Where have all the giants gone? Reconciling medical education and the traditions of patient care with limitations on resident work hours

The Accreditation Council for Graduate Medical Education recently approved regulations that would prohibit residents from working more than 80 hours per week and more than 24 hours at a stretch. These regulations are scheduled to take effect in all U.S. teaching hospitals on 1 July 2003. Those who approve of the proposed regulations argue that house staff fatigue is responsible for physician error, depression, anger, and a lack of compassion for patients. But critics point to the adverse effects on key goals of house staff training--the development of accountability and responsibility. Can the rigorous discipline of medical education and the long tradition of medicine as a profession be reconciled with the current calls for limiting resident duty hours and on-call schedules? The intensity of patient care in teaching hospitals today is far greater than it was in the past. These changes in medical care make it critical to develop new programs that will reconcile rigorous, scientifically based humanistic medicine with the needs of patients and physicians. This will require imaginative and creative solutions that take a larger view of medical education and medical care than mere manpower calculations and numerical solutions focused simply on compliance with an 80-hour work week.     

Fatigue and concerns about quality of care among Ontario interns and residents.

In postgraduate medical training the heavy and irregular workloads are thought to result in fatigue and a potential decrease in the quality of care provided by interns and residents. We investigated these concerns among Ontario interns and residents. Information from 1805 house staff in all specialties and different years of postgraduate education suggested a relation between hours of work, fatigue and concerns about the quality of care.     

Patient safety,resident well-being and continuity of care with different resident duty schedules in the intensive care unit: a randomized trial

Background:

Shorter resident duty periods are increasingly mandated to improve patient safety and physician well-being. However, increases in continuity-related errors may counteract the purported benefits of reducing fatigue. We evaluated the effects of 3 resident schedules in the intensive care unit (ICU) on patient safety, resident well-being and continuity of care.

Methods:

Residents in 2 university-affiliated ICUs were randomly assigned (in 2-month rotation-blocks from January to June 2009) to in-house overnight schedules of 24, 16 or 12 hours. The primary patient outcome was adverse events. The primary resident outcome was sleepiness, measured by the 7-point Stanford Sleepiness Scale. Secondary outcomes were patient deaths, preventable adverse events, and residents’ physical symptoms and burnout. Continuity of care and perceptions of ICU staff were also assessed.

Results:

We evaluated 47 (96%) of 49 residents, all 971 admissions, 5894 patient-days and 452 staff surveys. We found no effect of schedule (24-, 16- or 12-h shifts) on adverse events (81.3, 76.3 and 78.2 events per 1000 patient-days, respectively; p = 0.7) or on residents’ sleepiness in the daytime (mean rating 2.33, 2.61 and 2.30, respectively; p = 0.3) or at night (mean rating 3.06, 2.73 and 2.42, respectively; p = 0.2). Seven of 8 preventable adverse events occurred with the 12-hour schedule (p = 0.1). Mortality rates were similar for the 3 schedules. Residents’ somatic symptoms were more severe and more frequent with the 24-hour schedule (p = 0.04); however, burnout was similar across the groups. ICU staff rated residents’ knowledge and decision-making worst with the 16-hour schedule.

Interpretation:

Our findings do not support the purported advantages of shorter duty schedules. They also highlight the trade-offs between residents’ symptoms and multiple secondary measures of patient safety. Further delineation of this emerging signal is required before widespread system change. Trial registration: ClinicalTrials.gov, no. {"type":"clinical-trial","attrs":{"text":"NCT00679809","term_id":"NCT00679809"}}NCT00679809.Physician fatigue is common, is associated with worse physician well-being and more medical errors than for well-rested clinicians, and may compromise patient safety.^1–3 Shorter duty hours are purported to address these concerns,^4,5 but they necessitate more care transitions, which increases the risk of information loss.^6,7 The net effect on patient safety therefore depends on the relative balance between fatigue and continuity.^8–13 Currently, high-quality data to guide scheduling decisions are limited.The complexity, acuity and therapeutic intensity of patients’ conditions and their care make the intensive care unit (ICU) an ideal environment to evaluate the trade-offs between physician fatigue and continuity. Prior randomized studies have evaluated data for interns¹⁴ or intensivists,¹⁵ rather than the residents who provide most in-house overnight care in Canadian ICUs.¹⁶ We evaluated the impact of 3 commonly used schedules⁵ on patient safety and resident well-being.     

Evolving residency requirements for ambulatory care training for five medical specialties, 1961 to 1989.

Recent changes in the patient population of teaching hospitals, spurred by technologic advances and economic forces, have jeopardized the traditional hospital-based model of residency training. In consequence, there has been increasing attention paid to the need for ambulatory care experience. A primary force in shaping the content of postgraduate medical education is "The Essentials of Accredited Residencies," published in the Directory of Graduate Medical Education Programs. We reviewed recommendations and requirements for ambulatory settings and outpatient experience as specified in the Directory during the years 1961 to 1988 and investigated pending changes in requirements for five major specialties: internal medicine, pediatrics, family practice, general surgery, and obstetrics and gynecology. Increases in the amount of time residents spend in ambulatory care training recently have been mandated in internal medicine and are under consideration in two other specialties, indicating probable major shifts in the locus of postgraduate medical training.     

Personality Traits Affect Teaching Performance of Attending Physicians: Results of a Multi-Center Observational Study

Background

Worldwide, attending physicians train residents to become competent providers of patient care. To assess adequate training, attending physicians are increasingly evaluated on their teaching performance. Research suggests that personality traits affect teaching performance, consistent with studied effects of personality traits on job performance and academic performance in medicine. However, up till date, research in clinical teaching practice did not use quantitative methods and did not account for specialty differences. We empirically studied the relationship of attending physicians'' personality traits with their teaching performance across surgical and non-surgical specialties.

Method

We conducted a survey across surgical and non-surgical specialties in eighteen medical centers in the Netherlands. Residents evaluated attending physicians'' overall teaching performance, as well as the specific domains learning climate, professional attitude, communication, evaluation, and feedback, using the validated 21-item System for Evaluation of Teaching Qualities (SETQ). Attending physicians self-evaluated their personality traits on a 5-point scale using the validated 10-item Big Five Inventory (BFI), yielding the Five Factor model: extraversion, conscientiousness, neuroticism, agreeableness and openness.

Results

Overall, 622 (77%) attending physicians and 549 (68%) residents participated. Extraversion positively related to overall teaching performance (regression coefficient, B: 0.05, 95% CI: 0.01 to 0.10, P = 0.02). Openness was negatively associated with scores on feedback for surgical specialties only (B: −0.10, 95% CI: −0.15 to −0.05, P<0.001) and conscientiousness was positively related to evaluation of residents for non-surgical specialties only (B: 0.13, 95% CI: 0.03 to 0.22, p = 0.01).

Conclusions

Extraverted attending physicians were consistently evaluated as better supervisors. Surgical attending physicians who display high levels of openness were evaluated as less adequate feedback-givers. Non-surgical attending physicians who were conscientious seem to be good at evaluating residents. These insights could contribute to future work on development paths of attending physicians in medical education.     

Telemedicine in plastic surgery: E-consult the attending surgeon

Telemedicine has evolved into a valuable but underused resource for the delivery of health care to patients at a distance, particularly where patient transport is impractical, expensive, complicated, and/or urgent. Today, over 250,000 telemedicine consults are generated annually, involving various specialties in both military and civilian health delivery systems. The ability to evaluate and triage plastic surgery patients through the use of telemedicine has not been widely explored. We have designed, developed, and tested a "store-and-forward" solution at UMass Memorial Hospital and Beth Israel Deaconess Hospital whereby the plastic surgery residents who responded to a consult request transmitted digital photographs by means of the Internet to the attending physician on call. The customary telephone call between resident and attending physician benefited from the additional photographic data, and patient management resulted in a clear, concise, and unambiguous treatment plan. The initial management suggested by the resident was modified on some occasions, particularly with complex problems. The use of digital images was especially helpful for evaluation of radiographs and complex wounds of the hand and face. The solution proved to be very valuable for both attending physicians and residents in plastic surgery. The photographs provide rich detail and resolution comparable to high-quality prints. The mechanics of obtaining images and the process of sending them electronically was readily mastered. Images reached their destination in only a few minutes over standard telephone lines. No problems were encountered while sending or viewing images on Macintosh or Windows platforms. Determining course of action with a complete clinical history now includes a level of visual detail previously not available. As this application expands into wider use, data integrity and safety will have to be more formally secured and monitored. Our model of telemedicine has broad-reaching ramifications for the improvement of health-care delivery locally, nationally, and internationally.     

中国临终关怀服务现状与伦理探讨

随着社会经济的发展、人口老龄化和疾病谱的改变,临终关怀已成为我国社会所关注的重要民生问题,也成为医学伦理的热点。该文结合中国生命关怀协会对我国城市临终关怀服务利用与需要状况的调研,反映当前我国城市临终关怀服务的基本特征,对临终关怀中涉及医学伦理的部分概念,以及临终关怀服务中的相关权益进行阐述,并建议应当在逐步完善全民医疗保健制度的基础上,健全服务体系,包括临终关怀伦理道德法规体系,才能更好地为临终患者服务,提高患者的生命质量。     

Adolescent Medicine: Attitudes,Training, and Experience Of Pediatric,Family Medicine,and Obstetric-Gynecology Residents

Purpose: Several studies have documented a deficiency in the delivery of preventive services to adolescents during physician visits in the United States. This study sought to assess and compare pediatric, family medicine (FM), and obstetrics and gynecology (OB/GYN) resident perceptions of their responsibility, training, and experience with providing comprehensive health care services to adolescents.Methods: A 57-item, close-ended survey was designed and administered to assess resident perceptions of the scope of their practice, training, and experience with providing adolescent health care across a series of health care categories.Results: Of the 87 respondents (31 OB/GYN, 29 FM, and 27 pediatric), most residents from all three fields felt that the full range of adolescent preventive and clinical services represented in the survey fell under their scope of practice. Residents from all three fields need more training and experience with mental health issues, referring teenagers to substance abuse treatment programs, and addressing physical and sexual abuse. In addition, OB-GYN residents reported deficiencies in training and experience regarding several preventive counseling and general health services, while pediatric residents reported deficiencies in training and experience regarding sexual health services.Conclusions: Our results indicate that at this time, residents from these three specialties are not optimally prepared to provide the full range of recommended preventive and clinical services to adolescents.     

Day-night pattern in accidental exposures to blood-borne pathogens among medical students and residents

The purpose of this study was to determine whether the occurrence of accidental blood-borne pathogen exposure incidents in medical students and residents in training varies during the 24 h. A retrospective review of reported exposures was conducted in a large urban teaching institution--the University of Texas Health Science Center in Houston--between November 1993 and July 1998. Professional level (year of student or level of resident), time of exposure, means/route of exposure (needle stick, laceration, or splash), and type of medical service were recorded. Analysis of the clock time of the 745 reported blood-borne pathogen exposures showed they occurred more frequently during the day than night. Over the nearly 5-year span, 531 incidents took place between 06:00 and 17:59 in comparison to only 214 between 18:00 and 05:59. To account for the day-night difference in medical student and resident hospital staffing, the data were reexpressed as exposure rates, that is, in terms of the number of events per hour per 1000 medical students and residents. Based on the total number of reported exposures over the almost 5-year span of data collection, the average rate was 40 accidents per hour per 1000 doctors in training during the 12 h daytime span (6:00-17:59). It was 50% greater at night (18:00-05:59), with 60 incidents per hour per 1000 doctors in training. The day-night difference in rate of exposures was statistically significant (p < .04). The relative risk ratio for residents and students when working during the day shift compared to working the night shift was 0.67. This means that doctors in training are at a 1.50 higher risk of sustaining a blood-borne pathogen exposure when working nights than when working days.     

Educating Internists in Emergency Medicine

The education of internists in emergency medicine needs to be thoughtfully planned by those involved in their education. Objectives for their emergency medicine rotation include the recognition and initial treatment of true medical and surgical emergencies, clinical experience with and knowledge of common acute primary care problems, the ability to handle several patients with problems having different degrees of urgency, effective use of consultants in the follow-up and management of difficult patients and a knowledge of and clinical experience with the prehospital care system. A curriculum should be designed to give the resident a core of didactic material in addition to supervised clinical experience. The rotation should be evaluated by both residents and faculty from internal medicine and emergency medicine to determine if it is accomplishing the objectives set forth.     

"Sweeping up after the parade": professional, ethical, and patient care implications of "turfing"

"Turfing" denotes a patient transfer or triage from one physician to another when the care of that patient feels more troublesome than it is worth. A widespread phenomenon in medical training programs, turfing appears to allocate patient care to meet physicians' rather than patients' needs. Although turfing reportedly causes inter-physician discord and inter-specialty stereotyping, its deeper consequences are poorly understood. Turfing is an interpersonal conflict masquerading as a medical issue. After examining turfing alongside other patient-related slang, I analyze the distinction between "the turf," a person, and "to turf," a practice. Several explanatory models from medical practice are explored in order to illuminate turfing's implications for medical professionalism, ethics, and patient care. I suggest that a physician's medical specialty or practice type--that is, professional culture--may link to that physician's degree of altruism. If so, then what it means fundamentally to be a physician might vary across medical specialties. Such a link calls for a new notion of cultural competence, one that physicians may apply not to patients but to each other.     

Dying in hospital: the residents' viewpoint

A survey of residents'' (junior house officers'') experiences and attitudes to the terminal care part of their work in four Glasgow teaching hospitals showed that even a month after starting work one-fifth of the respondents had not actively managed a dying patient. Sixty-four per cent thought that they had received inadequate teaching in terminal care. Depression and anxiety had been the most difficult symptoms encountered. The residents thought that the ward nursing staff contributed much more than their senior medical colleagues to both the medical and psychological aspects of terminal care. The results indicate a need for more undergraduate education in the most relevant areas, such as coping with the psychological problems of dying patients and their relatives. Newly qualified residents require more support from senior medical staff in looking after the terminally ill.     

An Approach to Patient Care Classification

Employing the principles of progressive patient care and using data obtained from charts, nurses and resident physicians, 265 patients on the wards of a teaching hospital were classified into one of six optimal levels of care by the resident physicians and also by an outside observer. It was assumed that facilities for the three alternatives to general hospital care, i.e. long-term hospital care, nursing care and sheltered care, were available in the community. It was also assumed that socio-economic factors presented no barrier to hospital discharge.The outside observer allocated 96 patients, approximately one-third, to the alternative facilities outside the general hospital. Those factors found to have statistically significant effects on assigned levels of care were the diagnoses, length of stay, region of residence, bed status, extent of nursing care, hospital service and discharge status. The residents allocated 60 patients, approximately one-fifth, to alternative facilities.The extent of agreement between the residents and the outside observer reached 81% for those to alternate versus general hospital care.This method could be used by nurses and residents to screen out those most suitable for care in alternate facilities.     

规范医学影像诊断报告书写,提高医学生及住院医师临床技能

医学影像诊断报告是正确行使医疗行为和保证医疗质量的依据,书写高质量的医学影像学诊断报告是医学生及住院医师必须掌握的一项基本功和基本技能。本文将结合我院长期的医学生及住院医师临床教学经验和实际,以神经系统影像报告为例,从医学影像诊断报告的重要性、医学生及住院医师医学影像诊断报告技能教学的现状、规范化医学影像报告书写技能的培养、评估、反馈和评价进行探讨,以期在医学生和住院医师的培养中提高其临床技能,供广大同道在医学教育与实践中借鉴和改进。     

La participación de personas con demencia en las reuniones del plan de atención individualizada: impacto en el bienestar y la calidad del cuidado

Introduction

An individualised intervention plan (IIP) offers a new paradigm in the care of the elderly with dementia, with the aim of increasing their quality of life through personalisation, respect for their freedom, and their participation in the decisions that affect their lives.

Objective

To evaluate the impact of the residential home patient with dementia and their quality of care when they take part in the interdisciplinary meeting in which their care plan is decided.

Material and methods

A total of 52 elderly patients with dementia took part in the study. They were distributed into two groups, one experimental (37 residents) and another control (15 residents). The Dementia Care Mapping (DCM) tool was used to assess the well-being and quality of care of the residents. This tool was used twice, before and after the intervention.

Results

The well-being of the resident, evaluated using the DCM, was similar before and after the intervention in the experimental group. No differences were observed either on comparing the control and experimental groups. However, some indicators of carer behaviour were different before and after the intervention, and when the control and experimental group were compared.

Conclusion

The inclusion of elderly persons with dementia in their IIP meeting had a positive effect in the interaction of the staff with the residents, but not on the well-being of the resident.     

Impact of night-float rotation on sleep,mood, and alertness: the resident's perception

Night-float rotations were designed to alleviate the workload of residents on night call and thereby improve patient safety. However, the impact of the night float on residents is yet to be surveyed. We assessed the impact of the night-float rotation on pediatric residents using an anonymous questionnaire that covered topics, based on recall, about sleep, mood, alertness, adjustment, and others. The study was conducted in a major tertiary pediatric teaching hospital in the United States. Participants were pediatric residents who had completed one or two night-float rotations and were in active training at our teaching hospital at the time of the study. Fifty-two of 60 eligible residents (87%) responded. Sleep duration during the night-float rotation was shorter than during day-shift work in 24 residents (46%), longer in 20 (38%), and unchanged in eight (15%). A higher proportion of residents took longer to fall asleep, had more difficulty falling asleep, had more sleep interruptions, and felt less rested upon awakening. Twenty-four residents (46%) felt that their bodies never adjusted to the night shift. Also, 22 residents (43%) felt moody or depressed in contrast to seven (14%) who felt depressed during the daytime rotation (p=0.0001). Twenty-one residents (41%) felt they were slower in their thinking during the night float than daytime rotations. The results suggest that disturbances of sleep and mood and decreased alertness, typical of night shift, are present in the night-float rotation. Residency programs should monitor closely the impact of the night-float rotation on resident well being and patient safety. The impact of night-shift work should be considered in the design of night-float schedules, and teaching should be provided for residents to learn coping strategies for night-shift work.     

Estimating the impact of divergent mating phenology between residents and migrants on the potential for gene flow

Gene flow between populations can allow the spread of beneficial alleles and genetic diversity between populations, with importance to conservation, invasion biology, and agriculture. Levels of gene flow between populations vary not only with distance, but also with divergence in reproductive phenology. Since phenology is often locally adapted, arriving migrants may be reproductively out of synch with residents, which can depress realized gene flow. In flowering plants, the potential impact of phenological divergence on hybridization between populations can be predicted from overlap in flowering schedules—the daily count of flowers capable of pollen exchange—between a resident and migrant population. The accuracy of this prospective hybridization estimate, based on parental phenotypes, rests upon the assumptions of unbiased pollen transfer between resident and migrant active flowers. We tested the impact of phenological divergence on resident–migrant mating frequencies in experiments that mimicked a single large gene flow event. We first prospectively estimated mating frequencies two lines of Brassica rapaselected or early and late flowering. We then estimated realized mating frequencies retrospectively through progeny testing. The two estimates strongly agreed in a greenhouse experiment, where procedures ensured saturating, unbiased pollination. Under natural pollination in the field, the rate of resident–migrant mating, was lower than estimated by phenological divergence alone, although prospective and retrospective estimates were correlated. In both experiments, differences between residents and migrants in flowering schedule shape led to asymmetric hybridization. Results suggest that a prospective estimate of hybridization based on mating schedules can be a useful, although imperfect, tool for evaluating potential gene flow. They also illustrate the impact of mating phenology on the magnitude and symmetry of reproductive isolation.     

IMPACT OF NIGHT-FLOAT ROTATION ON SLEEP,MOOD, AND ALERTNESS: THE RESIDENT'S PERCEPTION

Night-float rotations were designed to alleviate the workload of residents on night call and thereby improve patient safety. However, the impact of the night float on residents is yet to be surveyed. We assessed the impact of the night-float rotation on pediatric residents using an anonymous questionnaire that covered topics, based on recall, about sleep, mood, alertness, adjustment, and others. The study was conducted in a major tertiary pediatric teaching hospital in the United States. Participants were pediatric residents who had completed one or two night-float rotations and were in active training at our teaching hospital at the time of the study. Fifty-two of 60 eligible residents (87%) responded. Sleep duration during the night-float rotation was shorter than during day-shift work in 24 residents (46%), longer in 20 (38%), and unchanged in eight (15%). A higher proportion of residents took longer to fall asleep, had more difficulty falling asleep, had more sleep interruptions, and felt less rested upon awakening. Twenty-four residents (46%) felt that their bodies never adjusted to the night shift. Also, 22 residents (43%) felt moody or depressed in contrast to seven (14%) who felt depressed during the daytime rotation (p=0.0001). Twenty-one residents (41%) felt they were slower in their thinking during the night float than daytime rotations. The results suggest that disturbances of sleep and mood and decreased alertness, typical of night shift, are present in the night-float rotation. Residency programs should monitor closely the impact of the night-float rotation on resident well being and patient safety. The impact of night-shift work should be considered in the design of night-float schedules, and teaching should be provided for residents to learn coping strategies for night-shift work.     

The sleep, subjective fatigue, and sustained attention of commercial airline pilots during an international pattern

International commercial airline pilots may experience heightened fatigue due to irregular sleep schedules, long duty days, night flying, and multiple time zone changes. Importantly, current commercial airline flight and duty time regulations are based on work/rest factors and not sleep/wake factors. Consequently, the primary aim of the current study was to investigate pilots' amount of sleep, subjective fatigue, and sustained attention before and after international flights. A secondary aim was to determine whether prior sleep and/or duty history predicted pilots' subjective fatigue and sustained attention during the international flights. Nineteen pilots (ten captains, nine first officers; mean age: 47.42+/-7.52 years) participated. Pilots wore wrist activity monitors and completed sleep and duty diaries during a return pattern from Australia to Europe via Asia. The pattern included four flights: Australia-Asia, Asia-Europe, Europe-Asia, and Asia-Australia. Before and after each flight, pilots completed a 5 min PalmPilot-based psychomotor vigilance task (PVT) and self-rated their level of fatigue using the Samn-Perelli Fatigue Checklist. Separate repeated-measures ANOVAs were used to determine the impact of stage of flight and flight sector on the pilots' sleep in the prior 24 h, self-rated fatigue, and PVT mean response speed. Linear mixed model regression analyses were conducted to examine the impact of sleep in the prior 24 h, prior wake, duty length, and flight sector on pilots' self-rated fatigue and sustained attention before and after the international flights. A significant main effect of stage of flight was found for sleep in the prior 24 h, self-rated fatigue, and mean response speed (all p < 0.05). In addition, a significant main effect of flight sector on self-rated fatigue was found (p < .01). The interaction between flight sector and stage of flight was significant for sleep in the prior 24 h and self-rated fatigue (both p < .05). Linear mixed model analyses indicated that sleep in the prior 24 h was a significant predictor of self-rated fatigue and mean response speed after the international flight sectors. Flight sector was also a significant predictor of self-rated fatigue. These findings highlight the importance of sleep and fatigue countermeasures during international patterns. Furthermore, in order to minimize the risk of fatigue, the sleep obtained by pilots should be taken into account in the development of flight and duty time regulations.