Reduction In Resident Work Hours Research Articles

Techniques: Utility of a 3D printed bladder model for teaching minimally invasive urethrovesical anastomosis.

The urethrovesical anastomosis (UVA) is one of the most challenging steps during a minimally invasive radical prostatectomy. Not surprisingly, minimally invasive, in particular laparoscopic, prostatectomy is associated with a steep learning curve.1 With competency-based training on the horizon, as well as the recent reduction in resident work hours, surgical educators have shifted some training outside of the operating room into surgical skills labs. To reduce learning curves and improve resident education at our centre, we use a hands-on 3D printed bladder bench model to emulate the UVA task during a minimally invasive prostatectomy.

Procedural Competence Among Faculty in Academic Health Centers: Challenges and Future Directions.

Increasingly, faculty are taking on more direct responsibilities in patient care because of reductions in resident work hours, increasing admissions, and an endless push for efficiency. Furthermore, the rise of different career tracks in academia (i.e., patient care, research, education, or administration) and a drive for efficiency and subspecialization have placed additional strains on academic health centers. Combined, these factors have led to faculty increasingly being placed in the position of supervising bedside procedures that they may have not performed in years or with tools they have never trained with at all. Despite these challenges, procedural retraining for faculty remains nonstandardized across most academic health centers. The resulting lack of procedural competence among faculty creates a number of challenges for the different parties involved.In this Perspective, the authors discuss the nature of the current problem of faculty procedural competence and the challenges it poses for faculty and academic health centers, medicolegal ramifications, and the challenges it poses to the faculty-trainee relationship. The authors then suggest several strategies to delineate and resolve this problem. To delineate the problem, they suggest single-center surveys to address the current paucity of data. To resolve the problem, they suggest the consideration of some modest, low-cost interventions such as having backup systems in place for procedure supervision (e.g., procedural service teams or interventional radiologists) and providing faculty with opportunities to retrain.

Faculty Development and Surgical Training: Are Audio Podcasts an Effective Tool?

BACKGROUND: Increased workload and reduction in resident work hours have made didactic teaching and faculty development more difficult to achieve. Needs assessment at the University of Oklahoma revealed a gap in effective faculty development. Audio podcasts are ideal developmental tools as they can be accessed in many settings while engaged in activities such as driving or exercise. Our objective was to create an audio podcast for departmental faculty development. The podcast will address identification of and early interventions for residents who are having difficulty with mastering surgical skills. METHODS: A single high fidelity audio podcast was created and distributed to our faculty. A survey was given to faculty before and after the podcast distribution. RESULTS: Most of the 24 faculty responding to the initial survey had no structured format for evaluating resident surgical skills. Although 67% had previously listened to a podcast, about half reported that it had been more than 2 months. Eight faculty listened to the podcast and responded to the post listening survey. The majority reported learning new information from listening which some have used and all felt it was an effective way of learning. DISCUSSION: Faculty in our department had some baseline knowledge and experience with audio podcasts. All who listened to our podcast felt it was an effective tool for faculty development and education.

Midwives in medical student and resident education and the development of the medical education caucus toolkit.

Midwives have been involved formally and informally in the training of medical students and residents for many years. Recent reductions in resident work hours, emphasis on collaborative practice, and a focus on midwives as key members of the maternity care model have increased the involvement of midwives in medical education. Midwives work in academic settings as educators to teach the midwifery model of care, collaboration, teamwork, and professionalism to medical students and residents. In 2009, members of the American College of Nurse-Midwives formed the Medical Education Caucus (MECA) to discuss the needs of midwives teaching medical students and residents; the group has held a workshop annually over the last 4years. In 2014, MECA workshop facilitators developed a toolkit to support and formalize the role of midwives involved in medical student and resident education. The MECA toolkit provides a roadmap for midwives beginning involvement and continuing or expanding the role of midwives in medical education. This article describes the history of midwives in medical education, the development and growth of MECA, and the resulting toolkit created to support and formalize the role of midwives as educators in medical student and resident education, as well as common challenges for the midwife in academic medicine. This article is part of a special series of articles that address midwifery innovations in clinical practice, education, interprofessional collaboration, health policy, and global health.

Application of the “See One, Do One, Teach One” Concept in Surgical Training

The traditional method of teaching in surgery is known as "see one, do one, teach one." However, many have argued that this method is no longer applicable, mainly because of concerns for patient safety. The purpose of this article is to show that the basis of the traditional teaching method is still valid in surgical training if it is combined with various adult learning principles. The authors reviewed literature regarding the history of the formation of the surgical residency program, adult learning principles, mentoring, and medical simulation. The authors provide examples for how these learning techniques can be incorporated into a surgical resident training program. The surgical residency program created by Dr. William Halsted remained virtually unchanged until recently with reductions in resident work hours and changes to a competency-based training system. Such changes have reduced the teaching time between attending physicians and residents. Learning principles such as experience, observation, thinking, and action and deliberate practice can be used to train residents. Mentoring is also an important aspect in teaching surgical technique. The authors review the different types of simulators-standardized patients, virtual reality applications, and high-fidelity mannequin simulators-and the advantages and disadvantages of using them. The traditional teaching method of "see one, do one, teach one" in surgical residency programs is simple but still applicable. It needs to evolve with current changes in the medical system to adequately train surgical residents and also provide patients with safe, evidence-based care.

Learning standardized sign-outs

The 21st century has seen great stresses on medicine and particularly neurology. There is increasing demand for neurologic care, especially as the Baby Boomers age. With an explosion in knowledge and available treatments and increasing demands for quality of care for the health dollar spent, but with dwindling resources and personnel, there is a premium on time and the need for efficiency. Graduate medical education has contributed to the pressure on time, given the mandated reduction in resident work hours, first in 2003 with the implementation of the 80-hour limits on duty hours,1 followed by the modified work-hours rules for 2011, including a 16-hour daily limit on intern hours.2 Whether this makes for better rested physicians and safer clinical practice is unclear, but …

Evaluating the Safety and Success of Bedside Lumbar Puncture in a Changing Academic Environment (P06.021)

Objective: To determine the impact on resident training and patient safety of a dedicated lumbar puncture (LP) service utilizing mid-level practitioners (MLP). Background LP is a common bedside procedure. An unsuccessful LP may lead to repeated procedures or fluoroscopy guided LP, increasing patient risks associated with radiation exposure. With reduction in resident work hours by the ACGME, many academic institutions are using MLPs to supplement the provision of patient care, including performing LPs. To our knowledge, the impact of the utilization of specialized MLPs on resident training and patient safety specific to LPs has not been studied. Design/Methods: We conducted a retrospective chart review of inpatients undergoing bedside LP by either a neurology resident physician or neurology MLP from July 2009 through August 2011. Results: A total of 97 LPs were reviewed, 40 performed by a MLP and 57 by a resident physician. Successful bedside LP was documented in 70% and 71.9% of cases by the MLP and residents, respectively (p=0.1815). The average number of skin punctures required to obtain CSF was 1.53 by the MLP vs. 1.67 by residents (p=0.252). There was a numerical but non-significant trend toward improvement when comparing success rate and number of puncture attempts of the MLP in the first six months compared to the second six months of clinical practice (70% vs 77%, p=0.252 and 1.57 to 1.47, p=0.659, respectively). There was insufficient recorded data to make similar comparisons for residents. Conclusions: This study demonstrates no difference between a trained neurology MLP and neurology resident physicians in success rates or safety of performing bedside LP. Nor did we find evidence for negative impact on resident training or proficiency. Specifically there was no evidence for decreased LP success rates in the resident group following introduction of a specialized MLP. Disclosure: Dr. Jordan has nothing to disclose. Dr. Greenberg has received personal compensation for activities with DioGenix, Greater Good Foundation, Biogen Idec, Serono, Inc., Sanofi-Aventis Pharmaceuticals, Inc., the Multiple Sclerosis Association of America and Teva Neuroscience as a consultant and/or speaker. Dr. Greenberg holds stock and/or stock options in Diogeix. Dr. Greenberg has received research support from Guthy-Jackson Charitable Foundation, Amplimmune, Inc. and the Accelerated Cure Project. Dr. Lee has received personal compensation for activities with Boehringer Ingelheim as a speaker.

Critical Care Simulation

ealth care providers continue to look for ways to prevent devastating edical errors that the Institute of Medicine has estimated contributes to pproximately 98,000 deaths per year in the USA. The incidence of ntensive care unit (ICU) medication errors ranges from 3% to 27% epending on the definition and study design. Conventional didactic eaching alone has not been shown to reduce fatal medical mistakes. eaders in critical care have begun to adopt innovative ways such as imulation to educate providers in an attempt to further reduce ICUelated medical errors. Simulation is defined as “the imitative representation of the functioning f one system or process by means of the functioning of another.” Often imes, critical care staff must make timely, effective decisions during mergency situations. However, real-life emergency events may not ccur with the required frequency for appropriate training. Simulation is vehicle by which a variety of clinical situations and uncommon henomenon can be presented to a large group of providers to enhance the ndividual and group experience. This style of training may transform the see one, do one, teach one” dogma into a process that focuses on rehearsal, repetition, and reaction within a master-apprentice atmophere.” Simulation (life-size mannequins and equipment used to aproximate reality as 1 example) can foster a multidisciplinary approach to ritical learning without risking harm to patients. This essay discusses the ngoing development of simulation training in critical care, the early esearch supporting its role in education and outcomes, and the future asks of simulation in the ICU. The recent reduction in resident work hours mandated by the Accredtation Council of Graduate Medical Education coupled with the Institute f Medicine’s recommendation to establish multidisciplinary training via imulation has paved the way for an increase in the development of

The Increased Financial Burden of Further Proposed Orthopaedic Resident Work-Hour Reductions

Increased funding for graduate medical education was not provided during implementation of the eighty-hour work week. Many teaching hospitals responded to decreased work hours by hiring physician extenders to maintain continuity of care. Recent proposals have included a further decrease in work hours to a total of fifty-six hours. The goal of this study was to determine the direct cost related to a further reduction in orthopaedic-resident work hours. A survey was delivered to 152 residency programs to determine the number of full-time equivalent (FTE) physician extenders hired after implementation of the eighty-hour work-week restriction. Thirty-six programs responded (twenty-nine university-based programs and seven community-based programs), encompassing 1021 residents. Previous published data were used to determine the change in resident work hours with implementation of the eighty-hour regulation. A ratio between change in full-time equivalent staff per resident and number of reduced hours was used to determine the cost of the proposed further decrease. After implementation of the eighty-hour work week, the average reduction among orthopaedic residents was approximately five work hours per week. One hundred and forty-three physician extenders (equal to 142 full-time equivalent units) were hired to meet compliance at a frequency-weighted average cost of $96,000 per full-time equivalent unit. A further reduction to fifty-six hours would increase the cost by $64,000 per resident. With approximately 3200 orthopaedic residents nationwide, sensitivity analyses (based on models of eighty and seventy-three-hour work weeks) demonstrate that the increased cost would be between $147 million and $208 million per fiscal year. For each hourly decrease in weekly work hours, the cost is $8 million to $12 million over the course of a fiscal year. Mandated reductions in resident work hours are a costly proposition, without a clear decrease in adverse events. The federal government should consider these data prior to initiating unfunded work-hour mandates, as further reductions in resident work hours may make resident education financially unsustainable.

Validating objectives and training in Canadian paediatrics residency training programmes

Background: Changing health care systems and learning environments with reduction in resident work hours raises the question: “Are we adequately training our paediatricians?”Aims: (1) Identify clinical competencies to be acquired during paediatric residency training to enable graduates to practise as consultant paediatricians; (2) Identify gaps in preparedness during training and; (3) Review and validate competencies contained in the Royal College of Physicians and Surgeons of Canada (RCPSC) objectives of training (OTR) for paediatrics.Methods: A questionnaire with 19 classification domains containing 92 clinical competencies was administered to RCPSC certified paediatricians who completed residency training in Canada from June 2004 to June 2008. For each competency, paediatricians were asked to indicate the importance and their degree of preparedness upon entering practice. Gap scores (GSs) between importance and preparedness were calculated.Results: Response rate was 43% (187/435); 91.3% (84/92) of competencies in the RCPSC OTR were identified as important. Paediatricians felt less than adequately prepared for 25% (23/92) of competencies; 40 competencies had GSs >10%.Conclusions: The unique approach used in this study is useful in validating OTR as well as the preparation of residents in relation to OTR. The results indicate a potential need for additional training in specific competencies.

The Institute of Medicine Resident Work Hours Recommendations: A Program Director's Viewpoint

Over the past several decades, the practice of medicine has changed dramatically. Hospitalized patients are sicker. The number of medication choices is larger. The pressure to discharge patients quickly is more intense. Despite these changes, the way in which we train residents has remained largely the same. The number of residents and the length of residency training have not changed significantly. Until recently, the hours remained quite long. In recent years, we have discovered that quantity and quality of sleep have a significant impact on the health and well-being of our patients. Driving while sleep-deprived is equivalent to driving under the influence of alcohol. We would never allow our residents to practice medicine while under the influence, and it makes sense to examine the impact of sleep deprivation on our residents' ability to learn and to practice medicine safely. If it is shown that medical mistakes increase with sleep deprivation, we should do what we can to minimize the risk to our patients. This is much more complicated, however, than mandating fewer work hours and protected sleep time for our trainees. With the last reduction in resident work hours, there was no concomitant increase in the number of residents accepted to training programs, nor to the number of supervising physicians. We essentially told our trainees to provide good quality medical care to larger numbers of patients with increased medical complexity. .. faster. Many residency programs have struggled with it, and further limitations in work hours cannot be made in a vacuum. If resident work hours are further limited, hospitals will have to find a way to provide adequate coverage for their patients. A seemingly innocuous solution would be the addition of more residency training positions. This might also be used to train more primary care physicians and other types of doctors for whom a shortage is anticipated. This is easier suggested than done, however. The way in which hospitals are reimbursed for their training of residents is already antiquated and inadequate. The training of more physicians would also require that more supervising physicians be hired. Alternatively, hospitals could forego the hiring of more trainees, and simply shift the burden of patient care to more senior physicians. After all, such physicians have no work hour restrictions. If interns and residents are more prone to mistakes as a result of sleep deprivation, it would follow that sleep-deprived supervising physicians would be less likely to notice and correct the errors of their trainees. Another potential solution would be to increase the duration of residency training programs. Difficulties abound here as well. Residents would require additional years of wages. The wages that they currently receive during their period of training are quite low, given their prior education and the number of hours they are asked to work. This would potentially deter a significant number of prospective physicians from entering the profession. There are innumerable other ways in which the challenges of further limiting work hours can be addressed. All of them are quite costly, as the Institute of Medicine (IOM) freely admits. I wonder where this extra funding will come from? I hope that as President-Elect Obama's incoming administration examines potential changes to our healthcare system, they remember to take a fresh look at how we train physicians.

Sleepiness in medical residents: Impact of mandated reduction in work hours

Objectives: To assess the sleepiness among Family Practice residents using subjective data, the Epworth sleepiness scale (ESS), as well as objective assessment, the multiple sleep latency test (MSLT). Method: We conducted the study on Family Practice residents at Texas A&M University, Corpus Christi. Sixteen residents, aged 21–40 yrs, were recruited and divided into two groups. The study group was comprised of residents who were on night-float rotation for at least three days and underwent MSLT post-call, and the control group was comprised of residents who were not on night-float and were not post-call. Daytime sleepiness was evaluated using both the ESS and MSLT. Respondents also completed a questionnaire assessing their beliefs regarding effects of sleep loss. Results: Sleep latencies <10 min were observed in 6 out of the 8 day shift-work interns, while only 1 out of 8 night-float residents had an average sleep latency <10 min ( p = 0.0195). Following night-float, despite less sleep, residents had sleep latencies which were higher [14.2 (±5.0) min] than those in the control group [8.4 (±5.4) min, ( p = 0.043)]. Despite the difference in objective sleepiness, subjective sleepiness (Epworth scores) did not differ. Over 80% of interns reported having driven while sleepy. Conclusion: Sleepiness continues to be a significant issue among medical residents despite recently mandated reductions in resident work hours. MSLT values in the pathologic range are seen in the majority of residents studied, but in those who were post-night call there seemed to be a paradoxical improvement.

Perceived Impact of Resident Work Hour Limitations on Medical Student Clerkships: A Survey Study

To assess medical students' perceptions of the impact of recent Accreditation Council for Graduate Medical Education policies limiting resident work hours on students' clerkship experiences, resident teaching, and quality of patient care. In May/June 2003 and May/June 2004, an original questionnaire was administered to 252 medical students completing required clinical rotations at two teaching hospitals to assess students' perceptions of endpoints that might be affected by resident work hours limits. Response data were analyzed to determine statistical significance of differences between the two years studied. Questionnaires were completed by 129 students in 2003 (98%) and 112 students in 2004 (93%), for an overall response rate of 96%. A higher proportion of students perceived limits on work hours in 2004 [46 (41%)] than 2003 [36 (28%), p = .03]. Ratings of resident availability and primary resident's interest in teaching improved in 2004. Otherwise, ratings of the interest, skill, and availability of resident teachers and attending physicians remained stable between 2003 and 2004. Students reported spending similar amounts of time in formal teaching sessions and rated feedback similarly between 2003 and 2004. In 2004, fewer students [28 (25%)] reported considering leaving medicine due to long hours in training than in 2003 [49 (38%), p = .04]. No significant differences in the proportion of students reporting suboptimal care were found [44 (34%) in 2003, 34 (35%) in 2004, p = .57]. This small, early study suggests that reductions in resident work hours might be implemented without a significant negative impact upon medical students' self-assessed learning experiences, and that limiting resident work hours may even have a positive impact on medical students.

Workload Redistribution: A New Approach to the 80-Hour Workweek

The new Accreditation Council for Graduate Medical Education-mandated 80-hour resident work week has resulted in busy trauma services struggling to meet these strict guidelines, or face loss of accreditation. Beginning in July 2003, our Level I trauma service began a policy of direct admission of isolated neurosurgical or orthopedic injuries to the specific subspecialty service after complete evaluation by the trauma service in the emergency department for associated injuries. Complications, missed injuries, delayed diagnoses, and admission rates were compared in two 6-month periods: PRE, before the policy change; and POST, after the new policy had been instituted. Resident work hours were likewise compared over the two time periods. Selected single-system injury admission to subspecialty services resulted in a 15% reduction in admissions to the trauma service. There were no significant differences in the overall complication rate, delayed diagnoses, or missed diagnoses between the PRE and POST time periods. Overall, there was a 9.7% reduction in resident work hours (p = 0.45; analysis of variance) between the PRE and POST periods, which allowed them, on average, to meet the Accreditation Council for Graduate Medical Education 80-hour workweek mandate. Direct admission of patients with isolated injuries to subspecialty services is safe and decreases the workload of residents on busy trauma services.

Effect of the 80-hour workweek on resident burnout.

With the introduction of the newly mandated restrictions on resident work hours, we expected improvement in subjective feelings of personal accomplishment and lessened emotional exhaustion and depersonalization. Residents and faculty members completed an anonymous online Maslach Burnout Inventory Human Services Survey (3rd ed; Consulting Psychologist Press Inc, Palo Alto, Calif) and work-hour registry before and after implementation of new restrictions. Urban, university-based department of surgery. All house staff (n = 37) and faculty (n = 27). Introduction of new Institutional Standards for Resident Duty Hours 2003. Main Outcome Measure Resident work hours and levels of emotional exhaustion, perceived degree of depersonalization, and personal accomplishment. Resident work hours per week decreased from 100.7 to 82.6 (P < .05) with introduction of the new schedule. Home call and formal educational activity time within working hours (eg, clinical conferences) significantly (P < .05) decreased from 11.5 and 4.8 hours to 4.6 and 2.5 hours per week, respectively. Operating room hours, clinic time, and duration of rounds did not show a significant change. Changes in parameters of resident and faculty emotional exhaustion, depersonalization, and personal accomplishment did not show statistical significance (P > .05). Despite successful reductions in resident work hours, measures of burnout were not significantly affected. However, important clinical activities such as time spent in the operating room, clinic, and making rounds were maintained. Formal in-hospital education time was reduced.