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Al-Humadi SM, Cáceda R, Bronson B, Paulus M, Hong H, Muhlrad S. Orthopaedic Surgeon Mental Health During the COVID-19 Pandemic. Geriatr Orthop Surg Rehabil 2021; 12:21514593211035230. [PMID: 34395046 PMCID: PMC8361516 DOI: 10.1177/21514593211035230] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 06/18/2021] [Accepted: 07/07/2021] [Indexed: 11/15/2022] Open
Abstract
Introduction: This study compares rates of depression, suicidal
ideation, and burnout among resident/fellow and attending physicians in
orthopaedic surgery to other specialties during height/end of the first wave of
the coronavirus disease 2019 (COVID-19) pandemic at our institution. Main
outcomes and measures included suicidal ideation, Patient Health Questionnaire
for Depression (PHQ-9) scores for depression, and 2 single-item measures for
emotional exhaustion and depersonalization. This study provides valuable
information regarding orthopaedic surgeon mental health during world crises.
Methods: This is a cross-sectional survey-based study of
resident, fellow, and attending physicians from 26 specialties during and after
the first wave of the COVID-19 pandemic at our institution from April 24, 2020
to May 15, 2020. The survey contained 22 items. This includes consent,
demographics and general data, 2 single-item questions of emotional exhaustion
and depersonalization, and the PHQ-9. Subjects were eligible if they were a
resident/fellow or attending physician at our institution. Results:
The response rate for the study was 16.31%. Across all specialties rates were
6.2% depression, 19.6% burnout, and 6.6% suicidal ideation. The results for
orthopaedic surgeons are as follows: 0% tentative diagnosis of depression, 3.8%
suicidal ideation, and 4% burnout. Anesthesiology had the highest rate of
depression (14.3%). Internal medicine and other non-surgical specialties had the
highest rate of suicidal ideation (10.2%). Orthopaedic surgeons were
significantly more likely to achieve work–life balance and experience less
burnout than anesthesiologists and pediatricians. Discussion:
Depression, suicidal ideation, and burnout continue to affect physicians across
all specialties. These issues are amplified in light of crisis. Job satisfaction
and rigorous training may be protective factors that allow orthopaedic surgeons
to adapt to novel clinical settings under stress when compared to
anesthesiologists and pediatricians. Resilience training and stress management
strategies should continue to be investigated to better prepare physicians for
world crises.
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Affiliation(s)
- Samer M Al-Humadi
- Department of Orthopaedic Surgery, SUNY Stony Brook University Hospital, Stony Brook, NY, USA
| | - Ricardo Cáceda
- Department of Psychiatry, SUNY Stony Brook University Hospital, Stony Brook, NY, USA
| | - Brian Bronson
- Department of Psychiatry, SUNY Stony Brook University Hospital, Stony Brook, NY, USA
| | - Megan Paulus
- Department of Orthopaedic Surgery, SUNY Stony Brook University Hospital, Stony Brook, NY, USA
| | - Houlin Hong
- Public Health Program, SUNY Stony Brook University, Stony Brook, NY, USA
| | - Samantha Muhlrad
- Department of Orthopaedic Surgery, SUNY Stony Brook University Hospital, Stony Brook, NY, USA
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Affiliation(s)
- Paria M Wilson
- Division of Emergency Medicine, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Maneesh Batra
- Department of Pediatrics, Division of Neonatology, Seattle Children's Hospital and the University of Washington, Seattle, WA
| | | | - John D Mahan
- The Ohio State University, Columbus, OH.,Department of Pediatrics, Division of Nephrology, Nationwide Children's Hospital and The Ohio State University, Columbus, OH
| | - Betty B Staples
- Department of Pediatrics, Duke University Medical Center, Durham, NC
| | - Janet R Serwint
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
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Nomura O, Mishina H, Kobayashi Y, Ishiguro A, Sakai H, Kato H. Limitation of duty hour regulations for pediatric resident wellness: A mixed methods study in Japan. Medicine (Baltimore) 2016; 95:e4867. [PMID: 27631253 PMCID: PMC5402596 DOI: 10.1097/md.0000000000004867] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Duty hour regulations have been placed in residency programs to address mental health concerns and to improve wellness. Here, we elucidate the prevalence of depressive symptoms after implementing an overnight call shift system and the factors associated with burnout or depression among residents.A sequential exploratory mixed methods study was conducted in a tertiary care pediatric and perinatal hospital in Tokyo, Japan. A total of 41 pediatric residents participated in the cross-sectional survey. We determined and compared the prevalence of depressive symptoms and the number of actual working hours before and after implementing the shift system. A follow-up focus-group interview with 4 residents was conducted to explore the factors that may trigger or prevent depression and burnout.Mean working hours significantly decreased from 75.2 hours to 64.9 hours per week. Prevalence of depressive symptoms remained similar before and after implementation of the shift system. Emotional exhaustion and depersonalization from the burnout scale were markedly associated with depression. High workload, stress intolerance, interpersonal difficulties, and generation gaps regarding work-life balance could cause burnout. Stress tolerance, workload monitoring and balancing, appropriate supervision, and peer support could prevent burnout.Although the overnight call shift system was effective in reducing working hours, its effectiveness in managing mental health issues among pediatric residents remains unclear. Resident wellness programs represent an additional strategy and they should be aimed at fostering peer support and improvement of resident-faculty interactions. Such an approach could be beneficial to the relationship between physicians of different generations with conflicting belief structures.
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Affiliation(s)
- Osamu Nomura
- Department of General Pediatrics and Interdisciplinary Medicine, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo
- Department of Integrated Medical Education, Graduate School of Medicine, Hirosaki University, 1 Zaifu-cho, Hirosaki City, Aomori, Japan
- Correspondence: Osamu Nomura, Department of Integrated Medical Education, Graduate School of Medicine, Hirosaki University, 1 Zaifu-cho, Hirosaki City, Aomori, Japan (e-mail: )
| | - Hiroki Mishina
- Department of General Pediatrics and Interdisciplinary Medicine, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo
| | - Yoshinori Kobayashi
- Department of General Pediatrics and Interdisciplinary Medicine, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo
| | - Akira Ishiguro
- Department of General Pediatrics and Interdisciplinary Medicine, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo
| | - Hirokazu Sakai
- Department of General Pediatrics and Interdisciplinary Medicine, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo
| | - Hiroyuki Kato
- Department of Integrated Medical Education, Graduate School of Medicine, Hirosaki University, 1 Zaifu-cho, Hirosaki City, Aomori, Japan
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Was A, Blankenburg R, Park KT. Pediatric Resident Workload Intensity and Variability. Pediatrics 2016; 138:peds.2015-4371. [PMID: 27358473 DOI: 10.1542/peds.2015-4371] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/20/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Research on resident workloads has focused primarily on the quantity of hours worked, rather than the content of those hours or the variability among residents. We hypothesize that there are statistically significant variations in resident workloads and better understanding of workload intensity could improve resident education. METHODS The Stanford Children's Health research database was queried for all electronic notes and orders written by pediatric residents from June 2012 to March 2014. The dataset was narrowed to ensure an accurate comparison among residents. A survey was used to determine residents' self-perceived workload intensity. Variability of total notes written and orders entered was analyzed by χ(2) test and a Monte Carlo simulation. Linear regression was used to analyze the correlation between note-writing and order-entry workload intensity. RESULTS A total of 20 280 notes and 112 214 orders were written by 26 pediatric interns during 6 core rotations between June 2012 and June 2013. Both order-entry and note-writing workload intensity showed highly significant (P < .001) variability among residents. "High workload" residents, defined as the top quartile of total workload intensity, wrote 91% more orders and 19% more notes than "low workload" residents in the bottom quartile. Statistically significant correlation was observed between note-writing and order-entry workload intensity (R(2) = 0.22; P = .02). There was no significant correlation between residents' self-perceived workload intensity and their objective workload. CONCLUSIONS Significant variations in workload exist among pediatric residents. This may contribute to heterogeneous educational opportunities, physician wellness, and quality of patient care.
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Affiliation(s)
| | | | - K T Park
- Department of Pediatrics, and Gastroenterology, Stanford University School of Medicine, Palo Alto, California
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Fletcher KE, Singh S, Whittle J, Ratkalkar V, Visotcky AM, Laud P, Kordus A, Schapira MM. Multisite Study to Examine the Amount of Inpatient Physician Continuity Experienced by Hospitalized Patients. J Grad Med Educ 2015; 7:624-9. [PMID: 26692976 PMCID: PMC4675421 DOI: 10.4300/jgme-d-14-00648.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Continuity for inpatient medicine has been widely discussed, but methods for measuring it have been lacking. OBJECTIVE To measure the continuity of care experienced by hospitalized patients and to identify predictors of continuity. METHODS This was a multisite prospective cohort study and retrospective chart review that took place at 3 hospitals: an academic tertiary care center, a Veterans Affairs medical center, and a community teaching hospital. Subjects were general medicine patients and internal medicine residents. We measured continuity of care using 3 metrics: (1) the percentage of hospital time covered by the primary intern; (2) the amount of time between admission and the first handoff of care; and (3) admission-discharge continuity. We conducted univariate analyses to identify patient and hospital factors that may be associated with each type of continuity of care. RESULTS Our sample included 869 patients with a mean age of 62.6 years (SD = 17.2) and 34% female patients. The mean percentage of hospital time covered by the primary intern was 39.2% (SD = 16.3%). The mean time between admission and the first handoff of care was 13.3 hours (SD = 7.1). Forty percent of patients experienced admission-discharge continuity. In univariate and multivariable modeling, the site was significantly associated with each type of continuity. CONCLUSIONS The amount of continuity varied greatly and was influenced by the site and other factors. No site maximized every aspect of continuity. Programs and institutions should decide which aspects of continuity are most important locally and design schedules accordingly.
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Affiliation(s)
- Kathlyn E. Fletcher
- Corresponding author: Kathlyn E. Fletcher, MD, MA, Clement J. Zablocki VA Medical Center, 5000 West National Avenue, Milwaukee, WI 53295, 414.384.2000, ext. 46450, fax 414.382.5017,
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Graduating Pediatrics Residents' Reports on the Impact of Fatigue Over the Past Decade of Duty Hour Changes. Acad Pediatr 2015; 15:362-6. [PMID: 25459229 DOI: 10.1016/j.acap.2014.10.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 09/26/2014] [Accepted: 10/12/2014] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Concern about resident and patient safety has led to changes in Accreditation Council on Graduate Medical Education requirements over the past decade, with duty hour limitations in 2003 and 2011. This study examines pediatric residents' experiences on the impact of fatigue before, during, and after this time. METHODS An annual survey of graduating pediatrics residents was administered to a national, random sample in 2002, 2004, and 2013. Respondents were asked about the impact of fatigue. Multivariable logistic regression was conducted to compare differences between survey years. RESULTS The combined response rate for all 3 years was 62.6% (1,251 of 2,000). In multivariable analyses, residents were less likely in both 2004 and 2013 than in 2002 to fall asleep during an educational conference (adjusted odds ratio [aOR] 0.61, 95% confidence interval [CI] 0.41-0.91 and aOR 0.32, 95% CI 0.22-0.45, respectively) and to fall asleep while driving from work (aOR 0.55, 95% CI 0.37-0.81 and 0.43, 95% CI 0.31-0.60, respectively). Residents were less likely in 2004 than in 2002 to report making an error in patient care due to fatigue (aOR 0.46, 95% CI 0.27-0.76); however, in 2013 resident report of making an error in patient care due to fatigue returned to levels similar those reported in 2002. CONCLUSIONS Surveys of graduating pediatrics residents over the past decade (2002-2013) indicate overall reduced fatigue effects. During this same time frame, however, reports about making patient care errors improved but then returned to a level not significantly different from 2002, a finding warranting further exploration.
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Law MP, Orlando E, Baker GR. Organizational interventions in response to duty hour reforms. BMC MEDICAL EDUCATION 2014; 14 Suppl 1:S4. [PMID: 25558915 PMCID: PMC4304281 DOI: 10.1186/1472-6920-14-s1-s4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
BACKGROUND Changes in resident duty hours in Europe and North America have had a major impact on the internal organizational dynamics of health care organizations. This paper examines, and assesses the impact of, organizational interventions that were a direct response to these duty hour reforms. METHODS The academic literature was searched through the SCOPUS database using the search terms "resident duty hours" and "European Working Time Directive," together with terms related to organizational factors. The search was limited to English-language literature published between January 2003 and January 2012. Studies were included if they reported an organizational intervention and measured an organizational outcome. RESULTS Twenty-five articles were included from the United States (n=18), the United Kingdom (n=5), Hong Kong (n=1), and Australia (n=1). They all described single-site projects; the majority used post-intervention surveys (n=15) and audit techniques (n=4). The studies assessed organizational measures, including relationships among staff, work satisfaction, continuity of care, workflow, compliance, workload, and cost. Interventions included using new technologies to improve handovers and communications, changing staff mixes, and introducing new shift structures, all of which had varying effects on the organizational measures listed previously. CONCLUSIONS Little research has assessed the organizational impact of duty hour reforms; however, the literature reviewed demonstrates that many organizations are using new technologies, new personnel, and revised and innovative shift structures to compensate for reduced resident coverage and to decrease the risk of limited continuity of care. Future research in this area should focus on both micro (e.g., use of technology, shift changes, staff mix) and macro (e.g., culture, leadership support) organizational aspects to aid in our understanding of how best to respond to these duty hour reforms.
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Affiliation(s)
- Madelyn P Law
- Department of Health Sciences, Brock University, St. Catharines, Ontario, Canada
| | - Elaina Orlando
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - G Ross Baker
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Morrow G, Burford B, Carter M, Illing J. Have restricted working hours reduced junior doctors' experience of fatigue? A focus group and telephone interview study. BMJ Open 2014; 4:e004222. [PMID: 24604482 PMCID: PMC3948452 DOI: 10.1136/bmjopen-2013-004222] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To explore the effects of the UK Working Time Regulations (WTR) on trainee doctors' experience of fatigue. DESIGN Qualitative study involving focus groups and telephone interviews, conducted in Spring 2012 with doctors purposively selected from Foundation and specialty training. Final compliance with a 48 h/week limit had been required for trainee doctors since August 2009. Framework analysis of data. SETTING 9 deaneries in all four UK nations; secondary care. PARTICIPANTS 82 doctors: 53 Foundation trainees and 29 specialty trainees. 36 participants were male and 46 female. Specialty trainees were from a wide range of medical and surgical specialties, and psychiatry. RESULTS Implementation of the WTR, while acknowledged as an improvement to the earlier situation of prolonged excessive hours, has not wholly overcome experience of long working hours and fatigue. Fatigue did not only arise from the hours that were scheduled, but also from an unpredictable mixture of shifts, work intensity (which often resulted in educational tasks being taken home) and inadequate rest. Fatigue was also caused by trainees working beyond their scheduled hours, for reasons such as task completion, accessing additional educational opportunities beyond scheduled hours and staffing shortages. There were also organisational, professional and cultural drivers, such as a sense of responsibility to patients and colleagues and the expectations of seniors. Fatigue was perceived to affect efficiency of skills and judgement, mood and learning capacity. CONCLUSIONS Long-term risks of continued stress and fatigue, for doctors and for the effective delivery of a healthcare service, should not be ignored. Current monitoring processes do not reflect doctors' true working patterns. The effectiveness of the WTR cannot be considered in isolation from the culture and context of the workplace. On-going attention needs to be paid to broader cultural issues, including the relationship between trainees and seniors.
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Affiliation(s)
- Gill Morrow
- Centre for Medical Education Research, Durham University, Durham, UK
| | - Bryan Burford
- School of Medical Sciences Education Development, The Medical School, Newcastle University, Newcastle upon Tyne, UK
| | - Madeline Carter
- Centre for Medical Education Research, Durham University, Durham, UK
| | - Jan Illing
- Centre for Medical Education Research, Durham University, Durham, UK
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Schumacher DJ, Frintner MP, Jain A, Cull W. The 2011 ACGME standards: impact reported by graduating residents on the working and learning environment. Acad Pediatr 2014; 14:149-54. [PMID: 24602577 DOI: 10.1016/j.acap.2013.09.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Revised: 08/27/2013] [Accepted: 09/14/2013] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Changes in Accreditation Council for Graduate Medical Education (ACGME) requirements, including duty hours, were implemented in July 2011. This study examines graduating pediatrics residents' perception of the impact of these standards. METHODS A national, random sample survey of 1000 graduating pediatrics residents was performed in 2012; a total of 634 responded. Residents were asked whether 9 areas of their working and learning environments had changed with the 2011 standards. Three combined change scores were created for: 1) patient care, 2) senior residents, and 3) program effects, with scores ranging from -1 (worse) to 1 (improved). Respondents were also asked about hours slept and perceived change in hours slept. RESULTS Most respondents felt that several areas had worsened, including continuity of care and senior resident workload, or not changed, including supervision and sleep. Mean change scores that included all study variables except those related to sleep all showed worsening: patient care (mean -0.37); senior residents (mean -0.36), and program effects (mean -0.06) (P < .01). Respondents reported a mean of 6.7 hours of sleep in a 24-hour period, with the majority (71%) reporting this amount of sleep has not changed with the 2011 standards. CONCLUSIONS In the year after implementation of the 2011 ACGME standards, graduating pediatrics residents report no changes or a worsening in multiple components of their working and learning environments, as well as no changes in the amount of sleep they receive each day.
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Affiliation(s)
- Daniel J Schumacher
- Boston Combined Residency Program in Pediatrics (Boston Children's Hospital/Boston Medical Center), Boston, Mass; Pediatric Emergency Medicine, Boston Medical Center, Boston, Mass.
| | - Mary Pat Frintner
- Department of Research, American Academy of Pediatrics, Elk Grove Village, Ill
| | - Anuja Jain
- Boston Combined Residency Program in Pediatrics (Boston Children's Hospital/Boston Medical Center), Boston, Mass
| | - William Cull
- Department of Research, American Academy of Pediatrics, Elk Grove Village, Ill
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Fargen KM, Rosen CL. Are duty hour regulations promoting a culture of dishonesty among resident physicians? J Grad Med Educ 2013; 5:553-5. [PMID: 24454999 PMCID: PMC3886449 DOI: 10.4300/jgme-d-13-00220.1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Leventer-Roberts M, Zonfrillo MR, Yu S, Dziura JD, Spiro DM. Overweight physicians during residency: a cross-sectional and longitudinal study. J Grad Med Educ 2013; 5:405-11. [PMID: 24404303 PMCID: PMC3771169 DOI: 10.4300/jgme-d-12-00289.1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Revised: 11/14/2012] [Accepted: 12/10/2012] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Resident physicians are at risk for increasing weight status given their changes in environment, resources, and stress level. OBJECTIVE To describe body mass index (BMI), blood pressure, eating habits, and physical activity during postgraduate training and to compare the findings to data for nationally matched controls. METHODS This was a combined cross-sectional study and longitudinal cohort, with a comparison to matched controls in 2 academic hospital centers in the eastern and western United States. BMI and blood pressure were objectively measured, and an eating and exercise habits recall was obtained for 375 enrolled medical and surgical residents (93 longitudinally) at the onset of each postgraduate year (PGY) in 2006, 2007, and 2008. RESULTS Nearly half (43%) of overweight residents described themselves as normal weight. Residents were more likely to be overweight (BMI ≥25) at the beginning of PGY-3 than at the beginning of PGY-1 (49% versus 30%; odds ratio 2.26; 95% confidence interval 1.19-4.28). The average BMI of residents at PGY-1 was lower than that of their matched controls, but the magnitude of this difference decreased with increasing PGY (P = .02). CONCLUSIONS Overweight status is underacknowledged by overweight residents and increases by PGY of training. These changes differ significantly from that of controls and may affect overweight physicians' long-term health.
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Shea JA, Willett LL, Borman KR, Itani KMF, McDonald FS, Call SA, Chaudhry S, Adams M, Chacko KM, Volpp KG, Arora VM. Anticipated consequences of the 2011 duty hours standards: views of internal medicine and surgery program directors. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2012; 87:895-903. [PMID: 22622221 PMCID: PMC3386358 DOI: 10.1097/acm.0b013e3182584118] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
PURPOSE To assess internal medicine (IM) and surgery program directors' views of the likely effects of the 2011 Accreditation Council for Graduate Medical Education duty hours regulations. METHOD In fall 2010, investigators surveyed IM and surgery program directors, assessing their views of the likely impact of the 2011 duty hours standards on learning environment, workload, education opportunities, program administration, and patient outcomes. RESULTS Of 381 IM program directors, 287 (75.3%) responded; of 225 surgery program directors, 118 (52.4%) responded. Significantly more surgeons than internists indicated that the new regulations would likely negatively impact learning climate, including faculty morale and residents' relationships (P < .001). Most leaders in both specialties (80.8% IM, 80.2% surgery) felt that the regulations would likely increase faculty workload (P = .73). Both IM (82.2%) and surgery (96.6%) leaders most often rated, of all education opportunities, first-year resident clinical experience to be adversely affected (P < .001). Respondents from both specialties indicated that they will hire more nonphysician/midlevel providers (59.5% IM, 89.0% surgery, P < .001) and use more nonteaching services (66.8% IM, 70.1% surgery, P = .81). Respondents expect patient safety (45.1% IM, 76.9% surgery, P < .001) and continuity of care (83.6% IM across all training levels, 97.5% surgery regarding first-year residents) to decrease. CONCLUSIONS IM and surgery program directors agree that the 2011 duty hours regulations will likely negatively affect the quality of the learning environment, workload, education opportunities, program administration, and patient outcomes. Careful evaluation of actual impact is important.
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Affiliation(s)
- Judy A Shea
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104-6021, USA.
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13
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Nuckols TK, Escarce JJ. Cost implications of ACGME's 2011 changes to resident duty hours and the training environment. J Gen Intern Med 2012; 27:241-9. [PMID: 21779949 PMCID: PMC3270247 DOI: 10.1007/s11606-011-1775-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2011] [Revised: 05/19/2011] [Accepted: 05/25/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND In July 2011, the Accreditation Council for Graduate Medical Education (ACGME) will implemented stricter duty-hour limits and related changes to the training environment. This may affect preventable adverse event (PAE) rates. OBJECTIVES To estimate direct costs under various implementation approaches, and examine net costs to teaching hospitals and cost-effectiveness to society across a range of hypothetical changes in PAEs. DESIGN A decision-analytical model represented direct costs and PAE rates, mortality, and costs. DATA SOURCES Published literature and publicly available data. TARGET POPULATION Patients admitted to hospitals with ACGME-accredited programs. TIME HORIZON One year. PERSPECTIVES All teaching hospitals, major teaching hospitals, society. INTERVENTION ACGME's 2011 Common Program Requirements. OUTCOME MEASURES Direct annual costs (all accredited hospitals), net cost (major teaching hospitals), cost per death averted (society). RESULTS OF BASE-ANALYSIS: Nationwide, duty-hour changes would cost $177 million annually if interns maintain current productivity, vs. up to $982 million if they transfer work to a mixture of substitutes; training-environment changes will cost $204 million. If PAEs decline by 7.2-25.8%, net costs to major teaching hospitals will be zero. If PAEs fall by 3%, the cost to society per death averted would be -$523,000 (95%-confidence interval: -$1.82 million to $685,000) to $2.44 million ($271,000 to $6.91 million). If PAEs rise, the policy will be cost-increasing for teaching hospitals and society. RESULTS OF SENSITIVITY ANALYSIS The total direct annual cost nationwide would be up to $1.34 billion using nurse practitioners/physician assistants, $1.64 billion using attending physicians, $820 million hiring additional residents, vs. 1.42 billion using mixed substitutes. LIMITATIONS The effect on PAEs is unknown. Data were limited for some model parameters. CONCLUSION Implementation decisions greatly affect the cost. Unless PAEs decline substantially, teaching hospitals will lose money. If PAEs decline modestly, the requirements might be cost-saving or cost-effective to society.
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Affiliation(s)
- Teryl K Nuckols
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at the University of California, 911 Broxton Avenue, Los Angeles, CA 90095, USA.
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Palma JP, Van Eaton EG, Longhurst CA. Neonatal Informatics: Information Technology to Support Handoffs in Neonatal Care. Neoreviews 2011; 2011. [PMID: 22199463 DOI: 10.1542/neo.12-10-e560] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Communication failures during physician handoffs represent a significant source of preventable adverse events. Computerized sign-out tools linked to hospital electronic medical record systems and customized for neonatal care can facilitate standardization of the handoff process and access to clinical information, thereby improving communication and reducing adverse events. It is important to note, however, that adoption of technological tools alone is not sufficient to remedy flawed communication processes. OBJECTIVES: After completing this article, readers should be able to: Identify key elements of a computerized sign-out tool.Describe how an electronic tool might be customized for neonatal care.Appreciate that technological tools are only one component of the handoff process they are designed to facilitate.
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Affiliation(s)
- Jonathan P Palma
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, 94305
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15
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Liu CC, Wissow L. How post-call resident doctors perform, feel and are perceived in out-patient clinics. MEDICAL EDUCATION 2011; 45:669-677. [PMID: 21649699 DOI: 10.1111/j.1365-2923.2010.03912.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
CONTEXT Recently, in the U.S.A., the Accreditation Council for Graduate Medical Education guidelines limited residents' consecutive duty to 24 hours. In Europe, the European Working Time Directive limits the average working week to 48 hours. OBJECTIVES This study aimed to examine the performance of post-call residents in out-patient interviews using subjective and objective measures and to assess residents' subjective feelings. METHODS We conducted a cross-sectional analysis of a systematic sample of 170 paediatric primary care consultations conducted during 117 clinic sessions served by 47 residents at a teaching hospital, including 34 consultations conducted during 23 sessions by 20 post-call residents. Interviews were audiotaped and quantitatively analysed using the Roter Interactional Analysis System (RIAS). Residents and patients' parents gave subjective appraisals of the visits using short questionnaires. Major covariates are resident gender and the timing of the clinic. RESULTS Results did not show significant differences between post-call residents and their peers who had left the hospital on time in most components of the out-patient interview. Subtle yet probably important differences emerged with findings that post-call residents were significantly less likely to ask a parent to repeat what she had just said, and parents seeing post-call residents were more likely to request the resident to repeat what he or she had just said and to check if the resident understood what they had said. Post-call residents were rated by objective coders as having better attitudes than their left-on-time counterparts, yet subjectively felt less satisfied and more fatigued. Female post-call residents felt less competent, less productive and less energetic; male post-call residents felt more challenged, more demoralised and busier. CONCLUSIONS The changes in activating and partnering talk that occur in post-call residents are consistent with findings concerning sleep deprivation and speech. Female and male residents tended to attribute their post-call performance to different factors. Setting limits on working hours might help to avoid potential negative impacts on post-call resident feelings, and the impact of working hours on resident performance warrants further exploration.
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Affiliation(s)
- Chen-Chung Liu
- Department of Psychiatry, National Taiwan University Hospital, Taipei.
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Bell EF, Hansen NI, Morriss FH, Stoll BJ, Ambalavanan N, Gould JB, Laptook AR, Walsh MC, Carlo WA, Shankaran S, Das A, Higgins RD. Impact of timing of birth and resident duty-hour restrictions on outcomes for small preterm infants. Pediatrics 2010; 126:222-31. [PMID: 20643715 PMCID: PMC2924191 DOI: 10.1542/peds.2010-0456] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE The goal was to examine the impact of birth at night, on the weekend, and during July or August (the first months of the academic year) and the impact of resident duty-hour restrictions on mortality and morbidity rates for very low birth weight infants. METHODS Outcomes were analyzed for 11,137 infants with birth weights of 501 to 1250 g who were enrolled in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network registry in 2001-2005. Approximately one-half were born before the introduction of resident duty-hour restrictions in 2003. Follow-up assessments at 18 to 22 months were completed for 4508 infants. Mortality rate, short-term morbidities, and neurodevelopmental outcome were examined with respect to the timing of birth. RESULTS There was no effect of the timing of birth on mortality rate and no impact on the risks of short-term morbidities except that the risk of retinopathy of prematurity (stage > or =2) was higher after the introduction of duty-hour restrictions and the risk of retinopathy of prematurity requiring operative treatment was lower for infants born during the late night than during the day. There was no impact of the timing of birth on neurodevelopmental outcome except that the risk of hearing impairment or death was slightly lower among infants born in July or August. CONCLUSION In this network, the timing of birth had little effect on the risks of death and morbidity for very low birth weight infants, which suggests that staffing patterns were adequate to provide consistent care.
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Affiliation(s)
- Edward F. Bell
- Department of Pediatrics, University of Iowa, Iowa City, Iowa
| | | | | | | | | | - Jeffrey B. Gould
- Department of Pediatrics, Stanford University, Palo Alto, California
| | - Abbot R. Laptook
- Department of Pediatrics, Brown University, Providence, Rhode Island
| | - Michele C. Walsh
- Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio
| | - Waldemar A. Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Abhik Das
- RTI International, Rockville, Maryland
| | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
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Cedfeldt AS, English C, El Youssef R, Gilhooly J, Girard DE. Institute of medicine committee report on resident duty hours: a view from a trench. J Grad Med Educ 2009; 1:178-80. [PMID: 21975974 PMCID: PMC2931259 DOI: 10.4300/jgme-d-09-00031.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND In late 2008, the Institute of Medicine (IOM) published a report recommending more restrictive limits on resident work hours to promote patient safety. Reaction from the graduate medical education community has focused on concerns about a lack of evidence supporting the IOM's recommendations. We highlight 3 concerns with the report: 1) a disproportionate attention to resident fatigue when changes in other areas may have a larger impact on patient safety. Data supporting a causal link between resident fatigue and medical errors that harm patients are not robust. Two areas where data support a stronger impact on patient safety include resident supervision and transitions of care; 2) a "one size fits all" model when specialty-specific recommendations may be more appropriate. For example, 16 hours on task is not at all similar for residents in different specialties (ie, surgery and primary care); and 3) the absence of a process to evaluate the impact of current or potential duty hour requirements on outcomes. Because these potential impacts have not been sufficiently researched, it is premature to support additional changes at this time. RECOMMENDATIONS TO MOVE FORWARD IN A COMPREHENSIVE MANNER, WE RECOMMEND THE FOLLOWING: 1) support more research to evaluate the effects of duty hours in conjunction with other interrelated factors on patient safety, 2) encourage individual Accreditation Council for Graduate Medical Education (ACGME) Review committees to develop specialty specific duty hour limitations, and 3) develop partnerships between the IOM, ACGME, and the institutions directly involved with medical education to study how to maximize patient safety while maintaining quality educational outcomes.
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Affiliation(s)
- Andrea S. Cedfeldt
- Corresponding author: Andrea S Cedfeldt, MD, Oregon Health & Science University, 3181 Sam Jackson Park Road, Mail Code L102, Portland, OR 97239, 503.494.2572,
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Mautone SG. Toward a new paradigm in graduate medical education in the United States: elimination of the 24-hour call. J Grad Med Educ 2009; 1:188-94. [PMID: 21975977 PMCID: PMC2931239 DOI: 10.4300/jgme-d-09-00061.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Sleep deprivation negatively affects resident performance, education, and safety. Concerns over these effects have prompted efforts to reduce resident hours. This article describes the design and implementation of a scheduling system with no continuous 24-hour calls. Aims included meeting Accreditation Council for Graduate Medical Education work hour requirements without increasing resident complement, maximizing continuity of learning and patient care, maintaining patient care quality, and acceptance by residents, faculty, and administration. METHODS Various coverage options were formulated and discussed. The final schedule was the product of consensus. After re-engineering the master rotation schedule, service-specific conversion of on-call schedules was initiated in July 2003 and completed in July 2004. Annual in-training and certifying examination performance, length of stay, patient mortalities, resident motor vehicle accidents/near misses, and resident satisfaction with the new scheduling system were tracked. RESULTS Continuous 24-hour call has been eliminated from the program since July 2004, with the longest assigned shift being 14 hours. Residents have at least 1 free weekend per month, a 10-hour break between consecutive assigned duty hours, and a mandatory 4-hour "nap" break if assigned a night shift immediately following a day shift. Program-wide, duty hours average 66 hours per week for first-year residents, 63 hours per week for second-year residents, and 60 hours per week for third-year residents. Self-reported motor vehicle accidents and/or near misses of accidents significantly decreased (P < .001) and resident satisfaction increased (P = .42). The change was accomplished at no additional cost to the institution and with no adverse patient care or educational outcomes. CONCLUSIONS Pediatric residency training with restriction to 14 consecutive duty hours is effective and well accepted by stakeholders. Five years later, the re-engineered schedule has become the new "normal" for our program.
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Affiliation(s)
- Susan G. Mautone
- Corresponding author: Susan G Mautone, MD, UMDNJ-New Jersey Medical School, 185 South Orange Avenue, MSB F584, Newark, NJ 07103, 9739727160,
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Mercurio MR, Peterec SM. Attending physician work hours: ethical considerations and the last doctor standing. Pediatrics 2009; 124:758-62. [PMID: 19581262 DOI: 10.1542/peds.2008-2953] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Based at least in part on concerns for patient safety and evidence that long shifts are associated with an increased risk of physician error, residents' and fellows' work hours have been strictly limited for the past several years. Little attention has been paid, however, to excessive attending physician shift duration, although there seems to be no reason to assume that this common practice poses any less risk to patients. Potential justifications for allowing attending physicians to work without hourly limits include physician autonomy, workforce shortages in certain communities or subspecialties, continuity of care, and financial considerations. None of these clearly justify the apparent increased risk to patients, with the exception in some settings of workforce shortage. In many hospital settings, the practice of allowing attending physicians to work with no limit on shift duration could pose an unnecessary risk to patients.
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Affiliation(s)
- Mark R Mercurio
- Department of Pediatrics, Yale Pediatric Ethics Program, Yale University School of Medicine, New Haven, Connecticut 06520-8064, USA.
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Nuckols TK, Bhattacharya J, Wolman DM, Ulmer C, Escarce JJ. Cost implications of reduced work hours and workloads for resident physicians. N Engl J Med 2009; 360:2202-15. [PMID: 19458365 DOI: 10.1056/nejmsa0810251] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although the Accreditation Council for Graduate Medical Education (ACGME) limits the work hours of residents, concerns about fatigue persist. A new Institute of Medicine (IOM) report recommends, among other changes, improved adherence to the 2003 ACGME limits, naps during extended shifts, a 16-hour limit for shifts without naps, and reduced workloads. METHODS We used published data to estimate labor costs associated with transferring excess work from residents to substitute providers, and we examined the effects of our assumptions in sensitivity analyses. Next, using a probability model to represent labor costs as well as mortality and costs associated with preventable adverse events, we determined the net costs to major teaching hospitals and cost-effectiveness across a range of hypothetical changes in the rate of preventable adverse events. RESULTS Annual labor costs from implementing the IOM recommendations were estimated to be $1.6 billion (in 2006 U.S. dollars) across all ACGME-accredited programs ($1.1 billion to $2.5 billion in sensitivity analyses). From a 10% decrease to a 10% increase in preventable adverse events, net costs per admission ranged from $99 to $183 for major teaching hospitals and from $17 to $266 for society. With 2.5% to 11.3% decreases in preventable adverse events, costs to society per averted death ranged from $3.4 million to $0. CONCLUSIONS Implementing the four IOM recommendations would be costly, and their effectiveness is unknown. If highly effective, they could prevent patient harm at reduced or no cost from the societal perspective. However, net costs to teaching hospitals would remain high.
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Affiliation(s)
- Teryl K Nuckols
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, USA.
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Abstract
OBJECTIVES To evaluate the perceived impact of work-hour limitations on paediatric residency training programmes and to determine the various strategies used to accommodate these restrictions. METHODS A three-page pre-tested survey was administered to programme directors at the 2004 Association of Paediatric Programme Directors meeting. The impact of work-hours was evaluated with Likert-type questions and the methods used to meet work-hour requirements were compared between large programmes (>or=30 residents) and small programmes. RESULTS Surveys were received from 53 programme directors. The majority responded that work-hour limitations negatively impacted inpatient continuity, time for education, schedule flexibility and attending staff satisfaction. Supervision by attending staff was the only aspect to significantly improve. Perceived resident satisfaction was neutral. To accommodate work-hour limitations, 64% of programmes increased clinical responsibility to existing non-resident staff, 36% hired more non-resident staff and 17% increased the number of residents. Only one programme hired additional non-clinical staff. Large programmes were more likely to use more total methods on the inpatient wards (P < 0.01) and in the intensive care units (P < 0.05) to accommodate work-hour limitations. CONCLUSIONS Programme directors perceived a negative impact of work-hours on most aspects of training without a perceived difference in resident satisfaction. While a variety of methods are used to accommodate work-hour limitations, programmes are not widely utilizing non-clinical staff to alleviate clerical burdens.
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Affiliation(s)
- Robert J Fortuna
- Department of Ambulatory Care and Prevention, Harvard Medical School, Boston, MA 02215, USA.
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Abstract
US adoption of health information technology as a path to improved quality of patient care (effectiveness, safety, timeliness, patient-centeredness, efficiency, and equity) has been promoted by the medical community. Children and infants (especially those with special health care needs) are at higher risk than are adults for medical errors and their consequences (particularly in environments in which children are not the primary patient population). However, development and adoption of health information technology tools and practices that promote pediatric quality and patient safety are lagging. Two inpatient clinical processes-medication delivery and patient care transitions-are discussed in terms of health information technology applications that support them and functions that are important to pediatric quality and safety. Pediatricians and their partners (pediatric nurses, pharmacists, etc) must develop awareness of technical and adaptive issues in adopting these tools and collaborate with organizational leaders and developers as advocates for the best interests and safety of pediatric patients. Pediatric health information technology adoption cannot be considered in terms of applications (such as electronic health records or computerized physician order entry) alone but must be considered globally in terms of technical (health information technology applications), organizational (structures and workflows of care), and cultural (stakeholders) aspects of what is best.
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Gordon MB, McGuinness GA, Stanton BF, Brooks S, Chiang VW, Vinci R, Sectish TC. Part-time training in pediatric residency programs: principles and practices. Pediatrics 2008; 122:e938-44. [PMID: 18809596 DOI: 10.1542/peds.2008-0719] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Despite growing interest in part-time work, few pediatricians are pursuing part-time residency training. There is currently little guidance for programs or residents who wish to design an alternative path through residency. In this article we review the need for part-time residencies and address obstacles to be overcome in their initiation. Strategies are offered for residents and program directors planning part-time training pathways, with recommendations for implementation amid a changing environment for graduate medical education. The needs of trainees, residency programs, hospitals, and credentialing organizations are considered.
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Affiliation(s)
- Mary Beth Gordon
- Boston Combined Residency Program in Pediatrics, Department of Pediatrics, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.
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Duty hours restriction and their effect on resident education and academic departments: the American perspective. Curr Opin Anaesthesiol 2008; 20:580-4. [PMID: 17989554 DOI: 10.1097/aco.0b013e3282f0efd4] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Resident duty hour limits were implemented in 2003 by the Accreditation Council for Graduate Medical Education to improve resident wellness, increase patient safety and improve the educational environment of American residents. Now that academic anesthesiology departments and medical centers have had more than 3 years of experience under the duty hour rules, it is critical to review the available evidence on the effectiveness of these rules. RECENT FINDINGS The available data clearly support that American residents across specialties perceive an improvement in their educational environment and an increase in their quality of life. It is not clear if the duty hour rules have affected patient safety or the quality of resident education. Faculty have been impacted by these rules, with many feeling their work loads have increased, and hospitals have had to fund additional providers to cover work previously done by residents. SUMMARY Accreditation Council for Graduate Medical Education duty hour rules are generally being followed by American anesthesiology residency programs. Residents perceive an improvement in their overall wellness, but it remains unclear if there has been an improvement in patient safety or quality of resident education.
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Abstract
BACKGROUND Our understanding of the effect of the Accreditation Council for Graduate Medical Education (ACGME)-mandated work-hour limitation on physicians' quality of life, sleepiness, and sleep-work habits is evolving. In this study, we sought to determine the effect of work-hour reduction on quality of life in residents and fellows (ICU housestaff) when subject to the ACGME-compliant schedule of one institution. To determine the effect of work-hour reduction on subjective and objective measures of sleepiness in ICU housestaff at a center. METHODS A single-center study of 34 residents and 10 fellows who were studied before and after the ACGME-mandated work-hour limitation went into effect in July 2003. RESULTS In a single center, after the work-hour reduction, residents reported statistically significant but minor improvements in sleep time, subjective sleepiness, and some aspects of quality of life (p < 0.05). Both before and after work-hour limitations, subjective sleepiness and quality-of-life indexes deteriorated during the course of the ICU rotation. Following work-hour reductions, subjective sleepiness improved (p < 0.05), but objective sleepiness was unchanged (p = 0.6). Moreover, after the implementation of work-hour reductions, 59%, 43%, and 25% of the ICU team had mean sleep latency < 10, 7, and 5 min, respectively, with 14% of the team manifesting sleep-onset rapid eye movement periods (signifying severe sleepiness) before beginning their extended work-hour period. CONCLUSIONS In ICU housestaff, at a single center, small benefits to quality of life and subjective sleepiness were realized by an ACGME-compliant work-hour schedule. Significant levels of objective sleepiness, however, remained. Further measures may need to be undertaken to address the persistence of sleepiness in ICU housestaff. These findings may not be generalized outside of the scheduling system studied.
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Affiliation(s)
- Sairam Parthasarathy
- Section of Pulmonary and Critical Care Medicine, Southern Arizona Veterans Administration Health Care System, 3601 South Sixth Ave, Tucson, AZ 85723, USA.
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