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Griffiths MD. Work addiction and quality of care in healthcare: Working long hours should not be confused with addiction to work. BMJ Qual Saf 2023; 33:4-6. [PMID: 37500562 DOI: 10.1136/bmjqs-2023-016175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2023] [Indexed: 07/29/2023]
Affiliation(s)
- Mark D Griffiths
- Psychology Department, Nottingham Trent University, Nottingham, UK
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Gates RS, Kemp MT, Evans J, Liesman D, Pumiglia L, Matusko N, George BC, Sandhu G. The Demands of Surgery Residency: More Than Just Duty Hours? J Surg Res 2023; 290:293-303. [PMID: 37327639 DOI: 10.1016/j.jss.2023.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 03/24/2023] [Accepted: 04/15/2023] [Indexed: 06/18/2023]
Abstract
INTRODUCTION Efforts to improve surgical resident well-being could be accelerated with an improved understanding of resident job demands and resources. In this study, we sought to obtain a clearer picture of surgery resident job demands by assessing how residents distribute their time both inside and outside of the hospital. Furthermore, we aimed to elucidate residents' perceptions about current duty hour regulations. METHODS A cross-sectional survey was sent to 1098 surgical residents at 27 US programs. Responses regarding work hours, demographics, well-being (utilizing the physician well-being index), and perceptions of duty hours in relation to education and rest, were collected. Data were evaluated using descriptive statistics and content analysis. RESULTS A total of 163 residents (14.8% response rate) were included in the study. Residents reported a median total patient care hours per week of 78.0 h. Trainees spent 12.5 h on other professional activities. Greater than 40% of residents were "at risk" for depression and suicide based on physician well-being index scores. Four major themes associated with education and rest were identified: 1) duty hour definitions and reporting mechanisms do not completely reflect the amount of work residents perform, 2) quality patient care and educational opportunities do not fit neatly within the duty hour framework, 3) resident perceptions of duty hours are impacted the educational environment, and 4) long work hours and lack of adequate rest negatively affect well-being. CONCLUSIONS The breadth and depth of trainee job demands are not accurately captured by current duty hour reporting mechanisms, and residents do not believe that their current work hours allow for adequate rest or even completion of other clinical or academic tasks outside of the hospital. Many residents are unwell. Duty hour policies and resident well-being may be improved with a more holistic accounting of resident job demands and greater attention to the resources that residents have to offset those demands.
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Affiliation(s)
- Rebecca S Gates
- Center for Surgical Training and Research, Department of Surgery, University of Michigan, Ann Arbor, Michigan.
| | - Michael T Kemp
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Julie Evans
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Daniel Liesman
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Luke Pumiglia
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Niki Matusko
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Brian C George
- Center for Surgical Training and Research, Department of Surgery, University of Michigan, Ann Arbor, Michigan; Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Gurjit Sandhu
- Center for Surgical Training and Research, Department of Surgery, University of Michigan, Ann Arbor, Michigan; Department of Surgery, University of Michigan, Ann Arbor, Michigan
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Brenna CT, Das S. Divides of identity in medicine and surgery: A review of duty-hour policy preference. Ann Med Surg (Lond) 2020; 57:1-4. [PMID: 32685142 PMCID: PMC7358620 DOI: 10.1016/j.amsu.2020.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 07/06/2020] [Indexed: 11/05/2022] Open
Abstract
Surgery and Medicine are broadly considered as the two fundamental paths that a physician's career can follow. But their convergence under the singular umbrella of doctoring is relatively recent in the context of medical history. Their co-existence within the structure of medical education and the healthcare system suggest that they bear great similarity to each other, when in reality several differences are intuitively recognizable between them. Here, we discuss recent evidence suggesting a discrepancy between these two streams in the work-hour policy preference of trainees. We argue that these differences betray a more radical divide between them, and one which illuminates an essential difference in the self-identification of surgical and non-surgical medical trainees. Additionally, these findings support a novel claim about the importance of uninterrupted relationships on the formation of professional identity among healthcare professionals. We suggest that the principal separation of surgical and non-surgical practice is significant enough to reconsider their dogmatic unification as well as warrant the adoption of unique rules and policies to govern each stream.
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Affiliation(s)
| | - Sunit Das
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, University of Toronto, Toronto, ON, Canada
- Centre for Ethics, University of Toronto, Toronto, ON, Canada
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Bilimoria KY. Association for Academic Surgery Presidential Address-Fanning the Burnout Fire: How Our Misconceptions and Good Intentions Could Fail Tomorrow's Surgeons. J Surg Res 2020; 257:A1-A11. [PMID: 32768197 DOI: 10.1016/j.jss.2020.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 06/17/2020] [Indexed: 10/24/2022]
Abstract
The issue of burnout among surgical trainees became evident during our work on the FIRST Trial. In studying the issue, we found that burnout symptoms occurred in a relatively large proportion of surgical trainees, and burnout was associated with significant risks of having thoughts of leaving the residency program or having suicidal thoughts. The SECOND Trial seeks to reduce trainee wellbeing and mistreatment by leveraging approaches used in healthcare quality performance improvement (e.g., comparative reports, toolkits, collaboration). Importantly, the epidemic of surgical trainee wellbeing issues have worsened (i.e., fanning the burnout fire) given our misconceptions about generational differences, our delayed adaptations to shifts in healthcare, and even some of our good intentions. However, there are several things we can do to improve the situation: (1) embrace the change that comes with each generation; (2) appreciate, respect, and enjoy our trainees; (3) teach residents constructively, leaving yelling and bullying behind; (4) embrace the concept of wellness for ourselves and each other; (5) provide meaningful feedback and mentorship; and (6) give each other the benefit of the doubt (e.g., principle of charity). Despite these issues, academic surgery remains the best job in the world, and the strength of our profession, leaders, and colleagues will see us through these challenges. The Association for Academic Surgery will help lead the way on these important issues.
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Affiliation(s)
- Karl Y Bilimoria
- Department of Surgery, Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
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5
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Masson V, Snell L, Dolmans D, Sun NZ. Exploring the evolving concept of 'patient ownership' in the era of resident duty hour regulations-experience of residents and faculty in an internal medicine night float system. Perspect Med Educ 2019; 8:353-359. [PMID: 31642049 PMCID: PMC6904378 DOI: 10.1007/s40037-019-00540-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
BACKGROUND Despite the use of 'patient ownership' as an embodiment of professionalism and increasing concerns over its loss among trainees, how its development in residents has been affected by duty hour regulations has not been well described. In this qualitative study, we aim to outline the key features of patient ownership in internal medicine, factors enabling its development, and how these have been affected by the adoption of a night float system to comply with duty hour regulations. METHODS In this qualitative descriptive study, we interviewed 18 residents and 12 faculty internists at one university centre and conducted a thematic analysis of the data focused on the concept of patient ownership. RESULTS We identified three key features of patient ownership: personal concern for patients, professional capacity for autonomous decision-making, and knowledge of patients' issues. Within the context of a night float system, factors that facilitate development of patient ownership include improved fitness for duty and more consistent interactions with patients/families resulting from working the same shift over consecutive days (or nights). Conversely, the increase in patient handovers, if done poorly, is a potential threat to patient ownership development. Trainees often struggle to develop ownership when autonomy is not supported with supervision and when role-modelling by faculty is lacking. DISCUSSION These features of patient ownership can be used to frame discussions when coaching trainees. Residency programs should be mindful of the downstream effects of shift-based scheduling. We propose strategies to optimize factors that enable trainee development of patient ownership.
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Affiliation(s)
- Vanessa Masson
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | - Ning-Zi Sun
- McGill University, Montreal, Quebec, Canada.
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Pierce JR. The Family Meeting. Am J Med 2019; 132:1112-1113. [PMID: 31152717 DOI: 10.1016/j.amjmed.2019.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 04/02/2019] [Accepted: 05/10/2019] [Indexed: 11/30/2022]
Affiliation(s)
- J Rush Pierce
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque.
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HONN KA, VAN DONGEN HP, DAWSON D. Working Time Society consensus statements: Prescriptive rule sets and risk management-based approaches for the management of fatigue-related risk in working time arrangements. Ind Health 2019; 57:264-280. [PMID: 30700674 PMCID: PMC6449640 DOI: 10.2486/indhealth.sw-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Traditionally, working time arrangements to limit fatigue-related risk have taken a prescriptive approach, which sets maximum shift durations in order to prevent excessive buildup of fatigue (and the associated increased risk) within shifts and sets minimum break durations to allow adequate time for rest and recovery within and/or between shifts. Prescriptive rule sets can be successful when, from a fatigue-related risk standpoint, they classify safe work hours as permitted and unsafe work hours as not permitted. However, prescriptive rule sets ignore important aspects of the biological factors (such as the interaction between circadian and homeostatic processes) that drive fatigue, which are critical modulators of the relationship between work hours and fatigue-related risk. As such, in around-the-clock operations when people must work outside of normal daytime hours, the relationship between regulatory compliance and safety tends to break down, and thus these rule sets become less effective. To address this issue, risk management-based approaches have been designed to regulate the procedures associated with managing fatigue-related risk. These risk management-based approaches are suitable for nighttime operations and a variety of other non-standard work schedules, and can be tailored to the particular job or industry. Although the purpose of these fatigue risk management approaches is to curb fatigue risk, fatigue risk cannot be measured directly. Thus, the goal is not on regulating fatigue risk per se, but rather to put in place procedures that serve to address fatigue before, during, and after potential fatigue-related incidents. Examples include predictive mathematical modeling of fatigue for work scheduling, proactive fatigue monitoring in the workplace, and reactive post-incident follow-up. With different risks and different needs across industries, there is no "one size fits all" approach to managing fatigue-related risk. However, hybrid strategies combining prescriptive rule sets and risk management-based approaches can create the flexibility necessary to reduce fatigue-related risk based on the specific needs of different work environments while maintaining appropriate regulatory oversight.
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Affiliation(s)
- Kimberly A. HONN
- Sleep and Performance Research Center and Elson S. Floyd
College of Medicine, Washington State University, USA
- *To whom correspondence should be addressed. E-mail:
| | - Hans P.A. VAN DONGEN
- Sleep and Performance Research Center and Elson S. Floyd
College of Medicine, Washington State University, USA
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Abstract
OBJECTIVE The authors surveyed psychiatry residents to determine who participates in moonlighting and to understand their views and opinions on the necessity, importance, and educational value of moonlighting. METHODS An electronic survey was distributed to psychiatry residents at 16 programs nationally. Descriptive characteristics were calculated. Logistic and linear regressions were performed to determine differences between those who moonlight and those who do not and to assess differences in measures of financial distress, quality of life, and work-life balance. RESULTS A total of 173/624 (27.6%) residents participated. Within the subset allowed to moonlight, 50% (47/94) reported moonlighting during prior academic year, for an average of 17.4 ± 8.6 hoursh per month. Within those eligible to moonlight, there were no differences in perceived financial distress, quality of life, work-life balance, and confidence between residents who moonlighted and those who did not. Among moonlighters, 10.6% moonlighted overnight before working the next day, and only 68.1% included moonlighting when recording duty hours. 45% reported no supervision available while moonlighting. CONCLUSIONS In the study sample, 50% of psychiatry residents eligible to moonlight opted to do so. Though most programs have policies in place regarding moonlighting, programs may benefit from ensuring that residents are reporting moonlighting in duty hours and that supervision is available to those moonlighting.
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Barnum TJ, Halverson AL, Helenowski I, Odell DD. All work and no play: Addressing medical students' concerns about duty hours on the surgical clerkship. Am J Surg 2018; 218:419-423. [PMID: 30739737 DOI: 10.1016/j.amjsurg.2018.12.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 12/06/2018] [Accepted: 12/10/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Given the option of preferencing rotations for a 3rd year core surgery clerkship, we observed students often requested services perceived as less time-intensive. We compare self-reported duty hours with academic outcomes. METHODS We examined duty hours from 165 third-year medical students on a surgery clerkship at a single institution for academic year 2016-2017. Partial correlations and logistic regression modeling were used to assess the number of hours medical students worked on academic outcomes. RESULTS Medical student duty hours did not significantly correlate with the NBME Surgery Subject examination score (r = 0.08; p = 0.34), CPE score (r = 0.14; p = 0.09) or a clerkship grade of Honors (OR 0.993; CI 0.925-1.065). Prior completion of an internal medicine clerkship was correlated with a higher NBME Surgery Subject examination score (r = 0.27; p < 0.001). CONCLUSION This analysis demonstrates duty hours on a surgical clerkship do not correlate with academic performance. These data can be used to counsel students on career planning and choosing surgical rotations based on interest and not perceived workload.
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Affiliation(s)
- Trevor J Barnum
- Department of Surgery, Northwestern University Feinberg School of Medicine, 251 E. Huron St., Suite 3-150, Chicago, IL, USA.
| | - Amy L Halverson
- Department of Surgery, Northwestern University Feinberg School of Medicine, 251 E. Huron St., Suite 3-150, Chicago, IL, USA; Center for Healthcare Studies, Institute for Public Health and Medicine, 633 N. St. Clair St., 20th Floor, Chicago, IL, USA.
| | - Irene Helenowski
- Department of Surgery, Northwestern University Feinberg School of Medicine, 251 E. Huron St., Suite 3-150, Chicago, IL, USA.
| | - David D Odell
- Department of Surgery, Northwestern University Feinberg School of Medicine, 251 E. Huron St., Suite 3-150, Chicago, IL, USA; Center for Healthcare Studies, Institute for Public Health and Medicine, 633 N. St. Clair St., 20th Floor, Chicago, IL, USA.
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10
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Abstract
Limitations on resident duty hours have been widely introduced with the intention of decreasing resident fatigue and improving patient outcomes. While there is evidence of improvement in resident well-being and education following such initiatives, they have inadvertently resulted in increased number of hand-offs between clinicians leading to potential errors in patient care. Current literature emphasizes need for more specialty/setting-specific scheduling, while considering residents' opinions when implementing duty-hour reforms. There are no reports examining the impact of duty-hour changes on residents or patients in psychiatric emergency service (PES) settings. Our purpose was to assess the impact of a recent scheduling change and decrease in overall duty hours, on resident well-being and sense of burnout, while also evaluating changes to patient wait-time and length of stay (LOS) in PES. Residents completed Maslach Burnout Inventory and anonymous surveys focusing on: fatigue, sleep, life outside work for shifts - regular (8 am-8 pm) and swing shifts (12 pm-10 pm). Data from the electronic medical records were collected for 6 months pre- and post-schedule change (January 2016-February 2017), for LOS and patient wait-time. Residents' preference for shifts was split. However, 86% reported getting enough sleep during swing shifts, while 83% reported lack of sleep during regular shifts. The average patient wait-time and LOS significantly decreased from 169 to 147 and 690 to 515 min, respectively. The change to swing shifts significantly impacts LOS and patient wait-time. The short shifts demonstrated an improvement in well-being for residents, but were not the singular factor for overall resident satisfaction.
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Affiliation(s)
- Navjot Brainch
- Department of Psychiatry, Maimonides Medical Center, Brooklyn, NY, 11219, USA
| | - Patrick Schule
- Department of Psychiatry, Maimonides Medical Center, Brooklyn, NY, 11219, USA
| | - Faith Laurel
- Department of Psychiatry, Maimonides Medical Center, Brooklyn, NY, 11219, USA
| | - Maria Bodic
- Department of Psychiatry, Maimonides Medical Center, Brooklyn, NY, 11219, USA
| | - Theresa Jacob
- Department of Psychiatry, Maimonides Medical Center, Brooklyn, NY, 11219, USA.
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Ouyang D, Chen JH, Krishnan G, Hom J, Witteles R, Chi J. Patient Outcomes when Housestaff Exceed 80 Hours per Week. Am J Med 2016; 129:993-999.e1. [PMID: 27103047 PMCID: PMC4996740 DOI: 10.1016/j.amjmed.2016.03.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 03/10/2016] [Accepted: 03/10/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND It has been posited that high workload and long work hours for trainees could affect the quality and efficiency of patient care. Duty hour restrictions seek to balance patient care and resident education by limiting resident work hours. Through a retrospective cohort study, we investigated whether patient care on an inpatient general medicine service at a large academic medical center is impacted when housestaff work more than 80 hours per week. METHODS We identified all admissions to a housestaff-run general medicine service between June 25, 2013 and June 29, 2014. Each hospitalization was classified by whether the patient was admitted by housestaff who have worked more than 80 hours per week during their hospitalization. Housestaff computer activity and duty hours were calculated by institutional electronic heath record audit, as well as length of stay and a composite of in-hospital mortality, intensive care unit (ICU) transfer rate, and 30-day readmission rate. RESULTS We identified 4767 hospitalizations by 3450 unique patients; of which 40.9% of hospitalizations were managed by housestaff who worked more than 80 hours that week during their hospitalization. There was a significantly higher rate of the composite outcome (19.2% vs 16.7%, P = .031) for patients admitted by housestaff working more than 80 hours per week during their hospitalization. We found a statistically significant higher length of stay (5.12 vs 4.66 days, P = .048) and rate of ICU transfer (3.53% vs 2.38%, P = .029). There was no statistically significant difference in 30-day readmission rate (13.7% vs 12.8%, P = .395) or in-hospital mortality rate (3.18% vs 2.42%, P = .115). There was no correlation with team census on admission and patient outcomes. CONCLUSIONS Patients taken care of by housestaff working more than 80 hours per week had increased length of stay and number of ICU transfers. There was no association between resident work-hours and patient in-hospital mortality or 30-day readmission rate.
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Affiliation(s)
- David Ouyang
- Department of Internal Medicine, Stanford University School of Medicine, Calif
| | - Jonathan H Chen
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Calif
| | - Gomathi Krishnan
- Stanford Center for Clinical Informatics, Stanford University School of Medicine, Calif
| | - Jason Hom
- Department of Internal Medicine, Stanford University School of Medicine, Calif
| | - Ronald Witteles
- Department of Internal Medicine, Stanford University School of Medicine, Calif
| | - Jeffrey Chi
- Department of Internal Medicine, Stanford University School of Medicine, Calif.
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12
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Yarnell CJ, Shadowitz S, Redelmeier DA. Hospital Readmissions Following Physician Call System Change: A Comparison of Concentrated and Distributed Schedules. Am J Med 2016; 129:706-714.e2. [PMID: 26976386 DOI: 10.1016/j.amjmed.2016.02.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 02/16/2016] [Accepted: 02/17/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Physician call schedules are a critical element for medical practice and hospital efficiency. We compared readmission rates prior to and after a change in physician call system at Sunnybrook Health Sciences Centre. METHODS We studied patients discharged over a decade (2004 through 2013) and identified whether or not each patient was readmitted within the subsequent 28 days. We excluded patients discharged for a surgical, obstetrical, or psychiatric diagnosis. We used time-to-event analysis and time-series analysis to compare rates of readmission prior to and after the physician call system change (January 1, 2009). RESULTS A total of 89,697 patients were discharged, of whom 10,001 (11%) were subsequently readmitted and 4280 died. The risk of readmission was increased by about 26% following physician call system change (9.7% vs 12.2%, P <.001). Time-series analysis confirmed a 26% increase in the readmission rate after call system change (95% confidence interval, 22%-31%; P <.001). The increase in readmission rate after call system change persisted across patients with diverse ages, estimated readmission risks, and medical diagnoses. The net effect was equal to 7240 additional patient days in the hospital following call system change. A modest increase was observed at a nearby acute care hospital that did not change physician call system, and no increase in risk of death was observed with increased hospital readmissions. CONCLUSION We suggest that changes in physician call systems sometimes increase subsequent hospital readmission rates. Further reductions in readmissions may instead require additional resources or ingenuity.
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Affiliation(s)
- Christopher J Yarnell
- Department of Medicine, University of Toronto, Ont., Canada; Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ont., Canada
| | - Steven Shadowitz
- Department of Medicine, University of Toronto, Ont., Canada; Division of General Internal Medicine, University of Toronto, Ont., Canada
| | - Donald A Redelmeier
- Department of Medicine, University of Toronto, Ont., Canada; Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ont., Canada; Division of General Internal Medicine, University of Toronto, Ont., Canada; Institute of Clinical Evaluative Sciences (ICES) in Ontario, Toronto, Canada; Institute for Health Policy Management and Evaluation, Toronto, Ont., Canada.
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13
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Hom J, Richman I, Chen JH, Singh B, Crump C, Chi J. Fulfilling outpatient medicine responsibilities during internal medicine residency: a quantitative study of housestaff participation with between visit tasks. BMC Med Educ 2016; 16:139. [PMID: 27160008 PMCID: PMC4862079 DOI: 10.1186/s12909-016-0665-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 05/05/2016] [Indexed: 05/15/2023]
Abstract
BACKGROUND Internal Medicine residents experience conflict between inpatient and outpatient medicine responsibilities. Outpatient "between visit" responsibilities such as reviewing lab and imaging data, responding to medication refill requests and replying to patient inquiries compete for time and attention with inpatient duties. By examining Electronic Health Record (EHR) audits, our study quantitatively describes this balance between competing responsibilities, focusing on housestaff participation with "between visit" outpatient responsibilities. METHODS We examined EHR log-in data from 2012-2013 for 41 residents (R1 to R3) assigned to a large academic center's continuity clinic. From the EHR log-in data, we examined housestaff compliance with "between visit" tasks, based on official clinic standards. We used generalized estimating equations to evaluate housestaff compliance with between visit tasks and amount of time spent on tasks. We examined the relationship between compliance with between visit tasks and resident year of training, rotation type (elective or required) and interest in primary care. RESULTS Housestaff compliance with logging in to complete "between visit" tasks varied significantly depending on rotation, with overall compliance of 45% during core inpatient rotations compared to 68% during electives (p = 0.01). Compliance did not significantly vary by interest in primary care or training level. Once logged in, housestaff spent a mean 53 min per week logged in while on electives, compared to 55 min on required rotations (p = 0.90). CONCLUSIONS Our study quantitatively highlights the difficulty of attending to outpatient responsibilities during busy core inpatient rotations, which comprise the bulk of residency at our institution and at others. Our results reinforce the need to continue development and study of innovative systems for coverage of "between visit" responsibilities, including shared coverage models among multiple residents and shared coverage models between residents and clinic attendings, both of which require a balance between clinic efficiency and resident ownership, autonomy and learning.
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Affiliation(s)
- Jason Hom
- Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, HC007, Stanford, CA, 94305-5133, USA.
| | - Ilana Richman
- Center for Innovation to Implementation at the Veteran Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Center for Health Policy/Primary Care and Outcomes Research at Stanford University, Stanford, CA, USA
| | - Jonathan H Chen
- Center for Innovation to Implementation at the Veteran Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Center for Health Policy/Primary Care and Outcomes Research at Stanford University, Stanford, CA, USA
| | - Baldeep Singh
- Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, HC007, Stanford, CA, 94305-5133, USA
| | - Casey Crump
- Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, HC007, Stanford, CA, 94305-5133, USA
| | - Jeffrey Chi
- Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, HC007, Stanford, CA, 94305-5133, USA
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Abstract
PURPOSE In an era of residency duty-hour restrictions, there has been a recent effort to implement simulation-based training methods in neurosurgery teaching institutions. Several surgical simulators have been developed, ranging from physical models to sophisticated virtual reality systems. To date, there is a paucity of information describing the clinical benefits of existing simulators and the assessment strategies to help implement them into neurosurgical curricula. Here, we present a systematic review of the current models of simulation and discuss the state-of-the-art and future directions for simulation in neurosurgery. METHODS Retrospective literature review. RESULTS Multiple simulators have been developed for neurosurgical training, including those for minimally invasive procedures, vascular, skull base, pediatric, tumor resection, functional neurosurgery, and spine surgery. The pros and cons of existing systems are reviewed. CONCLUSION Advances in imaging and computer technology have led to the development of different simulation models to complement traditional surgical training. Sophisticated virtual reality (VR) simulators with haptic feedback and impressive imaging technology have provided novel options for training in neurosurgery. Breakthrough training simulation using 3D printing technology holds promise for future simulation practice, proving high-fidelity patient-specific models to complement residency surgical learning.
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Affiliation(s)
- Roberta Rehder
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, Massachusetts, 02115, USA
| | - Muhammad Abd-El-Barr
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, Massachusetts, 02115, USA
| | - Kristopher Hooten
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Peter Weinstock
- Department of Anesthesia, Pediatric Simulator Program Director, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Joseph R Madsen
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, Massachusetts, 02115, USA
| | - Alan R Cohen
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, Massachusetts, 02115, USA.
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15
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Denson JL, McCarty M, Fang Y, Uppal A, Evans L. Increased Mortality Rates During Resident Handoff Periods and the Effect of ACGME Duty Hour Regulations. Am J Med 2015; 128:994-1000. [PMID: 25863148 DOI: 10.1016/j.amjmed.2015.03.023] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Accepted: 03/23/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Medical errors occur following handoff-related miscommunication. Data regarding the effect on patient-centered outcomes, specifically mortality, are lacking. Our objective was to investigate handoff-related mortality and the effect of duty-hour regulations. METHODS Retrospective cohort study of adult medical patients at a public, university-affiliated hospital from 2010 to 2012. Patients were divided into 2 cohorts: handoff group (discharged within 7 days following a change in resident physician team) vs control group (discharged the 3 weeks of each 4-week rotation before resident service change). The primary outcome was unadjusted and adjusted hospital mortality rate. As a secondary prespecified analysis, we examined the effect of 2011 Accreditation Council for Graduate Medical Education (ACGME) duty-hour changes. RESULTS Among 23,736 patients, unadjusted hospital mortality during the handoff group was higher than the control group (2.68% vs 2.08%, respectively; P = .007; odds ratio [OR] 1.30; 95% confidence interval [CI], 1.08-1.57). Following adjustment, this association remained statistically significant (adjusted OR 1.34; P = .003; 95% CI, 1.10-1.62). Similarly, pre-duty-hour unadjusted hospital mortality was higher in the handoff group vs control group (2.87% vs 2.01%, respectively; P = .006; OR 1.44; 95% CI, 1.11-1.86), which remained statistically significant following adjustment (adjusted OR 1.50; P = .002; 95% CI, 1.16-1.95). However, this association lost statistical significance following duty-hour revision with respect to both unadjusted (2.48% vs 2.15%, respectively; P = .30; OR 1.16; 95% CI, 0.88-1.53) and adjusted mortality (OR 1.18; P = .26; 95% CI, 0.89-1.56). CONCLUSIONS Resident transition in care was significantly associated with an increase in unadjusted and adjusted hospital mortality. Although improved by 2011 ACGME duty-hour amendments, a trend toward higher mortality remained following resident handoff.
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Affiliation(s)
- Joshua L Denson
- Department of Internal Medicine, Bellevue Hospital Center, New York University School of Medicine, New York.
| | - Matthew McCarty
- Department of Emergency Medicine, New York University School of Medicine, New York
| | - Yixin Fang
- Division of Biostatistics, Department of Population Health, New York University School of Medicine, New York
| | - Amit Uppal
- Division of Pulmonary, Critical Care and Sleep Medicine, Bellevue Hospital Center, New York University School of Medicine, New York
| | - Laura Evans
- Division of Pulmonary, Critical Care and Sleep Medicine, Bellevue Hospital Center, New York University School of Medicine, New York
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