Junior House Staff Research Articles

A Reduced Duty Hours Model for Senior Internal Medicine Residents: A Qualitative Analysis of Residents' Experiences and Perceptions.

To assess senior internal medicine residents' experience of the implementation of a reduced duty hours model with night float, the transition from the prior 26-hour call system, and the new model's effects on resident quality of life and perceived patient safety in the emergency department and clinical teaching unit at McMaster University. Qualitative data were collected during May 2013-July 2014, through resident focus groups held prior to implementation of a reduced duty hours model and 10 to 12 months postimplementation. Data analysis was guided by a constructivist grounded theory based in a relativist paradigm. Transcripts were coded; codes were collapsed into themes. Thematic analysis revealed five themes. Residents described reduced fatigue in the early morning, counterbalanced with worsened long-term fatigue on night float blocks; anticipation of negative impacts of the loss of distributed on-call experience and on-call shift volume; an urgency to sleep postcall in anticipation of consecutive night float shifts accompanied by conflicting role demands to stay postcall for care continuity; increased handover frequency accompanied by inaccurate/incomplete communication of patients' issues; and improvement in the senior resident experience on the clinical teaching unit, with increased ownership over patient care and improved relationships with junior housestaff. A reduced duty hours model with night float has potential to improve residents' perceived fatigue on call and care continuity on the clinical teaching unit. This must be weighed against increased handover frequency and loss of the postcall day, which may negatively affect patient care and resident quality of life.

Bedside Echocardiographically Guided Pericardiocentesis for Cardiac Tamponade after Coronary Artery Injury Secondary to Percutaneous Coronary Intervention: A Case Report and Descriptive Technique

Given over 2.64 million total percutaneous coronary interventions performed in the United States, and that acute cardiac tamponade is one of the most common complications of such percutaneous coronary interventions, clinicians should be familiar with diagnosing impending pericardial tamponade, and a simple and safe bedside technique for drainage. We describe a technique for echocardiographically guided rescue pericardiocentesis in the setting of acute tamponade to demonstrate the efficacy and safety of this technique for pericardial drainage with reduced complication risk as compared to a landmark-based approach. A case of a 52-year-old male was brought to the Emergency Department after a witnessed cardiac arrest. He underwent cardiac catheterization and percutaneous coronary stent implantation. Thirty minutes after stenting, the patient developed signs of cardiac tamponade, and point-of-care echocardiogram confirmed a pericardial effusion. An in-plane ultrasound-guided pericardiocentesis was successfully performed by the junior house-staff under direct attending supervision. Serial echocardiograms demonstrated preserved left ventricular systolic function without new effusion. The patient remained hemodynamically stable for 48 hrs following the procedure at which time the pericardial catheter was removed. Ultrasound image guided pericardiocentesis is a rapid and safe technique for pericardial drainage with reduced complication risk as compared to a landmark-based approach.

The practice of surgery.

The Practice of Surgery Karen Devon There’s no one on the snowy road driving beside me. It’s Christmas Eve, the night the newest attending surgeon on staff gets to be on call. Tonight feels like an anniversary of sorts. The first time I performed an appendectomy “alone” was on Christmas Eve. I can’t recall if it was snowing back then since I hadn’t left the hospital in days. I had assumed that while I was operating on that 26–year–old woman with new abdominal pain that moved towards the left lower quadrant, my attending staff on call was sleeping soundly. I didn’t even know where he lived, or how long it would take if something catastrophic were to happen. I phoned the white–haired man to get his blessing just before midnight. “Have you done this operation before?” he asked. “Yes, several, but not completely alone” I confessed. “Go for it and call me when you are done. Oh, and be safe!” Click. Gulp. As I drive in tonight, again past midnight, I reflect upon that night. Was it practice? A right of passage? The most appropriate treatment for the patient? Perhaps it was even safer this way since my attending really had never done this operation the way it is now done—laparoscopically—by residents. I clearly recall telling the patient and her mother, “We do this all the time! The staff surgeon on call will come in if I need him, but the chief residents always do this operation and I feel comfortable taking care of you.” Sign on the dotted line and make sure you read the part where you are told this is a teaching hospital. Not only was independence an expectation, but I was also supposed to teach the more junior house staff how to emulate what I was so expertly performing. That night I took out the rotting appendix without incident and called the grey haired surgeon in the wee hours. “Merry Christmas Doctor. Sorry to bother you. I just wanted to let you know that the patient is awake and doing well.” “Yes I know. Good work” he replied. “I was in my office. Just in case.” As a resident, I was often torn between the need to gain independence in order to learn and grow as a surgeon, and the idea that I was practicing. As most budding surgeons do, I wanted to be the person doing the surgery. Working on my technical skills was clearly an important part of expertise. Surgery is inherently different than other types of medicine. It seemed slightly more difficult for someone to stop my cutting, than to catch the error in a prescription, before some damage is done. Perhaps a little more like driving a car, than learning to use a calculator. Recently a more modern surgical education is evolving, whereby students practice by simulations on machines. Yet educators know that ultimately many “firsts” need to occur with real patients. That proficiency and expertise are more than a diagnosis, a steady hand, or even the two combined. If the experience of operating as the primary surgeon without immediate supervision, on a patient with acute appendicitis never occurred until we passed licensing exams wouldn’t that be more harmful? I may have been the least legally responsible for outcomes, that night of my own first, when the grey–haired surgeon took the [End Page E1] responsibility of trusting me. But in fact, the obligation I felt was enormous. We cannot simulate the weight of responsibility that comes when responsible for another human being, who you have met and who provides their trust in you. Furthermore, as the teachers of this art and science, we need to balance our obligations to each individual patient with our obligation to society to train competent and caring future surgeons. Surgery would have no history if the “practice” of surgery had nothing to do with practice, defined in its simplest form, yet how do we cover all of this during the late night conversation that is called informed consent. Interestingly since that December evening and for the next 200 laparoscopic appendectomies before my graduation in to...

Evaluation of an Advanced Trauma Life Support course in Taiwan

The Advanced Trauma Life Support (ATLS) course was implemented in Taiwan by the Taiwan Surgical Association in 1996. The purpose of this study was to examine whether the ATLS course increases physicians' ability to care for severely injured patients and to identify areas for improvement in running the course. We prospectively collected the demographic data of participants for the ATLS provider and refresher courses held in 2012. We analyzed the passing rates (PRs) of the courses stratified by age, sex, types of hospitals, levels of trauma centers, and participant subspecialty. We also compared the students' pre- and post-test responses to multiple-choice questions (MCQs). Statistical significance was set at p < 0.05. A total of 274 and 258 participants attended the provider and refresher courses, respectively. Five hundred (94%) participants were from either medical centers or regional hospitals and 437 also worked at trauma centers. The PR was affected by the age and the levels of the trauma centers in which the participants worked but not by sex or levels of training. More post-test MCQs on initial assessment and airway management topics were answered correctly than were pretest MCQs on the same topics ( p < 0.0001). By comparison, more responses to shock-management MCQs were answered incorrectly ( p < 0.0001). The ATLS course is a critical learning experience for physicians treating trauma patients. Junior house staff and physicians working at local hospitals, particularly those in rural areas, should be encouraged to attend the ATLS course.

Improving the Management of Diabetes in Hospitalized Patients: The Results of a Computer-Based House Staff Training Program

Poorly controlled diabetes in hospitalized patients is associated with poor clinical outcomes. We hypothesized that computer-based diabetes training could improve house staff knowledge and comfort for the management of diabetes in a large tertiary-care hospital. We implemented a computer-based training program on inpatient diabetes for internal medicine house staff at the Brigham and Women's Hospital (Boston, MA) in September 2009. House staff were required to complete the program and answer a set of questions, before and after the program, to evaluate their level of comfort and knowledge of inpatient diabetes. Chart reviews of all non-critically ill patients with diabetes managed by house staff in August 2009 (before the program) and December 2009 (after the program) were performed. Chart reviews were also performed for August 2008 and December 2008 to compare house staff management practices when the computer-based educational program was not available. A significant increase in comfort levels and knowledge in the management of inpatient diabetes was seen among house staff at all levels of training (P<0.02), but the increase was smaller for senior house staff compared with junior house staff. Nonsignificant trends suggesting increased use of basal-bolus insulin (P=0.06) and decreased use of sliding-scale insulin (P=0.10) were seen following the educational intervention in 2009, whereas no such change was seen in 2008 (P>0.90). Overall, house staff evaluated the training program as "very relevant" and the technology interface as "good." A computer-based diabetes training program can improve the comfort and knowledge of house staff and potentially improve their insulin administration practices at large academic centers.

Evaluation of a paediatric asthma education package for health professionals

To evaluate an evidence-based paediatric asthma management education package designed for health professionals with particular emphasis on formulation of written asthma action plans (AAPs) and inhalation device technique. A prospective cohort study was conducted involving graduate medical programme medical students and tertiary paediatric hospital junior house staff. Three case-based Microsoft Powerpoint presentations were used to highlight important aspects of asthma management including the formulation of an AAP and inhalation device technique. This was delivered in small-group sessions to medical students and as a self-directed learning exercise to junior house staff. Outcome measures were ability to write an accurate AAP, confidence and competence in using and teaching asthma devices, and knowledge of asthma. Forty medical students and 14 junior house staff were recruited. Mean scores for the written AAP improved from 4.2 (out of 19) to 16.2 for medical students (mean change 12.0; 95% confidence interval (CI) 11.0-13.0; P < 0.001) and from 11.5 to 16.8 for junior doctors (mean change 5.3; 95% CI 3.5-7.2; P < 0.001). Confidence in using and teaching asthma inhalation devices also improved (P < 0.001 for students and P < 0.05 for house staff), as did asthma knowledge and skills in using the devices in the students (P < 0.001). The education package was effective in teaching participants how to write an accurate AAP and improved their confidence and ability in demonstrating proper inhalation device technique. We believe that the package has the potential to be used more widely for either small-group or self-directed learning.

Assessment of education and computerized decision support interventions for improving transfusion practice

Overuse of blood products is common, but prior efforts to improve transfusion decisions have met with limited success. This study examines transfusion practices before and after a conventional educational intervention followed by a randomized controlled trial of a decision support (DS) intervention with computerized physician order entry (CPOE) for red blood cell, platelet, and fresh-frozen plasma orders. The study was conducted in an academic medical center between April 2003 and June 2004. Orders originating from units not using CPOE with DS (e.g., the emergency department) were excluded. Junior housestaff were randomly assigned into a control group and an intervention group who received DS for transfusion orders. Transfusion orders were initially classified according to guideline rules as DS-agree or DS-disagree. Chart reviews assessed inappropriateness for all DS-disagree orders and a sample of DS-agree orders. The total of inappropriate transfusion orders included chart review confirmed DS-disagree orders and DS-agree orders reclassified as inappropriate. The percentages of inappropriate nonemergent transfusion orders during the baseline phase for the entire staff and randomly assigned junior housestaff were 72.6 percent (2154/2967) and 71.9 percent (1259/1752) and improved after conventional education to 63.8 percent (1699/2663; p < 0.0001) and 63.3 percent (1263/1996; p < 0.0001), respectively. The percentage of inappropriate orders in the DS intervention group continued to improve (59.6%, 804/1350; p < 0.0001). Physicians accepted 14 percent (133/939) of new DS-recommended orders, especially recommendations to increase transfusion doses (73%). Education and computerized DS both decreased the percentage of inappropriate transfusions, although the residual amount of inappropriate transfusions remained high.

Implementing Resident Work Hour Limitations: Lessons From the New York State Experience

New York State has had residency work hour regulations for 15 years, and, since 1998, a strong effort to enforce these rules has been made. This study examines the impact of implementation of these rules on residency training, the quality of residents' lives, and patient care. Data were gathered with a carefully constructed questionnaire sent to all surgical residents in the state, including senior residents in their final year (n = 1037). Three hundred nineteen questionnaires were returned. Respondents felt their residency programs generally complied with the regulations and that support and enforcement were growing. Twenty-five percent reported stricter enforcement following an inspection that resulted in a fine for violation of regulations. Also, 19% noticed stricter enforcement after an adverse patient outcome, a site visit, or other event. Both residents and their residency programs reported a mean of 88 hours worked per week (range, 11-140 hr). The schedules reported by junior and senior house staff and by community and academic hospitals were in general agreement. Most residents said they took in-house calls no more frequently than every third night. Calls were taken from home more often by senior residents (16.7% vs. 4.7% for juniors; P <.05) and by those in academic programs compared with community hospitals (14.3 vs. 4.7%; P <.05). Respondents reported that hospitals used various strategies to cover night call, including night floats, increased cross-coverage, and increased use of nurse practitioners and physician assistants. Nearly 3/4 of the residents thought that, in general, the regulations were a good thing. Sixty-four percent and 66%, respectively, of participants said that with the implementation of the regulations they felt more 'well rested and that their quality of life outside the hospital was improved. Less than half, 42%, felt the quality of their work life inside the hospital was improved. A total of 33.4% senior residents and 28.2% academic residents reported a negative impact of regulations on their work life compared with 19.3% of junior residents and 20% of community hospital residents (P <.01 for both). Senior house staff were more likely to feel that the reduction in work hours left them with the burden of much of the scut work that once was the juniors' respponsibility (79.2% of seniors vs. 34.9% of juniors, P <.01). Overall, 71% of the residents from community hospitals more frequently reported a reduction in work hours (81%) than those in academic centers (66.4%, P <.05). Twenty-two percent of respondents said that the overall quality of resident training had improved whereas 35% felt the regulations had resulted in a decrease in the overall quality of their training. More time for reading and studying was noted by 47% of residents. However, 50% reported participating in fewer operations, and 51% said that they hail missed too many learning opportunities under the new regulations. These sentiments were more likely to be expressed by senior residents and residents in academic medical centers than by junior house staff or those in community residencies.

Simulation Case Library: The Case of the Coiled Cardiac Catheter

Many medical disciplines participate in the acute care of hemodynamically unstable patients. At WVU we have many opportunities for multidisciplinary critical care group instruction in our simulation facility. The main educational goals of this session are the recognition and management of a pulmonary artery catheter that is coiled in the right ventricle. Recognition of waveforms and identification of catheter malposition are a priority in our critical care education programs. We present the scenario using the METI model C manikin with system 5.5 software. The target audiences for this scenario at WVU include junior house staff from assorted disciplines, masters level physician assistant students, and medical students during the second and fourth years of training. This scenario has also been included in a critical care medicine CME course for a variety of health care practitioners. We present a variety of the manufacturer's pre-packaged hemodynamic instability scenarios. Standard man awake or relaxed with the hypotension-hemorrhage scenario is described in detail. The focus is on catheter misplacement rather than on disease state. Despite prior preparation from lecture with slides, textbook review, ordemonstration without patient context, most students do not recognize a right ventricular waveform when it is simulated in the context of a patient care scenario. Debriefing occurs immediately in the simulation laboratory and includes a review of typical waveform and pressure transitions as the catheter passes from the introducer to the wedge position. Measurement of cardiac output is demonstrated. A variety of electronic resources are suggested for further self-study and more complete review of invasive monitoring principles and techniques. Students over the past 4 years have had an overwhelmingly positive response to this simulation experience.

Formal Endoscopy Training for Senior and Junior House Staff

The upper endoscopic experience of junior and senior surgical residents was analyzed before (period 1) and after (period 2) creating a 2-month rotation with a dedicated surgical endoscopist. Three hundred sixty-two endoscopies were performed during the study period, with 295 (81%) being performed after formalizing training. A chi-square analysis was performed and found to be statistically significant for each group when compared to a control experience with colonoscopy. We conclude that a dedicated block of time and a committed surgical attending physician will have a significantly positive impact on resident caseload. Furthermore, the added benefits of being more closely involved with the patient rather than relying on another discipline will add to the resident's educational experience.

Fluids and Electrolytes in the Surgical Patient

fourth edition of a popular, serviceable manual begins, This book was written primarily for junior house staff members who are beginning surgical training. Changes from previous editions are not major. Encouragingly concise and brief, the logically allotted chapters cover normal needs, volume changes, tonicity, electrolytes, acid base balance, nutrition, and a final plan of therapy. An excellent short index follows. Throughout the text are a series of inviting, personable tables written in hand script, as though drawn by you, the reader, and the diagrams are linear sketches in beckoning style. The type resembles that from an ordinary typewriter and is laid out spaciously. The lightweight volume of some 240 pages carries a flexible cover but is somewhat too wide to fit in your coat pocket. The author, professor of surgery and associate dean of academic affairs at the University of Texas, San Antonio, covers the subject in direct, clear

The Indigestible Curriculum

Pity the plight of the contemporary medical student: his or her curriculum holds more material than can be digested even by the most zealous of students. The technological and scientific knowledge explosion since World War II has deluged the medical student with an enormous learning burden. The volume of information that must be committed to memory in order to pass National Board Examinations is truly staggering, not to mention the intellectual gymnastics required to integrate and employ such knowledge in the daily practice of clinical medicine. 1 Is it any wonder that more and more of our medical students and junior house staff seek psychiatric support for troubled emotional lives, divorce, and substance abuse? Furthermore, professional fatigue or burn out is all too common in middle-aged physicians. 24 We contend that an important factor in the genesis of these adverse emotional states is the extraordinary pressure generated by the large

Educational influences on consultation rates of house staff physicians in a primary care clinic.

Consultation rates of medical house staff physicians were examined in a primary care setting in order to determine the factors that lead to the use of consultants. The factors that were studied in the regression analysis were clinical experience and teaching in medical school, intensity of use of services, residency year, Alpha Omega Alpha (AOA) membership, and future practice plans. The factors were marginally useful in predicting surgical consultations but were helpful in explaining the use of other consultations. House staff physicians with a pattern of intense ancillary service utilization also requested more consultations. Senior house staff physicians requested fewer consultations than junior house staff members. AOA members and future academic physicians used more consultations than other physicians. Consultation rates were highest for specialties requiring the lowest quantity of education in medical school. Consultation patterns reflect past educational experiences and future practice plans of medical house staff physicians and may be useful in the formulation of the curriculum of medical schools and residencies.

The current and future role of surgical physician assistants. Report of a national survey of surgical chairmen in large U.S. hospitals.

The chairman of departments of surgery in general hospitals with more than 400 beds were surveyed to assess their current and projected use of surgical physician assistants. Of the 552 institutions represented in our survey, surgical physician assistants were working in one-third, providing preoperative, intraoperative, and postoperative care. Two-thirds of the chairmen felt that the introduction of physician assistants had improved surgical patient care in their institutions. In institutions with surgical housestaff, almost half the chairmen felt that surgical physician assistants had improved the quality of residency training. During the next five years an increase of 87% in the number of surgical physician assistants is projected by respondents. We conclude that appropriately trained and supervised surgical physician assistants will play an increasingly important role in improving the care of surgical patients and, by functioning as junior housestaff, make it possible to reduce the number of surgeons being trained.

Major complications of percutaneous subclavian vein catheters

New and reportedly safer techniques for subclavian venipuncture with the passage of central venous catheters appear regularly in the surgical literature 55–59 yet reports of major complications continue to appear as well. We have reported on eight patients with major complications of percutaneous subclavian vein catheters, two of whom died. In our own hospital an improved educational program for junior house staff and nurses has been instituted. Better supervision of junior house staff when performing this potentially lethal technique is necessary. Daily inspection of catheters, early removal of unnecessary catheters, and improved equipment should help to prevent these complications in the future.

Surgery in Infancy and Childhood: A Handbook For Medical Students, Junior Hospital Staff and General Practitioners.

This fact-filled, well-written book of 597 pages and 340 illustrations includes a brief discussion of practically every problem encountered in pediatric surgery. Even related subjects such as hemophilia, Ehlers-Danlos syndrome, and ammoniacal diaper rash are included. Many of the photographs are in color. Each subject is discussed only briefly, but the information presented is pertinent. Some statements impress one as being dogmatic and present only the author's point of view. Undoubtedly, this is the price of conciseness and the necessity to include a great deal of material into a few pages. There is no discussion of surgical technique or of results of surgery. The book is recommended—as it was intended—as a handbook for medical students, junior house staff, and general practitioners. It cannot be recommended as a reference book for the trained pediatric surgeon, although he may find it useful and it should be included in his library. It can