A Narrative Review of High-Quality Literature on the Effects of Resident Duty Hours Reforms

The use of virtual patients for breaking bad news: A rapid review

BACKGROUND

Breaking bad news is an imperative skill for clinical practice that health care professionals struggle with. Virtual patients have been adopted as a new teaching aide in medical education and have shown efficacy in teaching clinical skills; however, there is limited research for use in communication skills. Virtual patients are especially well-suited for difficult communication skills, as students can practice without risk to patients. This rapid review aimed to review literature observing the potential of virtual patients as an effective means to teach breaking bad news.

METHOD

A systematic search strategy was applied for papers published between November 2012 and November 2022 on Medline and Embase databases. Following the application of inclusion criteria, three studies were included. The Medical Education Research Study Quality Instrument and Critical Appraisal Skills Programme checklist were used for quality appraisal of the studies. Tabular and narrative synthesis was used to present the findings.

FINDINGS

The findings of the studies suggest that when teaching breaking bad news, virtual patients are valuable compared with no intervention and are not inferior compared with simulated patients. An unexpected benefit of virtual patients was videotaping. A barrier to learning was the lack of affect and interaction. More research into the design of virtual simulations and its integration into existing curricula is required.

CONCLUSION

Virtual patients are a valuable educational tool for breaking bad news; however, they are yet to replace existing educational approaches. There is a need for more large-scale, homogeneous studies to inform instructional design and curriculum integration.

GP trainees as teachers: a rapid review of the barriers, facilitators and outcomes

BACKGROUND

There is a workforce crisis in General Practice (GP) within the United Kingdom (UK). High-quality clinical placement experiences in GP influence medical students' interest and likelihood to enter this speciality. GP trainees often express a desire to teach, yet teaching does not feature significantly within their current practice. This study aims to explore outcomes, barriers, and facilitators of GP trainees teaching medical students through a rapid review of published literature.

METHODS

MEDLINE, EMBASE, PsychINFO, Web of Science were searched for articles relating to GP trainees teaching. Studies conducted in the UK and Australia, between January 2000 and October 2022 were included. The Medical Education Research Study Quality Index and the Critical Appraisal Skills Programme checklist were used to assess quality.

RESULTS

Twenty-seven publications, 11 qualitative, six quantitative, three mixed-methods and seven opinion pieces, were identified. Many studies have methodological limitations. Empirical studies show that there are benefits of near-peer teaching, but these are limited by trainees' capacity and capability to teach, and GPs' confidence in trainees' teaching. The culture within the practice influenced whether trainees were seen solely as learners or also as teachers for students.

DISCUSSION

When GP trainees teach there are positive outcomes for medical students and trainees. Teaching was considered an activity that trainees did in 'addition to' rather than 'part' of' their training. Appropriate teaching opportunities, and relevant training, were key to trainees' competence and confidence in teaching. Resources and recognition and a strong teaching culture are needed to support GP trainees to teach.

Predictors of Academic and Fieldwork Performance in Occupational Therapy Students: A Systematic Review

Introduction

Occupational therapy (OT) educational programs are aimed at enrolling a diverse student population that is likely to succeed in the academic and fieldwork components of the program. Comprehending the array of factors that influence students' learning and academic and fieldwork success is important for university educators. This study investigated the existing literature on predictors of academic and fieldwork performance in OT students.

Methods

The search process used in this review included screening, eligibility, and study quality. We searched the PubMed and Cochrane Library databases for literature published in the past 10 years (1 January 2012 to 30 March 2022). As a comprehensive search, the following keywords were used for abstract, title, and keywords sections: occupational therapy student, predictors, fieldwork, academic, academic success, academic performance, fieldwork success, and fieldwork performance. The Medical Education Research Study Quality Instrument was used to assess the quality of studies.

Results

The systematic review retrieved 14 articles that met inclusion criteria. Most were cross-sectional studies, followed by cohort, retrospective analysis of secondary data, and exploratory studies. Four articles focused on academic success, eight focused on fieldwork success, and two explored both aspects. Promising predictors of academic performance included the admission grade point average and the student's approach to studying. Predictors of fieldwork performance included a graduate record examination score, emotional intelligence, and interpersonal relationships.

Conclusion

This systematic review explores predictors of academic and fieldwork success in OT students, which provide opportunities to identify early the learning difficulties of students and assist educators to target modifiable predictors so they can provide high-quality education.

Healthcare policy changes in an era of health workforce shortage

In their recent IJHPR article, Wimpfheimer and colleagues outline the implications for the field of anesthesia of two major healthcare policy changes in Israel: The Yatziv Reform in licensing foreign medical graduates and the efforts to reduce residents' on-call shift duration. We argue that these reforms are necessary to strengthen the healthcare workforce and improve the quality of care in the long term, even though they may limit the availability of healthcare personnel for several years, particularly in the field of anesthesia. In this commentary, we examine the background to these policy changes, their likely impact on the medical workforce in Israel in general, and propose steps to reconcile these reforms with the global and national shortage of physicians. We urge policymakers to allocate the required resources and begin preparing for an era of continuous mismatch between physician supply and demand, which will necessitate creative solutions, increased reliance on technology, and the introduction of paramedical professionals to help offload tasks and better utilize the scarce physician workforce.

Shared decision-making training in general practice: a rapid review

Introduction

Although shared decision-making (SDM) is key to providing patient-centred care, SDM is lacking in primary care. Training programmes seeking to improve GP SDM have yet to be reviewed. Therefore, a rapid review of the literature was conducted to evaluate GP SDM training methods and their outcomes.

Methods

MEDLINE, EMBASE and CENTRAL were systematically searched. Results of the studies included were synthesised narratively. Study quality was appraised using the Medical Education Research Study Quality Instrument (MERSQI).

Results

Seven studies were identified. Study quality was high, with a mean MERSQI score of 17.2/18 (range 16-18). Theory/presentation was the most prevalent training method (n=6). Of the five studies assessing the impact of SDM training on patient outcomes, only one yielded positive results. Contrastingly, both studies assessing clinician behaviour produced positive results.

Conclusions

SDM training improved GP behaviour but the effects on patient outcomes were lacking. SDM training programmes that utilised teaching methods targeting practical SDM skills, such as role play, observed some positive findings. However, because their prevalence was lacking, further research into these methods, and their cost-effectiveness, are needed.

A narrative review of the impact of work hours and insufficient rest on job performance

OBJECTIVE

This review discusses the scientific evidence regarding effects of insufficient rest on clinical performance and house officer training programs, the associations of clinical duty scheduling with insufficient rest, and the implications for risk management.

STUDY DESIGN

Narrative review.

METHODS

Several literature searches using broad terms such as "sleep deprivation," "veterinary," "physician," and "surgeon" were performed using PubMed and Google scholar.

RESULTS

Sleep deprivation and insufficient rest have clear and deleterious effects on job performance, which in healthcare occupations impacts patient safety and practice function. The unique requirements of a career in veterinary surgery, which may include on-call shifts and overnight work, can lead to distinct sleep challenges and chronic insufficient rest with resultant serious but often poorly recognized impacts. These effects negatively impact practices, teams, surgeons, and patients. The self-assessment of fatigue and performance effect is demonstrably untrustworthy, reinforcing the need for institution-level protections. While the issues are complex and there is no one-size-fits-all approach, duty hour or workload restrictions may be an important first step in addressing these issues within veterinary surgery, as it has been in human medicine.

CONCLUSION

Systematic re-examination of cultural expectations and practice logistics are needed if improvement in working hours, clinician well-being, productivity, and patient safety are to occur.

CLINICAL SIGNIFICANCE (OR IMPACT)

A more comprehensive understanding of the magnitude and consequence of sleep-related impairment better enables surgeons and hospital management to address systemic challenges in veterinary practice and training programs.

Adding Nocturnal Advanced Practice Providers to an Academic Inpatient Neurology Service Improves Residents' Educational Experience

Background and Objectives: In the inpatient academic medical center, increased demand for clinical services often equates to an increased workload for trainees, which could have a positive or negative impact on their educational experience. In 2020, our academic medical center hired Advanced Practice Providers (APPs) to provide continuous additional overnight coverage for our neurology ward teaching service. We hypothesized that adding APPs and reducing overnight clinical workload for residents would have a positive impact on resident education. Methods: We performed a mixed-methods, prospective study that included needs-assessments by residents, semi-structured interviews with both residents and APPs, and surveys to residents and nursing staff. In addition, we collected quantitative data such as hours of sleep, number of admissions, and number of pages to capture the impact of APPs on resident overnight shifts. Results: The addition of APPs overnight increased the median hours of sleep overnight from 1 hour to 3 hours (P < .001) and decreased the median number of pages overnight from 31.5 to 17 (P < .001). The median number of patients the resident was responsible for cross-covering overnight decreased from 24 patients to 14 patients (P < .001). The majority of resident responses (94%) agreed that the addition of APPs benefited their education by reducing workload and increasing time allotted to reading and formulating plans for overnight admissions. 88% of residents agreed that the addition of APPs improved quality of life and reduced risk of burnout. Conclusion: Advanced Practice Providers significantly reduced resident workload, leading residents to report improvements in the educational experience overnight and reduced perceived risk of burnout.

Work like a Doc: A comparison of regulations on residents' working hours in 14 high-income countries

BACKGROUND

Medical residents work long, continuous hours. Working in conditions of extreme fatigue has adverse effects on the quality and safety of care, and on residents' quality of life. Many countries have attempted to regulate residents' work hours.

OBJECTIVES

We aimed to review residents' work hours regulations in different countries with an emphasis on night shifts.

METHODS

Standardized qualitative data on residents' working hours were collected with the assistance of experts from 14 high-income countries through a questionnaire. An international comparative analysis was performed.

RESULTS

All countries reviewed limit the weekly working hours; North-American countries limit to 60-80 h, European countries limit to 48 h. In most countries, residents work 24 or 26 consecutive hours, but the number of long overnight shifts varies, ranging from two to ten. Many European countries face difficulties in complying with the weekly hour limit and allow opt-out contracts to exceed it.

CONCLUSIONS

In the countries analyzed, residents still work long hours. Attempts to limit the shift length or the weekly working hours resulted in modest improvements in residents' quality of life with mixed effects on quality of care and residents' education.

The use of objective assessments in the evaluation of technical skills in cardiothoracic surgery: a systematic review

OBJECTIVES

With reductions in training time and intraoperative exposure, there is a need for objective assessments to measure trainee progression. This systematic review focuses on the evaluation of trainee technical skill performance using objective assessments in cardiothoracic surgery and its incorporation into training curricula.

METHODS

Databases (EBSCOHOST, Scopus and Web of Science) and reference lists of relevant articles for studies that incorporated objective assessment of technical skills of trainees/residents in cardiothoracic surgery were included. Data extraction included task performed; assessment setting and tool used; number/level of assessors; study outcome and whether the assessments were incorporated into training curricula. The methodological rigour of the studies was scored using the Medical Education Research Study Quality Instrument (MERSQI).

RESULTS

Fifty-four studies were included for quantitative synthesis. Six were randomized-controlled trials. Cardiac surgery was the most common speciality utilizing objective assessment methods with coronary anastomosis the most frequently tested task. Likert-based assessment tools were most commonly used (61%). Eighty-five per cent of studies were simulation-based with the rest being intraoperative. Expert surgeons were primarily used for objective assessments (78%) with 46% using blinding. Thirty (56%) studies explored objective changes in technical performance with 97% demonstrating improvement. The other studies were primarily validating assessment tools. Thirty-nine per cent of studies had established these assessment tools into training curricula. The mean ± standard deviation MERSQI score for all studies was 13.6 ± 1.5 demonstrating high validity.

CONCLUSIONS

Despite validated technical skill assessment tools being available and demonstrating trainee improvement, their regular adoption into training curricula is lacking. There is a need to incorporate these assessments to increase the efficiency and transparency of training programmes for cardiothoracic surgeons.

The impact of autism-related training programs on physician knowledge, self-efficacy, and practice behavior: A systematic review

LAY ABSTRACT

Autism spectrum disorder is estimated to impact 1.5 million children and almost 5.5 million adults. However, most physicians do not receive training on how to provide care to this increasingly large group of people. After performing a systematic review of the literature and screening over 4,500 unique articles focused on the effectiveness of autism-specific training programs designed for physicians and physician trainees, we determined that 17 studies met the pre-determined criteria for inclusion in this systematic review. The results reported by these studies suggest that by completing specialized training programs related to autism, physicians were more knowledgeable on topics related to the condition, more confident in their ability to provide care to autistic individuals, and more likely to screen their patients for autism spectrum disorder. However, further studies with higher quality data are needed to validate these findings and provide additional insight on the ability of these programs to improve physician behavior and patient outcomes. We are therefore advocating that medical educators develop and evaluate specialized autism training programs with an increased focus on improving physician behavior related to all aspects of providing care to autistic people.

Impact of Intercalated Degree on Post-graduate Career Progression and Academic Development in the UK: A Rapid Review of the Literature

An intercalated degree offers medical students an avenue to explore their interests and become competent in scientific literacy. Although intercalating can pose a financial burden and time commitment, they do provide competitive academic and speciality training applications. The aim of this review was to explore academic development and subsequent outcomes of career progression. Medline and EMBASE were systematically searched using keywords. After the removal of duplicates, the studies were screened against the inclusion criteria. For the five studies included in this review, a narrative synthesis was performed. The two main themes were academic development and career progression. All studies showed a plethora of academic achievements during and after intercalation. Two studies showed that students are more likely to enter a career in academic medicine. A further two studies have shown that the transferable skills of academia have allowed alumni to make more competitive applications for foundation year and speciality training. The results have shown a correlation between academic achievements and an increase in competitiveness in foundation programmes and speciality applications. There are clear discrepancies in the success of academic careers depending on the institution and type of intercalated degree. Current literature suggests a master's degree results in more academic success compared to a bachelor's degree. Due to the sheer diversity of intercalated degrees offered to medical students in the UK, there is limited literature on post-graduate career progression. More research should be undertaken to look at the implications of intercalation on post-graduate career progression.

Burnout among resident doctors: An observational study

Background

Burnout is a syndrome of emotional exhaustion and depersonalization that reduces efficiency at work. No studies have been reported focusing only on residency burnout and risk factors from our country until now. This study aimed to find out the impact and the association of specific demographic and practice characteristics with burnout among resident doctors.

Methods

A prospective cross-sectional survey of all resident doctors under training at that point of time in 2019 in the National Academy of Medical Sciences, Nepal in different specialties was done. We evaluated demographic variables, practice characteristics, and assessed burnout through validated Maslach burnout inventory (MBI) tools, and data were analyzed.

Results

A total 347 among 410 resident doctors (227 male) responded to the survey. Median age was 30 years (range 25–44). Overall, 147 (42.4%) of responding residents were burned out with high emotional exhaustion in 58 (16.6%), high depersonalization in 55 (15.9%), and low personal achievement in 34 (9.8). In regression analysis, out of independent variables gender, marital status, having children, specialty, hours of work per week and year of residency, specialties (general surgery odds ratio [OR]; 12.595, confidence interval [CI],[ 1.037–152.9], P; 0.047), obstetrics, and gynecology (odds ratio [OR]; 13.977, confidence interval [CI]; [1.324–147.5], P; 0.028), and anesthesiology (odds ratio [OR]; 11.54, confidence interval [CI]; [1.014–131.4], P; 0.049)) and hours of work per week (≥80 h) (odds ratio [OR]; 2.511, confidence interval [CI]; [1.128–5.589], P; 0.024), were significantly associated with high burnout.

Conclusions

Burnout is common among trainee resident doctors which is possibly preventable. Thus, the concern should be to prepare strategies to identify and minimize burnout from the individual, institutional, and societal sides. It is essential to preserve and promote the mental health of trainee residents to prevent serious consequences in the personal lives of resident doctors and as well as on patient outcomes.

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Burnout amongst resident doctors is extremely predominant which may be caused due to various reasons.

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We describe the impact of burnout among resident doctors and focus on identifying different risk factors for burnout.

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Preservation of mental health of resident doctors is essential to prevent serious consequences in their lives as well as on patient care.

Training and assessment of musculoskeletal ultrasound and injection skills-a systematic review

OBJECTIVES

To examine how residents are trained and assessed in musculoskeletal ultrasound (MSUS), MSUS-guided and landmark-guided joint aspiration and injection. Additionally, to present the available assessment tools and examine their supporting validity evidence.

METHODS

A systematic search of PubMed, Cochrane Library, and Embase was conducted in accordance with the PRISMA guidelines and studies published from January 1, 2000 to May 31, 2021 were included. Two independent reviewers performed the search and data extraction. The studies were evaluated using the Medical Education Research Quality Instrument (MERSQI).

RESULTS

9,884 articles were screened, and 43 were included; 3 were randomized studies, 21 pre- and post-test studies, 16 descriptive studies, and 3 studies developing assessment tools. The studies used various theoretical training modalities e.g. lectures, anatomical quizzes and e-learning. The practical training models varied from mannequins and cadavers to healthy volunteers and patients. The majority of studies used subjective "comfort level" as assessment, others used practical examination and/or theoretical examination. All training programs increased trainees' self-confidence, theoretical knowledge, and/or practical performance, however few used validated assessment tools to measure the effect. Only one study met the MERSQI high methodical quality cut-off score of 14.

CONCLUSION

The included studies were heterogeneous, and most were of poor methodological quality and not based on contemporary educational theories. This review highlights the need for educational studies using validated theoretical and practical assessment tools to ensure optimal MSUS training and assessment in rheumatology.

Maintaining Wellness and Instilling Resilience in General Surgeons

Obtaining wellness and enhancing resilience will be increasingly more important for General Surgeons. Although these concepts are not new, the increased complexity of health care delivery has elevated the importance of these essential attributes. Instilling these practices should be emphasized during surgery residency and be modeled by surgical educators and surgeon leaders. The enhanced emphasis of wellness and resiliency is a positive step forward; however, more must be accomplished to ensure the well-being of a particularly group of vulnerable physicians. This chapter discusses the history and scientific theory behind wellness and resiliency, as well as practical suggestions for consideration.

An evaluation of the effectiveness of induction programmes on foundation doctor preparedness: a rapid review of the literature

There is an increase in mortality when medical graduates replace the previous cohort of foundation doctors. As of 2012, it is now mandatory for new doctors in the UK to participate in induction training in order to ease this transition and reduce the negative impact on patient outcomes. However, there is no guidance on how best to deliver these induction programmes. This review aims to evaluate the effectiveness of several induction programmes to provide insight on this. Medline and Scopus were searched for relevant literature using keywords. Duplicates were removed and inclusion criteria were created to screen the remaining literature. Five studies were included in this review and they were all quality appraised using the Medical Education Research Study Quality Instrument. Different hospital trusts utilised varying induction programmes. The most common method of assessing their effectiveness involved exploring preparedness in junior doctors post-induction through surveys. Patient outcome, anxiety levels and knowledge were also measured. Induction programmes play a vital role in preparing new foundation doctors for practice and thus improving patient outcomes. Although there may be trust-specific variation, some elements of the programme should be standardised to ensure basic requirements are met universally. New doctors should be assessed on aspects of the programme after completion to increase confidence and knowledge. Organisational considerations such as costs and staff availability need to be taken into account. The quality of future research papers could be improved through inclusion of baseline data, control groups, multi-centred studies and outcomes higher on Kirkpatrick’s hierarchy.

An evaluation of educational interventions aimed at preparing medical students for discharge summary writing: a rapid review of the literature

Whilst discharge summaries are important for ensuring patient continuity of care, they often lack important information. Medical students and newly qualified doctors have attributed this to insufficient teaching, thereby indicating a need to improve discharge summary education within the undergraduate medical curriculum. The aim was to review educational approaches used to prepare undergraduate medical students for discharge summary writing, and their effectiveness Medline and Scopus were systematically searched using keywords, for studies published between 2009 and 2019. Narrative synthesis was used to integrate the findings of the included studies. Study quality was appraised using the Medical Education Research Study Quality Instrument. Six studies were included in this review. Allowing students to write a discharge summary following a real patient encounter and receive written feedback was the most common educational approach used (n = 4). Three of these studies improved student attitudes towards discharge summary writing. One study described the use of a mobile application, which improved discharge summary quality. Another study utilized interprofessional learning but the effect was statistically insignificant. Medical Education Research Study Quality Instrument scores were satisfactory (mean = 12, range = 8.4-15). The literature concerning this topic is limited. The results indicate that providing written feedback to students can positively influence attitudes towards discharge summary writing. Optimisation of the quality of discharge summaries written by medical students using feedback and checklists requires further investigation, as does the use of interprofessional learning. Future studies would additionally benefit from including participant baseline data and control groups, being multicentred and measuring behavioural or patient/healthcare outcomes.

Automated Methods of Technical Skill Assessment in Surgery: A Systematic Review

OBJECTIVE

The goal of the current study is to systematically review the literature addressing the use of automated methods to evaluate technical skills in surgery.

BACKGROUND

The classic apprenticeship model of surgical training includes subjective assessments of technical skill. However, automated methods to evaluate surgical technical skill have been recently studied. These automated methods are a more objective, versatile, and analytical way to evaluate a surgical trainee's technical skill.

STUDY DESIGN

A literature search of the Ovid Medline, Web of Science, and EMBASE Classic databases was performed. Articles evaluating automated methods for surgical technical skill assessment were abstracted. The quality of all included studies was assessed using the Medical Education Research Study Quality Instrument.

RESULTS

A total of 1715 articles were identified, 76 of which were selected for final analysis. An automated methods pathway was defined that included kinetics and computer vision data extraction methods. Automated methods included tool motion tracking, hand motion tracking, eye motion tracking, and muscle contraction analysis. Finally, machine learning, deep learning, and performance classification were used to analyse these methods. These methods of surgical skill assessment were used in the operating room and simulated environments. The average Medical Education Research Study Quality Instrument score across all studies was 10.86 (maximum score of 18).

CONCLUSIONS

Automated methods for technical skill assessment is a growing field in surgical education. We found quality studies evaluating these techniques across many environments and surgeries. More research must be done to ensure these techniques are further verified and implemented in surgical curricula.

Why do trainees leave hospital-based specialty training? A nationwide survey study investigating factors involved in attrition and subsequent career choices in the Netherlands

OBJECTIVE

To gain insight into factors involved in attrition from hospital-based medical specialty training and future career plans of trainees who prematurely left their specialty training programme.

DESIGN

Nationwide online survey study.

SETTING

Postgraduate education of all hospital-based specialties in the Netherlands.

PARTICIPANTS

174 trainees who prematurely left hospital-based medical specialty training between January 2014 and September 2017.

MAIN OUTCOME MEASURES

Factors involved in trainees' decisions to leave specialty training and their subsequent career plans.

RESULTS

The response rate was 38%. Of the responders, 25% left their programme in the first training year, 50% in year 2-3 and 25% in year 4-6. The most frequently reported factors involved in attrition were: work-life balance, job content, workload and specialty culture. Of the leaving trainees, 66% switched to another specialty training programme, of whom two-thirds chose a non-hospital-based training programme. Twelve per cent continued their career in a non-clinical role and the remainder had no specific plans yet.

CONCLUSIONS

This study provides insight in factors involved in attrition and in future career paths. Based on our findings, possible interventions to reduce attrition are: (1) enable candidates to develop a realistic view on job characteristics and demands, prior to application; (2) provide individual guidance during specialty training, with emphasis on work-life balance and fit with specialty.

Resident Survey on Gastroenterology Training in Canada

BACKGROUND

Gastroenterology training in Canada is guided by the Royal College of Physicians and Surgeons of Canada. Resident perspectives on training and the degree of heterogeneity across training programs have not been previously surveyed.

AIM

This study aims to evaluate the current Canadian adult gastroenterology training experience from a resident perspective and provide insight into the heterogeneity among training programs.

METHOD

A survey designed by three current gastroenterology residents was distributed to trainees attending the Gastroenterology Residents-in-Training course at Canadian Digestive Diseases Week 2018. Categorical data from the survey was analyzed in table format. Other continuous data was converted to dichotomous data and analyzed in groups of small and large programs, the large program defined as greater than six trainees.

RESULTS

The overall response rate was 45 of 56 (80%), representing 13 of 14 accredited training sites. Mandatory rotations and core procedures varied widely across respondents, with only inpatient training consistent across all sites. Small programs had a higher call burden (P=0.039), but staff were more likely to be available to cover call if the resident coverage was unavailable (P=0.002). There were nonsignificant trends in small programs in the inability to take a post-call day (P=0.07) and a resident perception of being well trained (P=0.07).

CONCLUSIONS

There is heterogeneity across programs in mandatory rotations and core procedures. With the upcoming shift to competency-based medical education, it is an opportune time to re-evaluate and perhaps standardize how gastroenterology training is delivered in Canada.

Associations Between In-Hospital Mortality, Health Care Utilization, and Inpatient Costs With the 2011 Resident Duty Hour Revision

BACKGROUND

The Accreditation Council for Graduate Medical Education (ACGME) has mandated revisions to residents' work hours to improve patient safety and enhance resident education and wellness. The impact on clinical outcomes on a national level is poorly understood.

OBJECTIVE

We examined data from before and after the ACGME 2011 duty hour revision and looked for differences between teaching and nonteaching US hospitals.

METHODS

A retrospective observational study of patients admitted to hospitals in the 2-year periods before and after the 2011 duty hour revision was conducted, utilizing a nationally representative data set. We compared patient and hospital characteristics using standardized differences. With nonteaching hospitals serving as the control group, we used multiple group interrupted time series segmented regression analysis to test for postrevision level and trend changes in mortality, length of stay (LOS), and costs.

RESULTS

We examined more than 117 million hospitalizations. At teaching and nonteaching hospitals, trends in mortality and LOS in prerevision and postrevision periods were not significantly different (all P > .05). A significant monthly reduction in cost per hospitalization was noted postrevision at teaching hospitals (P = .019) but not at nonteaching hospitals (P = .62). In the 2 years following the 2011 revision, there was a monthly reduction in cost per hospitalization (-$52.28; 95% confidence interval -$116.90 to -$12.32; P = .026) at teaching relative to nonteaching hospitals.

CONCLUSIONS

There were no differences in mortality or LOS between teaching and nonteaching hospitals. However, there was a small decrease in cost per hospitalization at teaching hospitals following the 2011 revision.

A study of resident duty hours and burnout in a sample of Saudi residents

BACKGROUND

Work hour restrictions in residency programs have been implemented over the last several decades in Europe, USA, and Canada. To best of our knowledge, there is no study of resident duty hours in the Kingdom of Saudi Arabia. In addition, few studies have looked at the prevalence of burnout amongst Saudi residents. The present study explored resident duty hours and burnout amongst residents in Saudi Arabia.

METHODS

A paper-based questionnaire was designed to survey resident duty hours in Saudi Arabia and was administered along with the Maslach Burnout Inventory. The questionnaires were administered to residents in medical and surgical residency programs at King Abdulaziz Medical City-Riyadh and two hospitals in Buraidah, Qassim Province.

RESULTS

A total of 181 residents from the three hospitals participated in the survey. In terms of average number of work hours per week, 50% of all residents reported working 60-79 h while 30% reported working 80 or more hours per week. The prevalence of burnout was 81%. There was no association between higher number of working hours and the prevalence of burnout.

CONCLUSION

This was the first study describing resident duty hours and exploring the relationship between duty hours and burnout in Saudi Arabia. Our main findings were that the majority of residents work 60 or more hours per week, and there was a very high degree of burnout amongst residents. A larger multi-centre study of resident duty hours and its effect on patient safety and resident well-being is needed to develop work hour regulations in Saudi Arabia. In addition, there is an urgent need to develop programs that address resident burnout.

Education Outcomes in a Duty-Hour Flexibility Trial in Internal Medicine

BACKGROUND

Concern persists that inflexible duty-hour rules in medical residency programs may adversely affect the training of physicians.

METHODS

We randomly assigned 63 internal medicine residency programs in the United States to be governed by standard duty-hour policies of the 2011 Accreditation Council for Graduate Medical Education (ACGME) or by more flexible policies that did not specify limits on shift length or mandatory time off between shifts. Measures of educational experience included observations of the activities of interns (first-year residents), surveys of trainees (both interns and residents) and faculty, and intern examination scores.

RESULTS

There were no significant between-group differences in the mean percentages of time that interns spent in direct patient care and education nor in trainees' perceptions of an appropriate balance between clinical demands and education (primary outcome for trainee satisfaction with education; response rate, 91%) or in the assessments by program directors and faculty of whether trainees' workload exceeded their capacity (primary outcome for faculty satisfaction with education; response rate, 90%). Another survey of interns (response rate, 49%) revealed that those in flexible programs were more likely to report dissatisfaction with multiple aspects of training, including educational quality (odds ratio, 1.67; 95% confidence interval [CI], 1.02 to 2.73) and overall well-being (odds ratio, 2.47; 95% CI, 1.67 to 3.65). In contrast, directors of flexible programs were less likely to report dissatisfaction with multiple educational processes, including time for bedside teaching (response rate, 98%; odds ratio, 0.13; 95% CI, 0.03 to 0.49). Average scores (percent correct answers) on in-training examinations were 68.9% in flexible programs and 69.4% in standard programs; the difference did not meet the noninferiority margin of 2 percentage points (difference, -0.43; 95% CI, -2.38 to 1.52; P=0.06 for noninferiority). od Institute and the ACGME; iCOMPARE ClinicalTrials.gov number, NCT02274818 .).

CONCLUSIONS

There was no significant difference in the proportion of time that medical interns spent on direct patient care and education between programs with standard duty-hour policies and programs with more flexible policies. Interns in flexible programs were less satisfied with their educational experience than were their peers in standard programs, but program directors were more satisfied. (Funded by the National Heart, Lung, and Blo

Understanding the Multidimensional Effects of Resident Duty Hours Restrictions: A Thematic Analysis of Published Viewpoints in Surgery

PURPOSE

Individuals representing various surgical disciplines have expressed concerns with the impact of resident duty hours (RDH) restrictions on resident education and patient outcomes. This thematic review of published viewpoints aimed to describe the effects of these restrictions in surgery.

METHOD

The authors conducted a qualitative systematic review of non-research-based literature published between 2003 and 2015. Articles were included if they focused on the RDH restrictions in surgery and resident wellness, health promotion, resident safety, resident education and/or training, patient safety, medical errors, and/or heterogeneity regarding training or disciplines. A thematic analysis approach guided data extraction. Contextual data were abstracted from the included articles to aid in framing the identified themes.

RESULTS

Of 1,482 identified articles, 214 were included in the review. Most were from authors in the United States (144; 67%) and focused on the 80-hour workweek (164; 77%). The emerging themes were organized into three overarching categories: (1) impact of the RDH restrictions, (2) surgery has its own unique culture, and (3) strategies going forward. Published opinions suggested that RDH restrictions alone are insufficient to achieve the desired outcomes and that careful consideration of the surgical training model is needed to maintain the integrity of educational outcomes.

CONCLUSIONS

Opinions from the surgical community highlight the complexity of issues surrounding the RDH restrictions and suggest that recent changes are not achieving all the desired outcomes and have resulted in unintended outcomes. From the perceptions of the various stakeholders in surgical education studied, areas for new policies were identified.

Do final-year medical students have sufficient prescribing competencies? A systematic literature review

Aims

Prescribing errors are an important cause of patient safety incidents and are frequently caused by junior doctors. This might be because the prescribing competence of final‐year medical students is poor as a result of inadequate clinical pharmacology and therapeutic (CPT) education. We reviewed the literature to investigate which prescribing competencies medical students should have acquired in order to prescribe safely and effectively, and whether these have been attained by the time they graduate.

Methods

PubMed, EMBASE and ERIC databases were searched from the earliest dates up to and including January 2017, using the terms ‘prescribing’, ‘competence’ and ‘medical students’ in combination. Articles describing or evaluating essential prescribing competencies of final‐year medical students were included.

Results

Twenty‐five articles describing, and 47 articles evaluating, the prescribing competencies of final‐year students were included. Although there seems to be some agreement, we found no clear consensus among CPT teachers on which prescribing competencies medical students should have when they graduate. Studies showed that students had a general lack of preparedness, self‐confidence, knowledge and skills, specifically regarding general and antimicrobial prescribing and pharmacovigilance. However, the results should be interpreted with caution, given the heterogeneity and methodological weaknesses of the included studies.

Conclusions

There is considerable evidence that final‐year students have insufficient competencies to prescribe safely and effectively, although there is a need for a greater consensus among CPT teachers on the required competencies. Changes in undergraduate CPT education are urgently required in order to improve the prescribing of future doctors.

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.

Association Between Learning Environment Interventions and Medical Student Well-being: A Systematic Review

IMPORTANCE

Concerns exist about the current quality of undergraduate medical education and its effect on students' well-being.

OBJECTIVE

To identify best practices for undergraduate medical education learning environment interventions that are associated with improved emotional well-being of students.

DATA SOURCES

Learning environment interventions were identified by searching the biomedical electronic databases Ovid MEDLINE, EMBASE, the Cochrane Library, and ERIC from database inception dates to October 2016. Studies examined any intervention designed to promote medical students' emotional well-being in the setting of a US academic medical school, with an outcome defined as students' reports of well-being as assessed by surveys, semistructured interviews, or other quantitative methods.

DATA EXTRACTION AND SYNTHESIS

Two investigators independently reviewed abstracts and full-text articles. Data were extracted into tables to summarize results. Study quality was assessed by the Medical Education Research Study Quality Instrument (MERQSI), which has a possible range of 5 to 18; higher scores indicate higher design and methods quality and a score of 14 or higher indicates a high-quality study.

FINDINGS

Twenty-eight articles including at least 8224 participants met eligibility criteria. Study designs included single-group cross-sectional or posttest only (n = 10), single-group pretest/posttest (n = 2), nonrandomized 2-group (n = 13), and randomized clinical trial (n = 3); 89.2% were conducted at a single site, and the mean MERSQI score for all studies was 10.3 (SD, 2.11; range, 5-13). Studies encompassed a variety of interventions, including those focused on pass/fail grading systems (n = 3; mean MERSQI score, 12.0), mental health programs (n = 4; mean MERSQI score, 11.9), mind-body skills programs (n = 7; mean MERSQI score, 11.3), curriculum structure (n = 3; mean MERSQI score, 9.5), multicomponent program reform (n = 5; mean MERSQI score, 9.4), wellness programs (n = 4; mean MERSQI score, 9.0), and advising/mentoring programs (n = 3; mean MERSQI score, 8.2).

CONCLUSIONS AND RELEVANCE

In this systematic review, limited evidence suggested that some specific learning environment interventions were associated with improved emotional well-being among medical students. However, the overall quality of the evidence was low, highlighting the need for high-quality medical education research.

Systematic review to establish absolute standards for technical performance in surgery

BACKGROUND

Standard setting allows educators to create benchmarks that distinguish between those who pass and those who fail an assessment. It can also be used to create standards in clinical and simulated procedural skill. The objective of this review was to perform a systematic review of the literature using absolute standard-setting methodology to create benchmarks in technical performance.

METHODS

A systematic review was conducted by searching MEDLINE, Embase, PsycINFO and the Cochrane Database of Systematic Reviews. Abstracts of retrieved studies were reviewed and those meeting the inclusion criteria were selected for full-text review. The quality of evidence presented in the included studies was assessed using the Medical Education Research Study Quality Instrument (MERSQI), where a score of 14 or more of 18 indicates high-quality evidence.

RESULTS

Of 1809 studies identified, 37 used standard-setting methodology for assessment of procedural skill. Of these, 24 used participant-centred and 13 employed item-centred methods. Thirty studies took place in a simulated environment, and seven in a clinical setting. The included studies assessed residents (26 of 37), fellows (6 of 37) and staff physicians (17 of 37). Seventeen articles achieved a MERSQI score of 14 or more of 18, whereas 20 did not meet this mark.

CONCLUSION

Absolute standard-setting methodologies can be used to establish cut-offs for procedural skill assessments.