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

Distribution of internal medicine rotations among resident physicians in Japan: a nationwide, multicenter, cross-sectional study

BACKGROUND

In Japan, postgraduate clinical training encompasses a 2-year residency program, including at least 24 weeks of internal medicine (IM) rotations. However, the fragmented structure of these rotations can compromise the training's quality and depth. For example, a resident might spend only a few weeks in cardiology before moving to endocrinology, without sufficient time to deepen their understanding or have clinical experience. This study examined current patterns and lengths of IM rotations within the Japanese postgraduate medical system. It scrutinized the piecemeal approach-whereby residents may engage in multiple short-term stints across various subspecialties without an overarching, integrated experience-and explored potential consequences for their clinical education.

METHODS

This nationwide, multicenter, cross-sectional study used data from self-reported questionnaires completed by participants in the 2022 General Medicine In-Training Examination (GM-ITE). Data of 1,393 postgraduate year (PGY) one and two resident physicians who participated in the GM-ITE were included. We examined the IM rotation duration and number of IM subspecialties chosen by resident physicians during a 2-year rotation.

RESULTS

Approximately half of the participants chose IM rotation periods of 32-40 weeks. A significant proportion of participants rotated in 5-7 internal medicine departments throughout the observation period. Notable variations in the distribution of rotations were observed, characterized by a common pattern where resident physicians typically spend 4 weeks in each department before moving to the next. This 4-week rotation is incrementally repeated across different subspecialties without a longer, continuous period in any single area. Notably, 39.7% of participants did not undertake general internal medicine rotations. These results suggest a narrowed exposure to medical conditions and patient care practices.

CONCLUSIONS

Our study highlights the need to address the fragmented structure of IM rotations in Japan. We suggest that short, specialized learning periods may limit the opportunity to gain broad in-depth knowledge and practical experience. To improve the efficacy of postgraduate clinical education, we recommend fostering more sustained and comprehensive learning experiences.

Changes in the working conditions and learning environment of medical residents after the enactment of the Medical Resident Act in Korea in 2015: a national 4-year longitudinal study

PURPOSE

In 2015, the South Korean government legislated the Act for the Improvement of Training Conditions and Status of Medical Residents (Medical Resident Act). This study investigated changes in the working and learning environment pre- and post-implementation of the Medical Resident Act in 2017, as well as changes in training conditions by year post-implementation..

METHODS

An annual cross-sectional voluntary survey was conducted by the Korean Intern Resident Association (KIRA) between 2016 and 2019. The learning and working environment, including extended shift length, rest time, learning goals, and job satisfaction, were compared by institution type, training year, and specialty

RESULTS

Of the 55,727 enrollees in the KIRA, 15,029 trainees took the survey, and the number of survey participants increased year by year (from 2,984 in 2016 to 4,700 in 2019). Overall working hours tended to decrease; however, interns worked the most (114 hours in 2016, 88 hours in 2019; P<0.001). Having 10 hours or more of break time has gradually become more common (P<0.001). Lunch breaks per week decreased from 5 in 2017 to 4 in 2019 (P<0.001). Trainees’ sense of educational deprivation due to physician assistants increased from 17.5% in 2016 to 25.6% in 2018 (P<0.001). Awareness of tasks and program/work achievement goals increased from 29.2% in 2016 to 58.3% in 2018 (P<0.001). Satisfaction with the learning environment increased over time, whereas satisfaction with working conditions varied.

CONCLUSION

The Medical Resident Act has brought promising changes to the training of medical residents in Korea, as well as their satisfaction with the training environment.

Learner Preference of Schedule Type Improves Engagement of Pediatric Residents: Results of a Mixed-Methods Analysis

OBJECTIVE

Determine whether a call or shift schedule is better for acquiring optimal knowledge and professionalism, while limiting fatigue for pediatric residents during the pediatric intensive care unit (PICU) rotation in a small residency program.

METHODS

This was a prospective, randomized, crossover, mixed-methods study in which pediatric residents were randomized to either a call or shift schedule during their PICU rotation. Attentiveness, bedside care, perceived knowledge, and professionalism were assessed by the resident participants, attending physicians, and nursing staff. Epworth Sleepiness Scale determined the level of resident fatigue. Statistical analysis utilized a t test of unequal variances. Two focus groups were conducted of resident non-participants and participants. Graduated resident participants and non-participants were surveyed via anonymous e-mail responses.

RESULTS

Thirty residents participated in the study and twenty residents were surveyed and participated in a focus group. No major differences were detected between each participating group, whether assigned to a call or shift schedule in regard to perceived knowledge, professionalism, or fatigue. Overall themes from qualitative analysis identified advantages and disadvantages for both work schedules. Participants recognized a learner preference for schedule type depending on level of training, suggesting a shift schedule for junior residents and a call schedule for senior residents.

CONCLUSIONS

There is no difference between the call or shift schedule in regard to residents' perceived knowledge, professionalism, and fatigue. Participants expressed learner preferences for one schedule over the other, recommending the shift schedule during the PGY-2 year and the call schedule during the PGY-3 year.

Current status of pain medicine training in anesthesiology and pain medicine residency programs in university hospitals of Korea: a survey of residents’ opinions

Background

In Korea, anesthesiologists are expected to be mainstream pain medicine (PM) practitioners. However, anesthesiology and pain medicine (APM) residency programs mostly emphasize anesthesia learning, leading to insufficient PM learning. Therefore, this study evaluated the current status of PM training in APM residency programs in 10 Korean university hospitals.

Methods

Overall, 156 residents undergoing APM training participated anonymously in our survey, focusing on PM training. We assessed the aim, satisfaction status, duration, opinion on duration, desired duration, weaknesses of the training programs and plans of residents after graduating. We divided the residents into junior (first and second year) and senior (third and fourth year). Survey data were compared between groups.

Results

Senior showed significantly different level of satisfaction grade than did junior (p=0.026). Fifty-seven (81.4%) residents in junior and forty (46.5%) residents in senior underwent PM training for ≤2 months. Most (108; 69.2%) residents felt that the training period was too short for PM learning and 95 (60.9%) residents desired a training period of ≥6 months. The most commonly expressed weakness of the training was low interventional opportunity (29.7%), followed by short duration (26.6%). After residency, 80 (49.1%) residents planned to pursue a fellowship.

Conclusions

Dissatisfaction with PM training was probably due to a structural tendency of the current program towards anesthesia training and insufficient clinical experience, which needs to be rectified, with a change in PM curriculum.

Factors related to burnout in resident physicians in Japan

OBJECTIVES

We explore the prevalence and characteristics of burnout among Japanese resident physicians and identifies factors associated with burnout.

METHODS

A cross-sectional study was conducted three times between April 2017 and March 2018 at a Japanese teaching hospital. Resident physicians were invited to answer an online survey that included existing valid instruments related to burnout, depression, and empathy. Demographic, background, occupational, and socioeconomic data were also collected. Participants were prompted to report the average daily work hours and the specialty they wish to pursue.

RESULTS

Overall, 39/76 (51%), 27/76 (36%), and 21/76 (28%) resident physicians responded to surveys in April 2017, October 2017, and March 2018, respectively. The percentages of participants with burnout for surveys in April 2017, October 2017, and March 2018 were 7/39 (18%), 6/27 (22%), and 7/21 (33.3%). Emotional exhaustion (EE) was the only burnout component strongly correlated with the severity of depression (r = .615, p < .001; r = .706, p < .001; r = .601, p < .01). EE and depersonalization (DP) had no significant correlation with average daily working hours (β = .156, p = .343 for EE; β = .061, p = .711 for DP).

CONCLUSIONS

The results suggest that capping working hours alone may not be effective in reducing burnout in Japanese resident physicians. Medical educators might need to consider not only working hours but also individual job quality and satisfaction to address burnout. Future studies may need to incorporate qualitative methods to explore the characteristics of burnout.

Distribution of Clinical Rotations Among Emergency Medicine Residency Programs in the United States

INTRODUCTION

There are over 200 emergency medicine (EM) residency programs in the United States. While there are basic criteria defined by the Accreditation Council for Graduate Medical Education (ACGME), there can be significant variation between programs with regard to rotation distribution. Therefore, it would be valuable to have a benchmark for programs to understand their rotation mix in the context of the national landscape. This study aimed to provide a breakdown of the length and percentage of EM residency programs with each clinical rotation in the United States. This study also sought to examine trends and changes in EM residency programs since 1986.

METHODS

A list of all current EM residency programs was obtained using the ACGME website. All program websites were reviewed, and data were independently dual extracted by two investigators with discrepancies resolved by consensus with a third investigator. Programs without curricular data available online were queried via e-mail for the data. Programs were separated into 3- versus 4-year lengths. Mean, standard deviation, and range were calculated for each rotation.

RESULTS

A total of 200 of 202 programs (99%) had data available. Of these programs, 84.5% had a dedicated pediatric EM rotation with mean length of 9.7 weeks among 3-year programs and 12.1 weeks among 4-year programs. A total of 88% had a dedicated ultrasound rotation, 60% had a dedicated toxicology rotation, 73.5% had a dedicated emergency medical services rotation, 74% had a dedicated orthopedics rotation, 60% had a dedicated administration rotation, 29% had a dedicated research rotation, and 95% had dedicated elective time.

DISCUSSION

This study provides summative data regarding the rotation distribution among EM programs in the United States. Compared with prior data, there is less time dedicated to internal medicine rotations and increased pediatric, trauma, ultrasound, toxicology, and critical care experiences. These data will inform current and new EM residency programs when determining rotation selection.