a systematic review

PURPOSE

Upward feedback is becoming more widely used in medical training as a means of quality control. Multiple biases exist, thus the accuracy of upward feedback is debatable. This study aims to identify factors that could influence upward feedback, especially in medical training.

METHODS

A systematic review using a structured search strategy was performed. Thirty-five databases were searched. Results were reviewed and relevant abstracts were shortlisted. All studies in English, both medical and non-medical literature, were included. A simple pro-forma was used initially to identify the pertinent areas of upward feedback, so that a focused pro-forma could be designed for data extraction.

RESULTS

A total of 204 articles were reviewed. Most studies on upward feedback bias were evaluative studies and only covered Kirkpatrick level 1-reaction. Most studies evaluated trainers or training, were used for formative purposes and presented quantitative data. Accountability and confidentiality were the most common overt biases, whereas method of feedback was the most commonly implied bias within articles.

CONCLUSION

Although different types of bias do exist, upward feedback does have a role in evaluating medical training. Accountability and confidentiality were the most common biases. Further research is required to evaluate which types of bias are associated with specific survey characteristics and which are potentially modifiable.

Computerised provider order entry and residency education in an academic medical centre

CONTEXT

Many academic medical centres (AMCs) have introduced institutional policies, changed processes of care and implemented new technologies to improve health care quality. The impact of such changes on medical education has received little attention. We examine the impact of computerised provider order entry (CPOE) on the educational experiences of medical trainees who work and train in AMCs.

METHODS

We conducted semi-structured interviews of postgraduate trainees and attending physicians in internal medicine at five AMCs (two with CPOE, three without CPOE). Trainees routinely rotate from CPOE to non-CPOE AMCs, whereas some attending physicians work at both types of AMC and are therefore well positioned to reflect on differences between CPOE and non-CPOE learning environments. Data collection and analysis used grounded theory methods. We sampled purposively until we achieved theoretical saturation.

RESULTS

Our study included 11 residents and six attending physicians. Computerised provider order entry had both positive and negative impacts on five aspects of postgraduate training: (i) learning (better for medication interactions and availability of learning resources; worse for learning medication doses); (ii) teaching (more medication information available to enhance case discussions; fewer face-to-face teaching opportunities); (iii) feedback (improved ability to observe medication ordering behaviours to inform feedback; less provision of direct feedback); (iv) clinical supervision (facilitates efficient and safe supervision from a distance; may impede trainee independence), and (v) trainee assessment (increased opportunity to assess clinical decision-making and organisational skills).

CONCLUSIONS

We identify five key educational themes that are positively and negatively impacted by CPOE. These themes form a conceptual framework that could be applied to define the educational impact of other health care quality and patient safety practices. This will help educators to identify educational opportunities and protect the safety of the training experience of residents in AMCs.

Creating a surgery clerkship in a changing environment: reality, simulation, and the rules of engagement

This review describes the current challenges associated with creating a successful surgical clerkship and the ways in which teacher-focused and curriculum-focused initiatives can address these challenges. The challenges are both systemic (reflected by changes in our health care system and training programs) and institutional (reflected by factors that affect curriculum design and faculty advancement). Particular attention is paid to residents as teachers, faculty as mentors, the educational impact of the operating room, and the role of simulation. Strategies for engaging students, residents, and faculty are explored. The premise and impact of a comprehensive simulation course on the clinical education of medical students is detailed. Emphasis is placed on the educational validity of accountability and engagement of both the teachers and the learners.

The teacher, the physician and the person: how faculty's teaching performance influences their role modelling

Objective

Previous studies identified different typologies of role models (as teacher/supervisor, physician and person) and explored which of faculty's characteristics could distinguish good role models. The aim of this study was to explore how and to which extent clinical faculty's teaching performance influences residents' evaluations of faculty's different role modelling statuses, especially across different specialties.

Methods

In a prospective multicenter multispecialty study of faculty's teaching performance, we used web-based questionnaires to gather empirical data from residents. The main outcome measures were the different typologies of role modelling. The predictors were faculty's overall teaching performance and faculty's teaching performance on specific domains of teaching. The data were analyzed using multilevel regression equations.

Results

In total 219 (69% response rate) residents filled out 2111 questionnaires about 423 (96% response rate) faculty. Faculty's overall teaching performance influenced all role model typologies (OR: from 8.0 to 166.2). For the specific domains of teaching, overall, all three role model typologies were strongly associated with “professional attitude towards residents” (OR: 3.28 for teacher/supervisor, 2.72 for physician and 7.20 for the person role). Further, the teacher/supervisor role was strongly associated with “feedback” and “learning climate” (OR: 3.23 and 2.70). However, the associations of the specific domains of teaching with faculty's role modelling varied widely across specialties.

Conclusion

This study suggests that faculty can substantially enhance their role modelling by improving their teaching performance. The amount of influence that the specific domains of teaching have on role modelling differs across specialties.

Shifting indirect patient care duties to after hours in the era of work hours restrictions

PURPOSE

Few data describe how often residents defer indirect patient care tasks to after hours or show whether residents report this time in duty hours logs. Thus, the authors examined how often residents perform one such task, discharge dictation, outside scheduled hours.

METHOD

The authors tracked all discharge summaries dictated by internal medicine residents at a single teaching hospital from January to June 2009. They determined the length and timing of discharge dictations by querying the hospital voice-dictation system. Definite work hours violations occurred when residents completed dictations on the postcall day after reaching mandated duty hours limits or on scheduled days off. Potential work hours violations arose when residents dictated after 6 pm or during the month subsequent to their rotation. The authors compared the number of residents they determined to have incurred duty hours violations with the number self-reporting violations.

RESULTS

The authors obtained data on 1,152 dictations performed by 39 residents. Residents spent a mean 6.5 hours dictating per month, averaging 13 minutes per dictation. Using objective criteria, the authors determined that the majority of residents (32; 82%) incurred definite duty hours violations. Far fewer (2; 5%) self-reported violations. Team census, total time spent dictating, and dictation length were associated with dictating during restricted hours.

CONCLUSIONS

Indirect patient care tasks, such as dictating discharge summaries, may contribute substantially to unrecognized duty hours violations. Accurate and objective ways to assess resident workflow can help create effective solutions for resident efficiency and inform changes to resident schedules.

Effect of the ACGME duty hours restrictions on surgical residents and faculty: a systematic review

PURPOSE

Educators in surgical training programs are concerned that the Accreditation Council for Graduate Medical Education (ACGME) duty hours limitations may adversely affect surgical residents' education, especially their operative experience, so the authors aimed to evaluate the impact of duty hours reductions on surgical residency.

METHOD

The authors searched English- and French-language literature (2000-2008) for articles about the impact of duty hours restrictions on surgical residents' education and well-being and on faculty educators. They used the following databases: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and ERIC. The authors included every report that examined the effects of duty hours limits on surgical training, excluding opinion papers and editorials. Two reviewers independently performed data extraction and quality assessment for all reports and resolved disagreements by consensus.

RESULTS

The authors retrieved 1,146 reports and included 56 in the study. They compiled positive and negative outcomes on (1) residents' education, (2) resident lifestyle, and (3) surgical faculty. Overall, the effects of duty hours reductions on residents' education and lifestyle were positive or neutral, but the effects on surgical faculty were negative. The 16 articles with the highest-quality scores had 27 positive themes and 11 negative themes.

CONCLUSIONS

This is the largest and most current review of the literature addressing the effect of the ACGME duty hours limitations on surgical training. Limitations had a positive effect on residents but a negative effect on surgical faculty. Importantly, duty hours limitations did not adversely affect surgical residents' operating-room experience.

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.

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.

Effects of "minimally invasive curricular surgery" - a pilot intervention study to improve the quality of bedside teaching in medical education

BACKGROUND

Bedside teaching is an important element of undergraduate medical education. However, the impact of curricular course structure on student outcome needs to be determined.

AIMS

This study assessed changes in fourth-year medical students' evaluations of clinical teaching sessions before and after the introduction of a new course format.

METHOD

The curricular structure of bedside teaching sessions in cardiology was modified without changing the amount of teaching time. Clinical teachers were instructed about the new teaching format and learning objectives. The new format implemented for adult but not paediatric cardiology sessions was piloted with 143 students in winter 2007/08. By computing effect sizes, evaluation results were compared to data obtained from 185 students before the intervention.

RESULTS

Significant rating increases were observed for adult cardiology teaching sessions (Cohen's d = 0.66) but not paediatric cardiology sessions (d = 0.22). In addition to improving the structure and organization of the course, the intervention significantly impacted on students' perceptions of their learning outcome regarding practical skills (d = 0.69).

CONCLUSIONS

Minimal curricular changes combined with basic faculty development measures significantly increase students' perception of learning outcome. Curricular structure needs to be considered when planning bedside teaching sessions in medical undergraduate training.

Uncovering system errors using a rapid response team: cross-coverage caught in the crossfire

BACKGROUND

Because of the 80-hour work week, extensive service cross-coverage creates great potential for patient care errors. These patient care emergencies are increasingly managed using a rapid response team (RRT) to reduce patient morbidity. We examine the proximate causes of a surgical RRT activation. We hypothesize that most RRTs would occur during cross-coverage hours and be preventable or potentially preventable.

METHODS

All surgical RRTs more than a 15-month period were captured using a nursing database and the note from the staffing intensivist/fellow. RRTs were reviewed for appropriateness (pre-existing criteria) and proximate cause. Proximate causes were further classified as patient disease, team error, nursing error, or system error as well as preventable, potentially preventable, or nonpreventable.

RESULTS

Of 98 RRT activations, complete data were available for 82 (84%); 100% met activation criteria; and 76 (93%) occurred between 2100 and 0600. Seventy-six patients were 48 hours to 72 hours postoperative; six had nonoperatively managed injuries. The most common reason for activation was impending respiratory failure and acute volume overload (n = 72; 88%). RRT therapies included diuretics (n = 72), antiarrhythmics (n = 48), oxygen (n = 82), and bronchodilators (n = 36); only 2 received blood component therapy. Seventy-eight patients (95%) were transferred to higher level of care (61, surgical intensive care unit; 17, SSDU). Only 46% of patients required intubation. Performance improvement review identified 90% of physician related RRTs as preventable/potentially preventable because of errors in judgment or omission. Four RRTs because of patient disease were unpreventable. Two potentially preventable errors were each ascribed to RN or system concerns.

CONCLUSION

RRT activations principally result from team-based errors of omission, more often occur between 2100 and 0600, and are more often preventable or potentially preventable. Careful attention to fluid balance and medications for comorbid diseases would reduce RRT needs.

Four years of accreditation council of graduate medical education duty hour regulations: have they made a difference?

OBJECTIVES/HYPOTHESIS

Measure compliance with the Accreditation Council of Graduate Medical Education (ACGME) residents' work hour regulations and evaluate their impact on patient care and residents' performance on the Otolaryngology Training Examination (OTE).

STUDY DESIGN

Retrospective review of an otolaryngology residency program's resident duty hours violations and OTE scores, and review of the associated hospital's benchmark patient data.

METHODS

Residents' duty hour violations were compiled and analyzed for individual violation, postgraduate year (PGY), and service in the program. Annual OTE scores and the department's hospital benchmark measures (inpatient mortality, inpatient length of stay, 30-day readmission rate) were compared before and after the institution of the ACGME duty hours mandate.

RESULTS

The 10-hour rule was most frequently violated; residents on the oncology service and PGY-2 year were most commonly in violation. There was no difference before and after institution of the ACGME duty hours mandate in 30-day hospital readmission rates (P = .42), hospital mortality index (P = .55), length of stay (P = .55), OTE scores (P = .11, Student's t test), and graduating resident's operative volume.

CONCLUSIONS

Institution of the ACGME duty hour regulations did not improve patient care as measured by the 30-day readmission rate, inhospital mortality, and patient's length of stay. Residents' performance on the OTE did not change after implementation of the ACGME rules. Further studies are warranted to assess the impact of the ACGME work hour regulations on patient care and resident-physicians' training.

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

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

Formalizing teaching responsibilities for junior surgical housestaff encourages educator development

PURPOSE

Resident-led teaching on surgical services is typically disorganized, and the primary responsibility is often unassigned. Creation of a specified role of "teaching resident" (TR) is hypothesized to encourage residents to teach more, develop leadership skills, and enhance medical student clerkship experiences.

METHODS

All residents in general surgery training at the University of California, San Francisco, were surveyed to determine perceptions of teaching responsibility. Independently, second-year residents were solicited for voluntary participation in a TR program that gave them primary responsibility for teaching medical students assigned to their services during a 1-month rotation. After completion of the TR rotation, these residents evaluated the TR experience with their prior rotation at the same hospital (which had the same service structure but no TR duties). Medical student clerkship evaluations were reviewed to compare experiences between the 2 periods as well.

RESULTS

Overall response rate for the general survey administered to all residents was 93% (67/72). All 6 second-year residents rotating through the designated services over a 6-month period volunteered to participate, but 2 did not have assigned medical students. Evaluations of the TR program were thus completed by 100% (4/4) residents. Time spent teaching medical students increased significantly, from 0.625 hours/week pre-TR to 2.75 hours/week during TR (p = 0.0026). All felt that teaching skills and motivation to teach increased, and 75% also reported improvement in leadership skills. Medical student scores on a 5-point scale revealed an increase in clinical instruction from 2.17 pre-TR to 3.25 (p = 0.0054). Satisfaction of clerkship objectives also increased from 3.17 pre-TR to 3.75 (p = 0.038).

CONCLUSIONS

Junior surgical residents have interest in teaching, and their time spent doing so is significantly increased by the specific assignment of responsibility in a mid-level leadership role. Both residents and students benefit from this clinical service structure. Further formal development and program evaluation are in progress.

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.

Defining service and education: the first step to developing the correct balance

BACKGROUND

Service and education activities have not been well defined or studied. The purpose of this study is to describe how attendings and residents categorize common resident activities on a service-education continuum.

METHODS

A web-based survey was designed to categorize resident activities. A panel of residents and surgical educators reviewed the survey for content validity. Residents and attendings categorized 27 resident activities on a 5-point scale from 1 (pure service) to 5 (pure education). Data analysis was performed using SPSS ver.12.

RESULTS

125 residents and 71 attendings from eight residency programs participated. 66% of residents and 90% of attendings were male. On average, attendings had practiced 14.3 years. Residents' post-graduate year ranged from PGY-1 to PGY-6 (mean of 2.78). Attendings and residents agreed on the categorization of most activities. Residents felt more time should be devoted to pure education than did attendings. Forty percent of residents felt that more than half of their time was spent in pure service versus 10% of attendings. Twenty-five percent of residents and 23% of attendings were dissatisfied with the service-education balance.

CONCLUSIONS

The Residency Review Committee mandates that education is the central purpose of the surgical residency without clearly defining the balance between education and service. Attendings and residents agree on the educational value of most activities and that the balance between education and service is acceptable. When compared with attendings, residents feel they need significantly more time in education. Adequate learning can be facilitated by the development of clear definitions of service and education and guidelines for the distribution of resident time.

Effective Surgical Residents Strongly Influence Medical Students to Pursue Surgical Careers

BACKGROUND

There is a paucity of data about the influence of surgical residents on the career choices of medical students. We hypothesized that medical students exposed to effective surgical residents would be more likely to pursue careers in surgery.

STUDY DESIGN

From 1998 to 2003, 108 surgical residents were evaluated by medical students rotating on the third-year clerkship. Residents were scored on a 4-point scale (1 = outstanding to 4 = poor). The career choices of all medical students were also tabulated.

RESULTS

We examined 2,632 evaluations on 108 residents. Medical students who eventually pursued surgical residency training were exposed to surgical residents who were more effective clinical teachers, role models, and overall residents. In addition, medical students exposed to the highest-rated residents were more likely to pursue surgical residency training compared with students exposed to the least effective residents (12% versus 4.9%, p = 0.022).

CONCLUSIONS

These data suggest that surgical residents who are effective educators and mentors influence medical students to pursue surgical careers. Efforts to provide more leadership and teaching workshops to surgical residents may not only create better future surgeon educators, but may also increase the number of students pursuing surgical training.

When policy meets physiology: the challenge of reducing resident work hours

Considerable controversy exists regarding optimal work hours for physicians and surgeons in training. In a series of studies, we assessed the effect of extended work hours on resident sleep and health as well as patient safety. In a validated nationwide survey, we found that residents who had worked 24 hours or longer were 2.3 times more likely to have a motor vehicle crash following that shift than when they worked < 24 hours, and that the monthly risk of a crash increased by 16.2% after each extended duration shift. We also found in a randomized trial that interns working a traditional on-call schedule slept 5.8 hours less per week, had twice as many attentional failures on duty overnight, and made 36% more serious medical errors and nearly six times more serious diagnostic errors than when working on a schedule that limited continuous duty to 16 hours. While numerous opinions have been published opposing reductions in extended work hours due to concerns regarding continuity of patient care, reduced educational opportunities, and traditionally-defined professionalism, there are remarkably few objective data in support of continuing to schedule medical trainees to work shifts > 24 hours. An evidence-based approach is needed to minimize the well-documented risk that current work hour practices confer on resident health and patient safety while optimizing education and continuity of care.