Aashish Didwania

Effects of the 2011 Duty Hour Reforms on Interns and Their Patients: A Prospective Longitudinal Cohort Study

IMPORTANCE In 2003, the first phase of duty hour requirements for US residency programs recommended by the Accreditation Council for Graduate Medical Education (ACGME) was implemented. Evidence suggests that this first phase of duty hour requirements resulted in a modest improvement in resident well-being and patient safety. To build on these initial changes, the ACGME recommended a new set of duty hour requirements that took effect in July 2011. OBJECTIVE To determine the effects of the 2011 duty hour reforms on first-year residents (interns) and their patients. DESIGN As part of the Intern Health Study, we conducted a longitudinal cohort study comparing interns serving before (2009 and 2010) and interns serving after (2011) the implementation of the new duty hour requirements. SETTING Fifty-one residency programs at 14 university and community-based GME institutions. PARTICIPANTS A total of 2323 medical interns. MAIN OUTCOME MEASURES Self-reported duty hours, hours of sleep, depressive symptoms, well-being, and medical errors at 3, 6, 9, and 12 months of the internship year. RESULTS Fifty-eight percent of invited interns chose to participate in the study. Reported duty hours decreased from an average of 67.0 hours per week before the new rules to 64.3 hours per week after the new rules were instituted (P < .001). Despite the decrease in duty hours, there were no significant changes in hours slept (6.8 → 7.0; P = .17), depressive symptoms (5.8 → 5.7; P = .55) or well-being score (48.5 → 48.4; P = .86) reported by interns. With the new duty hour rules, the percentage of interns who reported concern about making a serious medical error increased from 19.9% to 23.3% (P = .007). CONCLUSIONS AND RELEVANCE Although interns report working fewer hours under the new duty hour restrictions, this decrease has not been accompanied by an increase in hours of sleep or an improvement in depressive symptoms or well-being but has been accompanied by an unanticipated increase in self-reported medical errors.

Making july safer: Simulation-based mastery learning during intern boot camp

Purpose Patient care quality worsens during academic year turnover. Incoming interns’ uneven clinical skills likely contribute to this phenomenon, known as the “July effect.” The aim of this study was to evaluate the impact of a simulation-based mastery learning (SBML) boot camp on internal medicine interns’ clinical skills. Method This was a cohort study of an SBML intervention at Northwestern University. In 2011, 47 interns completed boot camp; 109 interns (from 2009 and 2010) who did not participate in boot camp were historical controls. Boot-camp-trained interns participated in three days of small-group teaching sessions, deliberate practice, and individualized feedback. Primary outcome measures were performance of boot-camp-trained interns and historical controls on five parts of a clinical skills examination (CSE). Assessments included recognition of physical examination findings (cardiac auscultation), performance of procedures (paracentesis and lumbar puncture), management of critically ill patients (intensive care unit skills), and communication with patients (code status discussion). Boot camp participants were required to meet or exceed a minimum passing standard (MPS) before beginning their internship. Results Boot-camp-trained interns all eventually met or exceeded the MPS and performed significantly better than historical control interns on all skills (P < .01), even after controlling for age, gender, and USMLE Step 1 and 2 scores (P < .001). The authors detected no relationship between CSE scores and age, gender, prior experience, self-confidence, or USMLE Step 1 and 2 scores. Conclusions An SBML boot camp allows for individualized training, assessment, and documentation of competence before interns begin providing medical care.

Meta‐analysis: Multidisciplinary fall prevention strategies in the acute care inpatient population

BACKGROUND Inpatient falls are common adverse events that lead to inpatient injury, increased length of stay, healthcare costs, litigation, and are a focus of patient safety and healthcare quality. Fall prevention methods are currently evolving to address the problem. PURPOSE To examine the available data evaluating multidisciplinary fall prevention strategies in the acute inpatient setting. DATA SOURCES A complete literature search of MEDLINE, CINAHL, EMBASE and the Cochrane Library through December 2011 was used. The bibliographies of all systematic reviews and meta-analyses were hand searched. STUDY SELECTION Only primary research studies relating to acute care inpatient hospital multidisciplinary fall prevention were included. Selected papers were assessed for quality by 2 authors using a 20-point scale previously used in the fall literature. DATA EXTRACTION Each selected study was carefully hand searched by 2 authors for the purposes of data extraction. Study results, in fall rate per 1000-patient days, and the characteristics of the interventions used were extracted for analysis. DATA SYNTHESIS Effect sizes (odds ratios) and 95% confidence intervals were derived for individual studies and then combined across research reports using a random-effects meta-analysis. CONCLUSIONS Fall prevention strategies have a significant but small effect on fall rates despite the use of complex, multidisciplinary interventions. Additional randomized trials are needed to examine the possible benefits of multidisciplinary fall prevention strategies in the acute inpatient setting.

Changes in perception of and participation in unprofessional behaviors during internship

Background Do perceptions of and participation in unprofessional behaviors change during internship? Method Interns at three Chicago medicine residencies anonymously reported participation in unprofessional behaviors before and after internship. On the basis of a prior survey, interns rated 28 unprofessional behaviors from 1 (unprofessional) to 5 (professional). Site-adjusted regression examined changes in participation rates and perception scores. Results Response rates were 93% (105) before and 88% (99) after internship. Participation in on-call unprofessional behaviors increased (“blocking” admissions [12% versus 41%, P < .001], disparaging the ER [27% versus 45%, P = .005], misrepresenting tests as urgent to expedite care [40% versus 60%; P = .003], and signing out by phone [20% versus 42%, P < .001]). Participation in egregious behaviors (fraud, disrespect, misrepresentation) and perceptions of most behaviors remained unchanged. Conclusions Although participation in egregious unprofessional behavior remained unchanged during internship, participation in on-call unprofessional behaviors increased.

Internal medicine postgraduate training and assessment of patient handoff skills.

BACKGROUND Effective communication during patient care transitions is essential for high-quality patient care. OBJECTIVE The purpose of this study was (1) to objectively assess patient handoff skills of internal medicine residents, and (2) to evaluate correlations between clinical experience and patient handoff skill self-assessment with directly observed skill. METHODS We studied simulated patient handoffs in postgraduate year (PGY)-1 and PGY-2 residents between July 2011 and September 2011, using a standardized scenario in an observed structured handoff exam (OSHE). Our design was a posttest-only, with nonequivalent groups. Assessment used a previously published checklist for evaluating handoff skills. Residents were asked about clinical experience with patient handoffs and about their self-confidence in performing a patient handoff independently. We evaluated between-group differences on OSHE checklist performance, patient handoff experience, and self-confidence and used multiple regression analyses to assess the association between performance, experience, and confidence. RESULTS Forty-seven PGY-1 residents and 38 PGY-2 residents completed the study. Interrater reliability was substantial (intraclass correlation  =  0.68). There was no significant difference in OSHE performance by PGY-1 residents (mean  =  79%, SD  =  4.6) and PGY-2 residents (mean  =  82%; SD  =  7.6; P  =  .07). The PGY-2 residents were significantly more experienced (P < .001) and confident (P < .001) than PGY-1 residents were, yet clinical experience and self-confidence did not significantly predict OSHE performance. CONCLUSIONS Clinical experience and self-assessment do not predict skills in simulated patient handoffs, and residents with substantial clinical experience still benefit from further skills development.

E-Learning—The New Frontier: A Report from the APDIM E-Learning Task Force

E-Learning—The New Frontier: A Report from the APDIM E-Learning Task Force John D. Myers, MD, Aashish Didwania, MD, Chirayu Shah, MD, David Jacobson, MD, Daphne Norwood, MD, Maniza Ehtesham, MD, Paul Aronowitz, MD Department of Medicine, Scott and White Hospital and Clinic/Texas AM Department of Medicine, orthwestern University, Feinberg School of Medicine, Chicago, Ill; Department of Medicine, Baylor College of Medicine, ouston, Texas; Department of Medicine, University of California, San Francisco; Department of Medicine, University of ennessee Graduate School of Medicine, Knoxville; Department of Medicine, University of Missouri Kansas City, Mo; Department of Medicine, California Pacific Medical Center, San Francisco.

Rapid response teams in teaching hospitals: Aligning efforts to improve medical education and quality

The use of RRTs in teaching hospitals raises impor-tant concerns. The ability of nurses and other profes-sionals to activate the RRT without need for priorapproval from a physician could potentially under-mine resident physician autonomy. Residents may feelthat their clinical judgment has been usurped or sec-ond guessed. Whether nurse led or physician led,RRTs always introduce new members to the careteam.

Duty hour reform: only a small piece of a larger problem--reply.

We agree with Dr. Runyan that addressing inter-professional communication and handoff training are critical factors in achieving meaningful improvement in both the quality of care that residents provide and the quality of life that they enjoy. Evidence from multiple studies indicate that the most recent set of ACGME duty hour reforms, which focused almost exclusively on reducing maximum shift length, have not achieved the intended improvements in quality of care or quality of life (1–3). If this experience with interns is instructive, then extending work hour limits to all residents, without address the additional factors raised be Dr. Runyan, will likely be ineffective. In addition to communication training, an essential piece of the puzzle not addressed by existing duty hour reforms is work compression. House officers now spend fewer hours in the hospital but their clinical workload and educational requirements have not decreased proportionally, resulting in an even more frenetic pace of work — a phenomenon known as “work compression” (4). In 2000 a typical call day lasted 36 hours. This was specifically reduced for interns from 36 hours to 30 hours in 2004 and to 16 hours with the latest duty hour changes. As a result, current interns have fewer hours to complete their work and engage in learning and team building experiences. This leaves the new intern generation in a frustrating situation where they are often criticized or chided for having less work when, in many cases, they are simply given less time to complete it. If we know that timed tests result in more errors than untimed ones, we should not be surprised that giving interns less time to complete the same amount of work would adversely affect their patient care. Paradoxically, with the addition of new, often untested, educational curriculum in communication skills and systems of care to traditional clinical topics, interns are also being asked to learn more in less time. Collectively, these changes often result in reduced opportunities to double-check orders, follow a disease course, spend time at the patient’s bedside, teach students or share a meal with their team. Incorporating solutions that address the problems associated with work compression are needed to fully achieve the goals of residency duty hour reform.

Improving the Efficiency of Advanced Life Support Training

TO THE EDITOR: We read the article by Perkins and colleagues (1) with interest. They studied advanced life support (ALS) education provided to 3732 health care professionals at 31 centers in the United Kingdom and Australia. We commend the authors for conducting such a large trial but are not surprised by the finding that learners assigned to the e-learning group performed worse on the cardiac arrest simulation test. Deliberate practice with feedback from a skilled instructor is a critical component of mastery. This has been shown by K. Anders Ericsson in many areas, including development of expertise in medicine and related domains (2). Therefore, we believe that removing deliberate practice from ALS education and replacing it with e-learning led to the decrease in performance on the simulation test. Current training in ALS has already been shown to be deficient because skills deteriorate rapidly after training (3). In contrast, simulation-based training that features deliberate practice has been shown to boost ALS skills, with improvement lasting up to 14 months (4). These skills have also been shown to transfer to the clinical setting, resulting in improved quality of care (5). We commend Perkins and colleagues for their sophisticated study that shows how costs can be reduced through e-learning. However, the ultimate goal is to design ALS courses that result in highly qualified ALS providers. We believe that more, not less, deliberate practice of simulated scenarios is required to achieve this aim.

Interactive Multimodal Curriculum on Use and Interpretation of Inpatient Telemetry

Introduction Inpatient telemetry monitoring is a commonly used technology designed to detect and monitor life-threatening arrhythmias. However, residents are rarely educated in the proper use and interpretation of telemetry monitoring. Methods We developed a training module containing an educational video, PowerPoint presentation, and hands-on interactive learning session with a telemetry expert. The module highlights proper use of telemetry monitoring, recognition of telemetry artifact, and interrogation of telemetry to identify clinically significant arrhythmias. Learners completed pre- and postcurriculum knowledge-based assessments and a postcurriculum survey on their experience with the module. In total, the educational curriculum had three 60-minute sessions. Results Thirty-two residents participated in the training module. Residents scored higher on the posttest (77% ± 12%) than on the pretest (70% ± 12%), t(31) = −4.3, p < .001. Wilcoxon signed rank tests indicated PGY-3s performed better on the posttest (Mdn = 0.86) than on the pretest (Mdn = 0.72), z = −2.19, p = .031. PGY-2s also performed better on the posttest (Mdn = 0.86) than on the pretest (Mdn = 0.76), z = −2.04, p = .042. There was no difference between pretest (Mdn = 0.66) and posttest (Mdn = 0.71) scores for PGY-1s, z = −1.50, p = .142. The majority of residents reported that the telemetry curriculum boosted their self-confidence, helped prepare them to analyze telemetry on their patients, and should be a required component of the residency. Discussion This module represents a new paradigm for teaching residents how to successfully and confidently interpret and use inpatient telemetry.