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Yu AT, Jepsen N, Prasad S, Klein JP, Doughty C. Adding Nocturnal Advanced Practice Providers to an Academic Inpatient Neurology Service Improves Residents' Educational Experience. Neurohospitalist 2023; 13:130-136. [PMID: 37064933 PMCID: PMC10091433 DOI: 10.1177/19418744221143207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/18/2023] Open
Abstract
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.
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Affiliation(s)
- Andrew T. Yu
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Nicole Jepsen
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Sashank Prasad
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Joshua P. Klein
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
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Pierre-Louis RE, Pannikodu K, Madhoun M, Hartnett J, Rose S. Implementing a Neurohospitalist Program Improves Stroke Care Metrics and Patient Satisfaction Scores. Neurohospitalist 2022; 12:241-248. [PMID: 35419152 PMCID: PMC8995615 DOI: 10.1177/19418744211069272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective Compare the differences in health outcomes and patient satisfaction between a neurohospitalist model of care and a community-based neurologists model at a single community-based teaching hospital among in-patients diagnosed with a cerebrovascular accident (CVA). Methods Data was collected from the Stamford Hospital’s electronic medical records system. An assessment of patient health outcomes and satisfaction scores was conducted, comparing both discrete and continuous variables between the two time periods. An omnibus P-value of 0.05 ( P < 0.05) was considered statistically significant. Results The sample consisted of 341 patients between the two periods, pre-period n = 168 (49.3%) post-period n = 173 (50.7%). Door to lab and door to tPA times decreased significantly between pre- and post-periods ( P = 0.003 and P = 0.002, respectively) as did the number of MRIs ( P < 0.001). In addition, statistically significant increases were found between pre-period and post-period percentages, all increasing over time: stroke education ( P < 0.001), discharged on anticoagulant medication ( P < 0.001), and discharged on anti-thrombolytic medication ( P = 0.019). Patient satisfaction scores demonstrated mean gain across both periods for five of six items. Two items “Doctor’s Concern of my Questions/Worries” and “Skill of Doctors” demonstrated statistical significance ( P = 0.020 and P = 0.029, respectively). Conclusions The introduction of a neurohospitalist service at a community-based teaching hospital improved patient health outcomes on time to intervention, stroke education, discharge medications as well as patient satisfaction. Therefore, it may be beneficial for hospitals to implement a neurohospitalist model of care for their patients presenting with CVA.
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Affiliation(s)
| | - Kelly Pannikodu
- Office of Research, Stamford Hospital, Stamford, Connecticut, USA
| | - Maher Madhoun
- Department of Medicine, Stamford Hospital, Stamford, CT, USA
| | - Josette Hartnett
- Office of Research, Stamford Hospital, Stamford, Connecticut, USA
| | - Suzanne Rose
- Office of Research, Stamford Hospital, Stamford, Connecticut, USA
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Sawatsky AP, O'Brien BC, Hafferty FW. Autonomy and developing physicians: Reimagining supervision using self-determination theory. MEDICAL EDUCATION 2022; 56:56-63. [PMID: 34091940 DOI: 10.1111/medu.14580] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/26/2021] [Accepted: 06/01/2021] [Indexed: 06/12/2023]
Abstract
In this article, we address the question, 'What is the role of autonomy in physician development?' Medical education is a developmental process, and autonomy plays a motivational role in physician development. Calls for increased supervision of residents have raised concerns that the resulting decreased autonomy might interfere with resident development, leading the authors to explore the relationship between supervision and autonomy. The medical education literature posits a simple inverse relationship between supervision and autonomy. Within competency frameworks, autonomy is operationalised as independence and viewed as the end goal of training. Alternatively, there is emerging empirical literature describing autonomy and supervision as dynamic and developmental constructs and point towards more complex relationship between supervision and autonomy. Self-determination theory (SDT) presents a framework for understanding this dynamic relationship and the role of autonomy in physician development. Within SDT, autonomy is a fundamental psychological need, associated with motivation for learning, self-regulation and an internal locus of control. Supporting learner autonomy can afford learners the opportunity to internalise the values and norms of the profession, leading to an integrated regulation of their behaviours and actions. Conceptualising autonomy through the lens of SDT provides an avenue for education interventions and future research on supervision and autonomy. Educators can integrate supervision and autonomy support in the clinical setting, seeking to motivate learner development by balancing optimal challenge and support and integrating autonomy support with 'hands-on' approaches to supervision. SDT also provides a theoretical framework relevant to current discussions regarding feedback conversations and coaching in medical education. Lastly, conceptualising autonomy using SDT opens new avenues for investigation, exploring the complex relationship between supervision and autonomy and developing efforts to integrate autonomy support with clinical supervision.
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Affiliation(s)
- Adam P Sawatsky
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Bridget C O'Brien
- Department of Medicine and Center for Faculty Educators, University of California, San Francisco, CA, USA
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Dunbar-Yaffe R, Wu RC, Oza A, Lee-Kim V, Cram P. Impact of an internal medicine nocturnist service on care of patients with cancer at a large Canadian teaching hospital: a quality-improvement study. CMAJ Open 2021; 9:E667-E672. [PMID: 34145049 PMCID: PMC8248558 DOI: 10.9778/cmajo.20200167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Nocturnists (overnight hospitalists) are commonly implemented in US teaching hospitals to adhere to per-resident patient caps and improve care but are rare in Canada, where patient caps and duty hours are comparatively flexible. Our objective was to assess the impact of a newly implemented nocturnist program on perceived quality of care, code status documentation and patient outcomes. METHODS Nocturnists were phased in between June 2018 and December 2019 at Toronto General Hospital, a large academic teaching hospital in Toronto, Ontario. We performed a quality-improvement study comparing rates of code status entry into the electronic health record at admission, in-hospital mortality, the 30-day readmission rate and hospital length of stay for patients with cancer admitted by nocturnists and by residents. Surveys were administered in June 2019 to general internal medicine faculty and residents to assess their perceptions of the impact of the nocturnist program. RESULTS From July 2018 to June 2019, 30 nocturnists were on duty for 241/364 nights (66.5%), reducing the mean maximum overnight per-resident patient census from 40 (standard deviation [SD] 4) to 25 (SD 5) (p < 0.001). The rate of admission code status entry was 35.3% among patients admitted by residents (n = 133) and 54.9% among those admitted by nocturnists (n = 339) (p < 0.001). The mortality rate was 10.5% among patients admitted by residents and 5.6% among those admitted by nocturnists (p = 0.06), the 30-day readmission rate was 8.3% and 5.9%, respectively (p = 0.4), and the mean acute length of stay was 7.2 (SD 7.0) days and 6.4 (SD 7.8) days, respectively (p = 0.3). Surveys were completed by 15/24 faculty (response rate 62%), who perceived improvements in patient safety, efficiency and trainee education; however, only 30/102 residents (response rate 29.4%) completed the survey. INTERPRETATION Although implementation of a nocturnist program did not affect patient outcomes, it reduced residents' overnight patient census, and improved faculty perceptions of quality of care and education, as well as documentation of code status. Our results support nocturnist implementation in Canadian teaching hospitals.
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Affiliation(s)
- Richard Dunbar-Yaffe
- Division of General Internal Medicine and Geriatrics (Dunbar-Yaffe, Wu, Cram), Sinai Health System and University Health Network; Division of General Internal Medicine (Dunbar-Yaffe, Wu, Cram), Department of Medicine, University of Toronto; Division of Medical Oncology and Hematology (Oza), University Health Network, Toronto, Ont.; School of Medicine (Lee-Kim), Queen's University, Kingston, Ont.
| | - Robert C Wu
- Division of General Internal Medicine and Geriatrics (Dunbar-Yaffe, Wu, Cram), Sinai Health System and University Health Network; Division of General Internal Medicine (Dunbar-Yaffe, Wu, Cram), Department of Medicine, University of Toronto; Division of Medical Oncology and Hematology (Oza), University Health Network, Toronto, Ont.; School of Medicine (Lee-Kim), Queen's University, Kingston, Ont
| | - Amit Oza
- Division of General Internal Medicine and Geriatrics (Dunbar-Yaffe, Wu, Cram), Sinai Health System and University Health Network; Division of General Internal Medicine (Dunbar-Yaffe, Wu, Cram), Department of Medicine, University of Toronto; Division of Medical Oncology and Hematology (Oza), University Health Network, Toronto, Ont.; School of Medicine (Lee-Kim), Queen's University, Kingston, Ont
| | - Victoria Lee-Kim
- Division of General Internal Medicine and Geriatrics (Dunbar-Yaffe, Wu, Cram), Sinai Health System and University Health Network; Division of General Internal Medicine (Dunbar-Yaffe, Wu, Cram), Department of Medicine, University of Toronto; Division of Medical Oncology and Hematology (Oza), University Health Network, Toronto, Ont.; School of Medicine (Lee-Kim), Queen's University, Kingston, Ont
| | - Peter Cram
- Division of General Internal Medicine and Geriatrics (Dunbar-Yaffe, Wu, Cram), Sinai Health System and University Health Network; Division of General Internal Medicine (Dunbar-Yaffe, Wu, Cram), Department of Medicine, University of Toronto; Division of Medical Oncology and Hematology (Oza), University Health Network, Toronto, Ont.; School of Medicine (Lee-Kim), Queen's University, Kingston, Ont
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Allen M, Gawad N, Park L, Raîche I. The Educational Role of Autonomy in Medical Training: A Scoping Review. J Surg Res 2019; 240:1-16. [DOI: 10.1016/j.jss.2019.02.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 01/30/2019] [Accepted: 02/22/2019] [Indexed: 12/18/2022]
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Greene JG. Collaborative Comanagement Between Neurohospitalists and Internal Medicine Hospitalists Decreases Provider Costs and Enhances Satisfaction With Neurology Care at an Academic Medical Center. Neurohospitalist 2018; 8:74-81. [PMID: 29623157 DOI: 10.1177/1941874417735173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background and Purpose The majority of academic medical centers are moving to a neurohospitalist model of care for hospital neurology coverage. Potential benefits over a more traditional academic model of patient care include greater expertise in acute neurologic disease, increased efficiency, and improved availability to patients, providers, and learners. Despite these perceived advantages, switching to a neurohospitalist model can come at substantial financial cost, so finding ways to maximize the positive impact of a limited number of neurohospitalists is very important to the future health of academic neurology departments. Over the past 7 years, we have implemented a model for inpatient neurological care based on an intimate collaborative relationship between the neurology and hospital medicine services at our main academic hospital. Our goal was to optimize the value of care by decreasing cost while improving quality. Methods Cost and revenue associated with professional services was evaluated on a yearly basis. As part of ongoing quality improvement efforts, yearly surveys were administered to referring providers during the transition to a collaborative care model in which NHs and medicine hospitalists comanage neurology inpatients. Results Net operating loss was dramatically decreased upon transition to the new care model. Concomitantly, there was a robust positive impact on perception of overall quality, timeliness, and communication skills of neurology services. Conclusions Collaborative comanagement is an effective strategy to improve overall satisfaction with neurology services at a tertiary academic medical center while maintaining financial viability.
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Affiliation(s)
- James G Greene
- Department of Neurology, Emory University, Atlanta, GA, USA
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Singman EL, Srikumaran D, Green L, Tian J, McDonnell P. Supervision and autonomy of ophthalmology residents in the outpatient Clinic in the United States: a survey of ACGME-accredited programs. BMC MEDICAL EDUCATION 2017; 17:105. [PMID: 28651531 PMCID: PMC5485577 DOI: 10.1186/s12909-017-0941-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 06/13/2017] [Indexed: 06/09/2023]
Abstract
BACKGROUND The development and demonstration of incremental trainee autonomy is required by the ACGME. However, there is scant published research concerning autonomy of ophthalmology residents in the outpatient clinic setting. This study explored the landscape of resident ophthalmology outpatient clinics in the United States. METHODS A link to an online survey using the QualtricsTM platform was emailed to the program directors of all 115 ACGME-accredited ophthalmology programs in the United States. Survey questions explored whether resident training programs hosted a continuity clinic where residents would see their own patients, and if so, the degree of faculty supervision provided therein. Metrics such as size of the resident program, number of faculty and clinic setting were also recorded. Correlations between the degree of faculty supervision and other metrics were explored. RESULTS The response rate was 94%; 69% of respondents indicated that their trainees hosted continuity clinics. Of those programs, 30% required a faculty member to see each patient treated by a resident, while 42% expected the faculty member to at least discuss (if not see) each patient. All programs expected some degree of faculty interaction based upon circumstances such as the level of training of the resident or complexity of the clinical situation. 67% of programs that tracked the contribution of the clinic to resident surgical caseloads reported that these clinics provided more than half of the resident surgical volumes. More ¾ of resident clinics were located in urban settings. The degree of faculty supervision did not correlate to any of the other metrics evaluated. CONCLUSIONS The majority of ophthalmology resident training programs in the United States host a continuity clinic located in an urban environment where residents follow their own patients. Furthermore, most of these clinics require supervising faculty to review both the patients seen and the medical documentation created by the resident encounters. The different degrees of faculty supervision outlined by this survey might provide a useful guide presuming they can be correlated with validated metrics of educational quality. Finally, this study could provide an adjunctive resource to current international efforts to standardize ophthalmic residency education.
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Affiliation(s)
- Eric L. Singman
- Wilmer Eye Institute General Eye Services Clinic, @ Johns Hopkins Hospital, Wilmer B-29, 600 N. Wolfe St, Baltimore, MD 21287 USA
| | - Divya Srikumaran
- Wilmer Eye Institute General Eye Services Clinic, @ Johns Hopkins Hospital, Wilmer B-29, 600 N. Wolfe St, Baltimore, MD 21287 USA
| | - Laura Green
- Ophthalmology Residency Program Director, Lifebridge Health Krieger Eye Institute, 2411 W. Belvedere Ave, Baltimore, MD 21215 USA
| | - Jing Tian
- Biostatistics Consulting Center, Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe St, Room 3148, Baltimore, MD 21287 USA
| | - Peter McDonnell
- Wilmer Eye Institute, @ Johns Hopkins Hospital, Maumenee 727, 600 N. Wolfe St, Baltimore, MD 21287 USA
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Weltz AS, Cimeno A, Kavic SM. Strategies for improving education on night-float rotations: a review. JOURNAL OF SURGICAL EDUCATION 2015; 72:297-301. [PMID: 25439176 DOI: 10.1016/j.jsurg.2014.09.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Revised: 08/25/2014] [Accepted: 09/04/2014] [Indexed: 06/04/2023]
Abstract
INTRODUCTION Night float rotations (NF) have been developed as a means of achieving duty hour compliance among residency programs. These were initially pioneered in the late 1980s as a response to fatigue among residents. The NF experience had its genesis in work hour reform and providing hospital service moreso than education. However, as NF has become ubiquitous, it is not clear that we have adequately revisited the educational component of this experience. We systematically reviewed the literature on educational aspects of a night float experience. METHODS PubMed searches were conducted for the terms "night float" and "night, curriculum, residency." This yielded 320 articles. Concerning educational aspects of the NF reduced the total to 134 articles. Editorials and those concerning procedural volumes or handoffs were also excluded. Most articles used surveys as methodology, so formal statistical analysis was not possible. RESULTS In total, 42 independent articles were found that directly related to the educational value of NF rotations, spanning all of the medical disciplines. Each study was searched for interventions or strategies that may affect the educational value of the NF experience. These may be grouped broadly into 3 discrete categories: (1) attention to the sleep-wake cycle, (2) addition of personal to augment the experience and (3) incorporation of formal educational elements to night rotations. A summary of these strategies is presented in Table 3. CONCLUSIONS NF is a practical solution to the challenge of work hour restrictions in residency, and is likely to persist in the future. Some educational issues arise due to the altered physiology of a reversed sleep-wake cycle, which may be best resolved through structural limitations of the night rotations. Other deficiencies are based on lack of interactions, for which there are strategies to improving the NF educational experience.
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Affiliation(s)
- Adam S Weltz
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Arielle Cimeno
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Stephen M Kavic
- University of Maryland School of Medicine, Baltimore, Maryland.
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Velez-Ruiz N, Khan J, Greene JG. Defining the role of the academic neurohospitalist in residency education. Neurohospitalist 2014; 4:127-32. [PMID: 24982716 DOI: 10.1177/1941874414530722] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE We sought to better understand the potential impact of the burgeoning neurohospitalist model of inpatient care on education of neurology residents and to better define possible roles for "neurohospitalists" in residency education. METHOD We designed a brief qualitative open-ended survey directed toward academic leaders in neurology and distributed it by e-mail to every academic neurology department in the United States and Canada. RESULTS Of 83 respondents, 36 (43%) had an active neurohospitalist program and only 10% felt certain they would not have 1 within the next 5 years. All respondents expected to have residents continue to be involved with inpatient care. The main perceived advantage for resident education associated with neurohospitalists was inpatient care expertise, and the main expected disadvantage was decreased exposure to subspecialty attendings. The majority anticipated positive impact on all Accreditation Council for Graduate Medical Education core competencies predominantly based on neurohospitalists' expertise in the inpatient setting. CONCLUSION The majority of academic neurology departments are expected to have a neurohospitalist program within the next 5 years. There are several perceived advantages and disadvantages to such a program for education of neurology residents. In general, the impact of these programs is expected to improve resident education. Regardless of expectations, neurohospitalists will likely play a prominent role in the education of the next generation of neurologists.
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Affiliation(s)
- Naymee Velez-Ruiz
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Jaffar Khan
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - James G Greene
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
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