Debra F. Weinstein

The educational impact of ACGME limits on resident and fellow duty hours: a pre-post survey study.

Purpose To assess the educational impact of Accreditation Council for Graduate Medical Education resident work-hour limits implemented in July 2003. Method All trainees in all 76 accredited programs at two large teaching hospitals were surveyed between May and June 2003 (before work-hour reductions) and then between May and June 2004 (after work-hour reductions) about hours, education, and fatigue. Based on changes in weekly duty hours, 13 programs experiencing substantial reduction in hours were classified into a reduced-hours group. Differences in assessments of educational endpoints before and after policy implementation by trainees in the reduced-hours group were compared with those in other programs to control for potential temporal trends, using two-way ANOVA with interaction. Results The number of respondents was 1,770 (60% response rate). The reduced-hours group reported a significant decrease in time spent directly caring for patients (from 48.5 to 42.3 mean h/wk, P = 0.03), but the volume of important clinical experiences, including procedures, was preserved, as was the sense of clinical preparedness. On 22 questions related to educational quality and adequacy, only three differences in differences were significant, with the reduced-hours group reporting a relative increase in opportunities for research, decrease in quality of faculty teaching, and decrease in educational satisfaction. The percentage of trainees reporting frequent negative effects of fatigue dropped more in the reduced-hours programs than in the other programs (P < 0.05). Conclusion This study shows that it may be possible to reduce residents’ hours—and the perceived adverse impact of fatigue—while generally preserving the self-assessed quality, quantity, and outcomes of graduate medical education.

Innovation in Medical Education

The design of U.S. graduate medical education is the product of tradition and has changed little despite substantial changes in patient needs and care delivery. Research is needed on the most appropriate structure, content, funding mechanisms, and organization of GME.

Perceived impact of resident work hour limitations on medical student clerkships: a survey study.

Purpose 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. Method 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. Results 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]. Conclusion 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.

The Ethics of Conducting Graduate Medical Education Research on Residents

The field of graduate medical education (GME) research is attracting increased attention and broader participation. The authors review the special ethical and methodological considerations pertaining to medical education research. Because residents are at once a convenient and captive study population, a risk of coercion exists, making the provision of consent important. The role of the institutional review board (IRB) is often difficult to discern because GME activities can have multiple simultaneous purposes, educational activities may go forward with or without a research component, and the subjects of educational research studies are not patients. The authors provide a road map for researchers with regard to research oversight by the IRB and also address issues related to research quality. The matters of whether educational research studies should have educational value for the study subject and whether to use individual information obtained when residents participate as research subjects are explored.

The Elusive Goal of Accountability in Graduate Medical Education.

Repeated calls for greater accountability of graduate medical education (GME) have been issued in recent years. In this context, Kenneth Ludmerer’s Let Me Heal examines the issue of duty hours limits and paints a picture of failed accountability. The ways in which duty hours regulations have failed are discussed, pointing toward a need to focus on goals and outcomes (such as patient safety) rather than process (such as schedules and shift length). This Commentary considers key issues—who should be accountable, for what, and to whom?—and proposes a potential path for achieving accountability in GME. The author draws from consensus reports published by the Josiah Macy Jr. Foundation and the Institute of Medicine to outline the case for why the U.S. system of GME should be accountable to the public, to individual patients, and to the residents and fellows being educated. Domains of accountability include graduating competent physicians, producing the right workforce, and ensuring an efficient and cost-effective training process that is designed to protect patients. In addition, the author argues that GME should be accountable for providing trainees with reasonable working conditions and compensation. Key requirements for achieving meaningful GME accountability are proposed, including (1) a more effective partnership with the public; (2) explicit goals and assigned responsibilities, reflecting reasonable expectations of what GME can accomplish; (3) reliable metrics for GME outcomes; and (4) a governance system that provides coordination and has the authority to effect changes.

Residency Training — A Decade of Duty-Hours Regulations

Panelists discuss the effects of the controversial ACGME regulations regarding duty hours and supervision.

Nonsurgical treatment of cholelithiasis. An analysis of clinical opportunity.

This article examines the potential impact of recently developed nonsurgical treatments for gallstones on patient care and resource utilization. Using epidemiological and efficacy data from the literature and current patient selection criteria, the authors evaluate UDCA, extracorporeal shock-wave lithotripsy, and direct instillation of methyltertbutyl ether in terms of short-term clinical results, health policy, and economic implications.

Use of an objective structured clinical exam (OSCE) for early identification of communication skills deficits in interns

Abstract Introduction: There is limited information about whether OSCE during GME orientation can identify trainee communication deficits before these become evident via clinical performance evaluations. Methods: Ninety-seven interns matriculating to eight residency programs in six specialties at four hospitals participated in a nine-station communication skills OSCE. Ratings were based on the “Kalamazoo, adapted” communication skills checklist. Possible association with intern performance evaluations was assessed by repeated-measures logistic regression and ROC curves were generated. Results: The mean OSCE score was 4.08 ± 0.27 with a range of 3.3–4.6. Baseline OSCE scores were associated with subsequent communication concerns recorded by faculty, based on 1591 evaluations. A 0.1-unit decrease in the OSCE communication score was associated with an 18% higher odds of being identified with a communication concern by faculty evaluation (odds ratio 1.18, 95% CI 1.01–1.36, p = 0.034). ROC curves did not demonstrate a “cut-off” score (AUC= 0.558). Non-faculty evaluators were 3–5 times more likely than faculty evaluators to identify communication deficits, based on 1900 evaluations. Conclusions: Lower OSCE performance was associated with faculty communication concerns on performance evaluations; however, a “cut-off” score was not demonstrated that could identify trainees for potential early intervention. Multi-source evaluation also identified trainees with communication skills deficits.

DACA and the Dream of Becoming a Physician

While we wait for Congress to act to protect the “Dreamers” — the young immigrants who were covered by the Deferred Action for Childhood Arrivals program — graduate medical education programs and their potential applicants have tough decisions to make.

Optimizing GME by Measuring Its Outcomes

Assessment of the impact of individual residency graduates, the performance of graduate medical education programs, and the collective contribution of our GME “system” would help inform policy decisions and facilitate efforts to cultivate evidence-based GME.