Upper-level Residents Research Articles

Surgical residents and the adequacy of dictated operative reports

IntroductionThe surgeon's clinical note has been previously shown to poorly reflect both physician-centered and patient-centered outcomes. We hypothesized that dictated operative reports do not adequately demonstrate surgeons' workload, preoperative involvement, clinical decision-making, or core competencies. Materials and methodsWe retrospectively reviewed operative reports in the month of January for the years 2007–2011. Operative reports were dictated by interns, residents (R1–R5), and surgical staff. All resident reports were approved by staff surgeons. We qualitatively assessed each for 15 items that encompassed physician-centered outcomes, patient-centered outcomes, and Joint Commission/Medicare-required fields. Groups were compared to each other with 1-way analysis of variance with Bonferroni correction. ResultsWe reviewed 999 operative reports. Nearly every chart included an indication and preoperative and postoperative diagnoses. Only 57.3% listed whether or not there were any complications. Half recorded operative findings. The mean number of fields missed based on level of surgical training was R1: 4.83, R2: 4.46, R3: 3.68, R4: 3.35, R5: 3.29, and staff: 3.09. Interns and second-year residents missed significantly more data fields than upper-level residents and staff (P < 0.0001). Staff surgeons missed fewer data fields than third-year residents (P = 0.004). There was no statistical difference between R4, R5, and surgical staff (P > 0.999). ConclusionsThe dictated operative report does not accurately document preoperative surgeon involvement, clinical decision-making, maintenance of core competencies, or full compliance with Joint Commission regulations. Focused education and enhanced staff oversight of junior-level dictated operative reports might be required to improve quality.

The ACGME’s 2011 Changes to Resident Duty Hours: Are They an Unfunded Mandate on Teaching Hospitals?

Throughout America, teaching hospitals are struggling to meet the Accreditation Council for Graduate Medical Education’s (ACGME) new resident duty-hour standards. Effective July 2011, the Common Program Requirements state that duty hours must be limited to 80 hours per week, averaged over a four-week period, including in-house call and moonlighting (although exceptions may be granted up to 88 hours “based on a sound educational rationale”). Residents must be scheduled for at least one duty-free day (without at-home call) every week, averaged over four weeks. Duty periods of interns must not exceed 16 hours. Upper level residents may be scheduled up to 24 hours of continuous duty, with up to four additional hours for transitions in care, but “strategic napping… is strongly suggested.” PGY-1 and intermediate-level residents must have eight duty-free hours between scheduled duty periods, and 14 duty-free hours after 24 hours of in-house duty. Residents must not be scheduled for more than six consecutive nights of night float, and higher level residents must be scheduled for in-house call no more frequently than every third night (averaged over four weeks). Finally, the ACGME mandated changes to the training environment to improve residents’ educational experience and to mitigate potential adverse effects of the duty-hour restrictions.1

That’s Why It’s a 5-Year Program: Resident Acquisition of Anorectal Disease Management Competence

Although surgical residents are expected to be proficient in the diagnosis and management of anorectal pathology upon graduation, there is little data related to the timing and degree of proficiency acquired during training. Prospective study of new patients presenting to a colorectal surgical clinic for evaluation of anorectal complaints over a 3-y period. Trainees performed an initial evaluation and recorded their exam findings, diagnosis, and treatment plan. A separate evaluation by a staff colorectal surgeon was performed, with results compared by an independent reviewer. A total of 236 patient evaluations were included. The accuracy of referral diagnosis was significantly better when originated from a surgeon than from all other referral sources (91.7% versus 59.1%, P = 0.031). The most common conditions were internal hemorrhoids (25%), anal fissures (22%), and external hemorrhoids (19.5%). Internal hemorrhoids were most commonly misdiagnosed as external hemorrhoids (58%). Anal fissures were missed 38% of the time, and were most often given the diagnosis of internal hemorrhoids (45%). Residents also demonstrated difficulty in identifying thrombosis in external hemorrhoids, with a 45% error rate. Medical students and residents had an overall correct primary diagnosis of 69.5%; however, there was a significant improvement in the accuracy of diagnosis from medical students and interns to upper level residents (62.9% versus 81.2%, P = 0.003). Medical treatment plans agreed between resident and staff in 74%, the surgical management agreed in 62%, and overall the residents had the correct diagnosis and corresponding treatment plan in 44%. Additional adjunctive procedures were proposed in 66 patients with residents stating the correct adjunct in 79%. The most frequently missed adjuncts were endorectal ultrasound (34%) and colonoscopy (28%). Surgical trainees demonstrated significant deficiencies in the ability to evaluate and manage anorectal pathology; however, marked improvement occurred with time in training. Common areas of misdiagnosis and therapeutic errors were identified which could aid in curriculum development.

Sleeping at Home: A New Model for a Hospital Teaching Service

The traditional marriage between teaching hospitals and residents pivots on a central prenuptial agreement: residents offer their hospitals round-the-clock patient care, and, in exchange, hospitals provide an experiential learning modality. This long-held covenant may require an update due to 3 significant changes: the increased spotlight on protecting resident education from excessive service demands; the development of hospital medicine as a specialty; and the need to provide more experiential learning in ambulatory care settings for primary care programs, including family medicine. The rapid growth of hospitalist care—84% of all teaching hospitals in the United States have at least 3 hospitalists1—has been sparked in part by pressure placed on primary care doctors to increase outpatient visits and on hospitals to reduce length of stay.2 The desire to have better work/life balance coupled with fewer inpatient admissions and increased financial demands have resulted in a decline in family medicine physicians who provide both inpatient and outpatient care. Many hospitals are moving to hospitalist care, citing improved care and decreased cost.,3,4 In 2006, the year before we implemented our new model of inpatient teaching, 62.5% of our program's new graduates entered into practice without an inpatient component. We describe a unique adult inpatient teaching service in a family medicine residency program that integrates resident teaching with hospitalist care. The novelty stems from the use of hospitalists, not residents, as the primary workforce in the hospital. By uncoupling the educational experience of teaching residents how to care for hospitalized patients from the service demands of the hospital, it is possible to achieve both of these goals and comply with duty hour limits. The added advantage of our system is that residents are able to spend more time in the outpatient setting. This gain in ambulatory training aligns with most of our residents' postgraduation plans to work as primary care physicians in the outpatient setting.

Use of Ecological Momentary Assessment to Guide Curricular Change in Graduate Medical Education

To assess whether a novel evaluation tool could guide curricular change in an internal medicine residency program. The authors developed an 8-item Ecological Momentary Assessment tool and collected daily evaluations from residents of the relative educational value of 3 differing ambulatory morning report formats (scale: 8 = best, 0 = worst). From the evaluations, they made a targeted curricular change and used the tool to assess its impact. Residents completed 1388 evaluation cards for 223 sessions over 32months, with a response rate of 75.3%. At baseline, there was a decline in perceived educational value with advancing postgraduate (PGY) year for the overall mean score (PGY-1, 7.4; PGY-2, 7.2; PGY-3, 7.0; P < .01) and for percentage reporting greater than 2 new things learned (PGY-1, 77%; PGY-2, 66%; PGY-3, 50%; P < .001). The authors replaced the format of a lower scoring session with one of higher cognitive content to target upper-level residents. The new session's mean score improved (7.1 to 7.4; P = .03); the adjusted odds ratios before and after the change for percentage answering, "Yes, definitely" to "Area I need to improve" was 2.53 (95% confidence interval [CI], 1.45-4.42; P = .001) and to "Would recommend to others," it was 2.08 (95% CI, 1.12-3.89; P = .05). The Ecological Momentary Assessment tool successfully guided ambulatory morning report curricular changes and confirmed successful curricular impact. Ecological Momentary Assessment concepts of multiple, frequent, timely evaluations can be successfully applied in residency curriculum redesign.

Doing the Dirty Work: Measuring and Optimizing Resident Workload

The importance of patient care in the development of future physicians has been recognized since well before Osler’s time. Indeed, patient care experiences are the cornerstone of undergraduate and graduate medical education. While the purpose of residency training is to cultivate competent physicians primarily through direct patient care experiences, the optimal level of clinical work necessary to ensure resident learning and quality of care has not been well defined. In this issue of the Journal of General Internal Medicine, Coit and colleagues consider whether reducing resident workload improves quality of patient care. 1 The investigators implemented an experimental inpatient medicine rotation to reduce residents’ workload at a community hospital. The intervention teams were comprised of three interns and two upper level residents, and the control teams consisted of two interns and one upper level resident. In addition, the intervention teams took call every sixth night and were limited to five admissions per resident, while the control teams were on call every fourth night and could admit up to twelve patients. Both teams were in compliance with ACGME duty hour standards. The outcome of interest in this study was the quality of residents’ discharge summaries, as measured by an instrument based on Joint Commission standards. The investigators demonstrated significant improvement in the quality of discharge summaries prepared by the intervention teams compared to those prepared by the control teams. Of note, certain aspects of discharge summaries were inadequately completed by residents in both groups, highlighting the need for further innovations to enhance the quality of discharge

The Incidence of Periodontal Defects Distal to the Maxillary Second Molar After Impacted Third Molar Extraction

This study assessed the incidence of periodontal defects on the distal aspect of maxillary second molars after extraction of impacted maxillary third molars. Subjects enrolled in this institutional review board-approved prospective study consisted of healthy young patients having extraction of at least 1 asymptomatic impacted maxillary third molar adjacent to a second molar. Preoperative periodontal probing data were collected from 4 sites (midbuccal, distobuccal, midpalatal, and distopalatal) on each adjacent second molar, and a similar probing examination was performed at a mean of 6 months postoperatively. All subjects were treated under general anesthesia or conscious sedation by upper-level residents in the outpatient clinic. Twenty subjects with a total of 38 impacted maxillary third molars were treated. There were 9 male subjects (45%) and 11 female subjects (55%), with a mean age of 17 years (range, 14-22 years). The mean follow-up interval was 6 months, with a range of 3 to 15 months. Of the 152 probing sites measured, 92 (61%) decreased, 56 (37%) remained unchanged, and only 4 (2.6%) increased. A decrease in probing depth of 1 mm was found in 35 (23%) of the sites, a decrease of 2 mm was seen in 32 (21%), and 25 (16%) decreased by 3 mm or more. Of the 152 sites probed, 4 (2.6%) increased by 1 or 2 mm. Extraction of the impacted maxillary third molar does not result in significant periodontal defects on the distal aspect of the adjacent second molar, and in many cases it results in an improvement of the probing depths on these teeth.

Commentary: Identifying Attitudes Towards Empathy: An Essential Feature of Professionalism

Preserving and promoting empathy are ethical imperatives in medical education. The authors of this commentary propose that the "hidden curriculum" and mixed messages learners frequently receive during clinical rotations may erode humanistic traits essential to high-quality care. Three articles in this issue focus on assessing attitude towards empathy in the health care setting using the Jefferson Scale of Physician Empathy. The authors discuss salient points from these reports, reinforce the concept of empathy as a cognitive attribute, and offer recommendations for teaching and nurturing empathy in health professionals. In the reports, construct validity and reliability of the instrument were confirmed and were comparable with previous results, thus providing medical educators with a sound instrument to measure empathic attitudes in the context of patient care. The authors agree with the distinctions made in the three studies between empathy (described as a cognitive attribute) and sympathy (described as an emotional attribute) and believe that empathy as a cognitive skill can be role modeled, taught, and assessed. Barriers to empathic practice (lack of sufficient role models, failing to teach empathy as a cognitive skill, negative experiences, time pressures, overreliance on technology) can be remedied in medical education through interprofessional education and practice and institutional promotion of relationship-centered care, which maintains the centrality of the patient-clinician relationship while recognizing the importance of relationships with self and others.

Pediatric Hospital Medicine Elective

OPEN ACCESSJuly 20, 2009Pediatric Hospital Medicine Elective Jennifer Walthall, MD, FAAP, FAAEM, Michele Saysana, MD, FAAP, Jeffrey Sperring, MD, FAAP Jennifer Walthall, MD, FAAP, FAAEM Indiana University School of Medicine Google Scholar More articles by this author , Michele Saysana, MD, FAAP Indiana University School of Medicine Google Scholar More articles by this author , Jeffrey Sperring, MD, FAAP Indiana University School of Medicine Google Scholar More articles by this author https://doi.org/10.15766/mep_2374-8265.3160 SectionsAbout ToolsDownload Citations ShareFacebookTwitterEmail AbstractPediatric hospital medicine is a relatively new field in pediatrics and has seen rapid expansion in community and academic hospitals. Residents in training are often exposed only to modeling of clinical aspects of hospital medicine and are also time limited in the ability to experience the administrative components, quality improvement, transitioning of care, and opportunity for procedures in which practicing hospitalists must have competency for daily practice. Thus, we created this pediatric hospital medicine elective to provide upper-level residents with exposure to the various roles of pediatric hospitalists. This pediatric hospital medicine elective curriculum includes goals and objectives for the rotation; a novel elective menu that allows for individualized learning; a calendar of events for residents that includes administrative meetings, preparation time for team didactics, and protected time for clinical pathway development; coding and billing pre- and posttests; a billing and coding lecture series; a procedural sedation introductory lecture; reading materials; an advocacy project for the ward; and mentoring session worksheets. During the first 6 years of our pediatric hospital medicine service, there was minimal resident exposure to the paradigm and no formal training venue for those interested in pursuing this career. We did a needs assessment survey in our residency to determine if residents wanted more exposure to what pediatric hospitalists do. Our residents responded that they were interested in pediatric hospital medicine as a specialty, would participate in a hospital medicine elective, and thought that hospital medicine was important to patient care. Thus, we developed this resource. On the basis of learner feedback from focus groups, which had 100% participation, we have modified this curriculum to incorporate detailed description of the menu options, as well as expanded the procedural sedation component. Educational Objectives By using this resource, learners will be able to: Define and demonstrate the clinical and administrative responsibilities of a pediatric hospitalist, including, but not limited to, attention to length of stay, quality inpatient indicators, family and patient satisfaction, team communication, referring physician satisfactory transition of care, and current evidence-based pediatric practice.Bill, code, and document as pediatric hospitalists.Demonstrate evidence of developing a lifelong learning plan.Demonstrate proficiency in completing an academic project, which can include continuing quality improvement, formal academic didactics, research, or clinical pathway/protocol development.Demonstrate the ability to advocate for patients and families by focusing on family health care needs and systems-based improvements. Sign up for the latest publications from MedEdPORTAL Add your email below FILES INCLUDEDReferencesRelatedDetails FILES INCLUDED Included in this publication: Evaluation Exit.doc Coding and Billing I.ppt Coding and Billing II.ppt Coding and Billing III.ppt Advocacy Sample.doc Pediatric Hospitalist Rotation for House Staff.doc Template Exit Letter.doc Ward Advocacy Evaluation.doc Transitioning Care Phone Script and Evaluation.doc Sample Calendar.pub Pediatric Procedural Sedation I.ppt Ward Advocacy.pub Gastroenteritis Order Set.doc Hospitalist Menu.pub Pediatric Hospital Medicine Menu Item Description.doc Pediatric Hospital Medicine Post test.doc Pediatric Hospital Medicine Pre test.doc Gastroenteritis order set.doc Template exit letter.doc To view all publication components, extract (i.e., unzip) them from the downloaded .zip file. Download editor’s noteThis publication may contain technology or a display format that is no longer in use. CitationWalthall J, Saysana M, Sperring J. Pediatric Hospital Medicine Elective. MedEdPORTAL. 2009;5:3160. https://doi.org/10.15766/mep_2374-8265.3160 Copyright & Permissions© 2009 Walthall et al. This is an open-access publication distributed under the terms of the Creative Commons Attribution-Share Alike license.KeywordsForms and Records ControlHospitalsBilling and CodingHospitalistsDocumentation Disclosures None to report. Funding/Support None to report. Prior Presentations Pediatric hospital medicine resident education: sharing experience with a novel pilot curriculum. Presented at: Pediatric Academic Society Meeting; May 2007. Loading ...

Procedures Consult

Procedures Consult

Survey of pediatric resident experiences with resuscitation training and attendance at actual cardiopulmonary arrests

The literature suggests pediatric residents are inadequately prepared to perform resuscitation maneuvers when a child suffers a cardiopulmonary arrest (CPA). Our objective was to characterize the resuscitation training and CPA resuscitation experience of residents, including hands on experience with discharging a defibrillator. : Cross-sectional survey. Tertiary care, academic pediatric residency program. Pediatric residents. Seventy-six of 80 (95%) pediatric residents responded. The median (interquartile range) number of CPAs attended increased significantly by level of training, with some attending as many as 20 CPAs during residency (postgraduate year [PGY]1: 2.0 [1.0-3.0] vs. PGY2: 5.0 [3.0-8.0] vs. PGY3: 10.0 [5.0-12.0], p < 0.001). Nine of 25 (36%) senior residents had led a resuscitation. The proportion of third-year residents who had attended at least 1 CPA in the following locations was: general ward 20 of 25 (80%), Emergency Department 18 of 25 (72%), Neonatal intensive care unit 24 of 25 (96%), pediatric intensive care unit 23 of 25 (92%), and secondary training hospital 19 of 25 (76%). Twelve of 76 (16%) residents had discharged a defibrillator on an actual patient; however, 25 of 76 (33%) had never discharged a defibrillator, either on a patient or during training exercises. Although most residents had received required training in American Heart Association Basic Life Support and Pediatric Advance Life Support (i.e., BLS and PALS), 6 of 76 (8%) residents had never taken basic life support and 4 of 48 (8%) of upper level residents had never taken pediatric advanced life support. Multivariate analysis revealed that level of training, pediatric advanced life support training, and attendance at a mock code in the past year were not independently associated with having discharged a defibrillator (i.e., patient, mannequin, etc.), whereas attendance at an institutional Code Team training course was. Almost every pediatric resident was involved in attempting to resuscitate a child suffering a CPA, yet many were inadequately trained to respond. Formal mechanisms are needed to guarantee adequate resuscitation training for pediatric residents, especially regarding participation in basic life support and hands on defibrillator training.

Do the laparoscopic skills of trainees deteriorate over time?

Without ongoing practice, acquired motor skills may deteriorate over time. The purpose of this study is to document the level of retention of laparoscopic skills over time. Thirty-three general-surgery PGY 1, 2, and 3 residents trained to established criteria and passed an exam for each of seven technical skills (camera navigation, instrument navigation, camera/instrument coordination, grasping, lifting and grasping, cutting, and clip applying) on a virtual simulator (LapSim Surgical Science Ltd., Göteborg, Sweden). Six months later, the residents again completed the exam for each of the seven skills. During the 6 months, the simulators were available, but additional practice was not required. The retesting process consisted of three attempts, the first of which was acclimatization. The results of the subsequent two exams were compared with baseline data. At retest, the number of residents who passed clip applying (7, 21%) and cutting tasks (18, 55%) was significantly lower than for the other five tasks (p < 0.05). In failed tests, instrument wandering and tissue damage were more common than increases in task time. Upper-level residents were significantly more likely to pass than first-year residents were (p < 0.01). Time of day did not influence passing rates. Six months after training to criteria, instrument and tissue-handling skills deteriorated more than the speed with which a task is completed. Evidence of skill retention was present for some but not all tasks. Fine motor skills, required to perform more difficult tasks, deteriorated more than skills needed for easier tasks.

Evaluation of midlevel and upper-level residents performing their first robotic-sutured intestinal anastomosis

Background This study analyzed the experience of residents performing their first robotic intestinal anastomosis. Methods Eleven residents were tested. Participants performed 2 ex vivo hand-sewn suture lines followed by 3 robotic suture lines. Results The leak pressures in hand-sewn groups were 28.5 and 28.1 mm Hg; and 17.4, 7.6, and 21.4 mm Hg for 3 consecutive robotic groups. Completion time was longer in the robotic groups. The need for haptic assistance decreased between the first and third robotic drills. An analysis of the subjective evaluations also was performed. Conclusions Complex hand-sewn tasks can be reproduced successfully by the residents using the robot-suturing technique. The quality of suturing and completion time improved over 3 consecutive exercises, although it did not reach the level of the hand-sewn suturing group.

Self-Confidence in and Perceived Utility of the Physical Examination: A Comparison of Medical Students, Residents, and Faculty Internists

Little is known about the differences in attitudes of medical students, Internal Medicine residents, and faculty Internists toward the physical examination. We sought to investigate these groups' self-confidence in and perceived utility of physical examination skills. Cross-sectional survey of third- and fourth-year medical students, Internal Medicine residents, and faculty Internists at an academic teaching hospital. Using a 5-point Likert-type scale, respondents indicated their self-confidence in overall physical examination skill, as well as their ability to perform 14 individual skills, and how useful they felt the overall physical examination, and each skill, to be for yielding clinically important information. The response rate was 80% (302/376). The skills with overall mean self-confidence ratings less than "neutral" were interpreting a diastolic murmur (2.9), detecting a thyroid nodule (2.8), and the nondilated fundoscopic examination using an ophthalmoscope to assess retinal vasculature (2.5). No skills had a mean utility rating less than neutral. The skills with the greatest numerical differences between mean self-confidence and perceived utility were distinguishing between a mole and melanoma (1.5), detecting a thyroid nodule (1.4), and interpreting a diastolic murmur (1.3). Regarding overall self-confidence, third-year students' ratings (3.3) were similar to those of first-year residents (3.4; p = .95) but less than those of fourth-year students (3.8; p = .002), upper-level residents (3.7; p = .01), and faculty Internists (3.9; p < .001). Self-confidence in the physical exam does not necessarily increase at each stage of training. The differences found between self-confidence and perceived utility for a number of skills suggest important areas for educational interventions.

Part I: Preparing First-Year Radiology Residents and Assessing their Readiness for On-Call Responsibilities

The aim of the study is to evaluate the effectiveness of an Emergency Radiology (ER) Core Curriculum training module and a Digital Imaging and Communications in Medicine (DICOM)-based interactive examination system to prepare first-year (postgraduate year 2 [PGY-2]) radiology residents and assess their readiness for taking overnight radiology call. Institutional review board approval was obtained, and the study was compliant with Health Insurance Portability and Accountability Act (HIPAA) regulations. A dedicated month-long ER curriculum was designed to prepare new radiology residents for overnight radiology call that includes interpretation of off-hour urgent and emergent studies without immediate direct attending supervision. Lectures of the curriculum, provided by department staff, were based on the American Society of Emergency Radiology core curriculum. The lecture series was implemented after PGY-2 residents had completed formal introductory resident rotations during their first 6 months of training. A DICOM-based interactive computer-based testing module was developed and administered at the end of the lecture series. The module consisted of 19 actual emergency department cases with entire series of images, simulating an on-call setting. Tests were scored by two staff members blinded to resident identifying information. Upper-level residents also were tested, and comparison was made between first-year and upper-level resident test scores to determine the effectiveness of the test in determining first-year resident preparedness for call. Statistical analysis of results was performed by using t-test (P < .05). All residents in the residency program present during the month (nine PGY-2, six PGY-3, seven PGY-4, seven PGY-5 residents) attended the lecture series and finished the testing module at the end of the lecture series. Of 19 actual emergency cases on the testing module, five cases were neuroradiology, three cases were thoracic imaging, eight cases were body imaging, and three cases were musculoskeletal. PGY-2 residents scored an average of 73.0% (range, 63.2%-81.6%) of total points possible. PGY-3 residents scored an average of 76.8% (range, 68.4%-86.8%); PGY-4 residents scored an average of 77.4% (range, 65.8%-100%), and PGY-5 residents scored an average of 81.2% (range, 68.4%-94.7%). There was no statistically significant difference in scores according to level of training. First-year radiology residents who underwent 6 months of formal radiology training followed by an intensive ER lecture series before taking overnight call had scores similar to upper-level colleagues on an interactive computer-based ER simulation module.

Part II: Preparing and Assessing First-Year Radiology Resident On-Call Readiness: Technical Implementation

The effectiveness of using a Digital Imaging and Communications in Medicine (DICOM)-based interactive examination system in evaluating the readiness of first year radiology residents before taking overnight call in the emergency department (ED) was reported in part I of this article. This report describes technical aspects for the design and implementation of this system. The examination system consists of two modules: Data Collection and Image Viewing. The Data Collection module was a personal computer (PC)-based DICOM storage server based on a free public domain software package, the Mallinckrodt Central Test Node. The Image Viewing module was a Java-based DICOM viewer created using another freeware package: zDicom ActiveX component. The examination takes place once a year at the end of the first 6-month rotation. Cases selected for the examination were actual clinical cases according to the American Society of Emergency Radiology core curriculum. In the 3-hour timed examination, each resident was required to read the cases and provide clinical findings and recommendations. Upper-level residents also participated in the examination to serve as a control. Answers were scored by two staff radiologists. We have been using this examination system successfully in our institution since 2003 to evaluate the readiness of the first-year residents before they take overnight call in the ED. This report describes a step-by-step procedure for implementing this system into a PC-based platform. This DICOM viewing software is available as freeware to other academic radiology institutions. The total cost for implementing this system is approximately 2000 US dollars.

Effect of intern's consecutive work hours on safety, medical education and professionalism

We would like to thank Dr Sarani and Dr Alarcon for their critique of our work, published online in Critical Care on 12 January 2005 [1]. We have reviewed the critique, and in general we think that it appropriately describes both the strengths and limitations of our studies. We would like to make a few minor factual clarifications. First, although the study by Lockley and colleagues used a within-subjects analytical design [2], the study by Landrigan and colleagues did not [3]. A systemic-level approach rather than a within-subjects analysis was used in comparing interns' serious medical error rates, making these analyses comparable with analyses of errors system wide (i.e. those that involved both interns and other personnel), where a within-subjects design was not appropriate. Data from 20 interns were analyzed in Lockley and colleagues' study, as the authors note; however, data from an additional four interns contributed to the analysis in the study by Landrigan and colleagues. Our power to detect a 16% difference in serious medical errors was calculated to be 80%, not 90%. In addition, there is one error in the description of the limitations that we would like to point out. Dr Sarani and Dr Alarcon note: There were more patients admitted to the ICU and more ICU patient-days in the traditional arm than in the intervention arm. Although these differences were not statistically significant, it does raise the possibility that interns in the traditional arm had more opportunities to make serious errors. Differences in the incidence of serious errors were analyzed using rates (per patient-day), and therefore the fact that there were more patient-days in the traditional schedule cannot explain the results. On a per patient-day basis, there were no more opportunities to err in the traditional schedule. This is further confirmed by the fact that there were no more medications ordered or diagnostic tests interpreted in the traditional schedule per patient-day, and there were in fact fewer procedures performed in the traditional schedule per patient-day. With respect to the recommendations following from our findings, we strongly disagree with Dr Sarani and Dr Alarcon's statement that our study supports the Accreditation Council for Graduate Medical Education (ACGME) duty-hour standards: Based on the results of these studies, it seems that the ACGME resident work hour restrictions are warranted, at least for interns, and that efforts to reduce the number of hours worked by interns may improve patient care. Although we would agree that efforts to reduce the number of hours worked by interns may improve patient care, our traditional schedule was in fact compliant with the ACGME duty-hour standards. In effect, we were comparing these standards with a schedule that much more substantially reduced continuous working hours than the ACGME regulations demand, with a maximum of 16 scheduled consecutive hours. Our data support an extensive literature, derived from laboratory and field studies in other safety-sensitive industries, that 24 hours or more consecutive work are unsafe. Efforts to reduce work hours should focus first and foremost not on the frequency of extended-duration work shifts, but on the duration of consecutive work hours during such shifts. Research from laboratory and industrial settings suggests that performance deteriorates rapidly and the propensity to err rapidly increases after 16 hours of sustained wakefulness, a finding reflected in the twofold increase in interns' attentional failures after they had been working for more than 16 hours on the traditional schedule [2]. We agree with the recommendation that further research should study the effects of sleep deprivation and work schedule interventions on the performance of upper-level residents and other medical staff across a variety of disciplines. We likewise agree that optimizing patient hand-offs, medical education, and trainees' sense of professionalism should be priorities as interventions are developed that reduce consecutive work hours to ensure the safety of patient care. We believe, however, that development of 'a sense of professionalism' is not a function of whether a shift is 30 hours or is 16 hours, but is a function of the ethical priorities engendered through the medical training process; first among these is the moral obligation to 'Do No Harm'. Carefully controlled studies of our own systems and practices are essential to determine how best to protect patients and, ultimately, the integrity of our profession. With respect to medical education, it is important to recognize that sleep deprivation has been found to adversely affect education as well as resident and patient safety. Recent work has demonstrated markedly impaired learning among research subjects deprived of sleep [4-6]. Whether residents exposed to recurrent acute sleep deprivation learn more or learn less than better-rested residents who spend fewer hours in the hospital remains to be tested, and should be a major focus of future work.

Providing mobile phones to emergency medicine residents: perceived effects on physician communication and work

Study objectives: Effective communication in the complex emergency department (ED) environment is challenging. In the course of routine care, emergency medicine residents place and receive multiple telephone calls, many that are critical to patient decisions and care. Institutional constraints on resources may limit implementation of effective tools; in our ED, individual mobile telephones were not initially available for most emergency medicine residents. We want to evaluate the perceptions of emergency medicine residents who routinely use mobile telephones, and when additional mobile telephones are being implemented and made available to postgraduate year (PGY)-1 residents, we want to evaluate how the PGY-1 residents' perceptions changed after having routine access to a mobile telephone. Our first hypothesis is that upper-level emergency medicine residents who routinely use mobile telephones perceive improved work habits, efficiency, and satisfaction. Second, we hypothesize that after implementing expanded mobile telephone access for PGY-1 residents and surveying before and after, there will be perceived improvement in the same measures. Methods: This study was at an urban academic Level I ED with annual visits of 90,000 patients. The emergency medicine residency is a 3-year program with 30 residents. Before the study, there were approximately 20 mobile telephones in use in the ED, reserved for emergency medicine attending physicians, some upper-level emergency medicine residents, and other key support staff. The survey consisted of 12 questions, 7 with percentile responses and 5 with Likert scale (0 to 6) satisfaction/agreement scores. Part 1 of the study was conducted in December 2003, with a survey of upper-level emergency medicine residents. Part 2 of the study was the same survey, administered before and after to PGY-1 emergency medicine residents after additional mobile telephones were implemented (December 2003) and after PGY-1 residents had access for at least 2 months. Data were analyzed using dependent t tests. Results: Part 1 surveys were completed by 18 upper-level emergency medicine residents (90%). Upper-level emergency medicine residents reported access to a mobile telephone during 76.9% of their shifts (95% confidence interval [CI] 63.0% to 90.9%). They perceived missing return calls 11.0% of the time (95% CI 6.0% to 16.1%) and reported waiting around the central working area for a return page about 23.2% of the time (95% CI 9.5% to 36.9%). Regarding use of the mobile telephone, the upper-level residents preferred to call the page operator to place a page, rather than use a posted numeric code system (57.0% versus 33.4%, 95% CI −3.6% to 50.8%). They were satisfied with the current telephone system, with an average satisfaction scale of 4.4 (0 to 6 scale; 95% CI 3.8 to 5.0). Likewise, they strongly perceived that routine use of a mobile telephone would increase their efficiency (5.5 on a 0 to 6 scale; 95% CI 5.1 to 5.9), improve patient care (5.4 on a 0 to 6 scale; 95% CI 4.9 to 6.0), and allow being located easily (5.8 on a 0 to 6 scale; 95% CI 5.5 to 6.0). Part 2 before-and-after surveys were completed by 9 PGY-1 residents (90%). As a measure of implementation, PGY-1 residents reported increased access to a mobile telephone from an average of 2.3% to 91.6% of their shifts (89.3% increase, 95% CI 99.4% to 79.2%). All reported a decrease in perceived missed return calls from an average of 20.3% to 4.6% (15.7% decrease, 95% CI −0.2% to −31.2%), as well as less waiting around the central working area for a return page from an average of 67.8% to 13.9% (53.9% decrease; 95% CI −32.0% to −75.8%). With regard to their telephone usage, there was no significant change in the use of 3 paging systems. After implementation of the mobile telephones, all PGY-1 residents reported an increase in satisfaction with the telephone system from an average of 2.4 to 4.1 (0 to 6 scale, 1.7 increase; 95% CI 0.0 to 3.5). They all believed as well that routine use of a mobile telephone would increase their efficiency, improve patient care, and allow being located easily. That perception remained unchanged after distribution of the mobile telephones. Conclusion: Providing a personal mobile telephone to emergency medicine residents improves perceived work habits, efficiency, and satisfaction. Resources need to be available to provide tools for emergency medicine residents and other physicians to provide high-quality patient care in the challenging and demanding ED environment.

Chief Residency

Chief Residency

Are family practice residents able to interpret electrocardiograms?

Teaching electrocardiogram (ECG) interpretation is a recommended component of the family practice residency curriculum. Published information concerning the ECG interpretation ability of residents is sparse. This study sought to ascertain the baseline knowledge of family practice residents' ECG interpretation skills and extent of improvement after one year of training. A 15 ECG examination was administered to 38 PG-1 and 14 upper level residents at 5 residency programs at the beginning of the academic year and to residents at the authors' program at the end of the academic year. Pre-test scores among the five programs were compared using an analysis of variance (ANOVA). Pre-test and post-test scores were compared using a paired randomization test. No difference was found between average scores from each site, or between the beginning and end of the academic year. Residents were more likely to misinterpret items such as myocardial infarction, myocardial ischemia, and atrial fibrillation. Residents in family practice have considerable deficiencies in ECG interpretation skills. Further studies are needed to determine effective ECG teaching curricula.