A key goal of resident duty hour reform by the Accreditation Council for Graduate Medical Education (ACGME) in 2003 was to improve patient outcomes.
To assess whether the reform led to a change in readmission rates.
Observational study using multiple time series analysis with hospital discharge data from July 1, 2000 to June 30, 2005. Fixed effects logistic regression was used to examine the change in the odds of readmission in more versus less teaching-intensive hospitals before and after duty hour reform.
All unique Medicare patients (n = 8,282,802) admitted to acute-care nonfederal hospitals with principal diagnoses of acute myocardial infarction, congestive heart failure, gastrointestinal bleeding, or stroke (combined medical group), or a DRG classification of general, orthopedic, or vascular surgery (combined surgical group).
Primary outcome was 30-day all-cause readmission. Secondary outcomes were (1) readmission or death within 30 days of discharge, and (2) readmission, death during the index admission, or death within 30 days of discharge.
For the combined medical group, there was no evidence of a change in readmission rates in more versus less teaching-intensive hospitals [OR = 0.99 (95% CI 0.94, 1.03) in post-reform year 1 and OR = 0.99 (95% CI 0.95, 1.04) in post-reform year 2]. There was also no evidence of relative changes in readmission rates for the combined surgical group: OR = 1.03 (95% CI 0.98, 1.08) for post-reform year 1 and OR = 1.02 (95% CI 0.98, 1.07) for post-reform year 2. Findings for the secondary outcomes combining readmission and death were similar.
Among Medicare beneficiaries, there were no changes in hospital readmission rates associated with resident duty hour reform.
education, medical, graduate; hospital; readmission
OBJECTIVE: To describe the views of residency program directors regarding the effect of the 2010 duty hour recommendations on the 6 core competencies of graduate medical education.
METHODS: US residency program directors in internal medicine, pediatrics, and general surgery were e-mailed a survey from July 8 through July 20, 2010, after the 2010 Accreditation Council for Graduate Medical Education (ACGME) duty hour recommendations were published. Directors were asked to rate the implications of the new recommendations for the 6 ACGME core competencies as well as for continuity of inpatient care and resident fatigue.
RESULTS: Of 719 eligible program directors, 464 (65%) responded. Most program directors believe that the new ACGME recommendations will decrease residents' continuity with hospitalized patients (404/464 [87%]) and will not change (303/464 [65%]) or will increase (26/464 [6%]) resident fatigue. Additionally, most program directors (249-363/464 [53%-78%]) believe that the new duty hour restrictions will decrease residents' ability to develop competency in 5 of the 6 core areas. Surgery directors were more likely than internal medicine directors to believe that the ACGME recommendations will decrease residents' competency in patient care (odds ratio [OR], 3.9; 95% confidence interval [CI], 2.5-6.3), medical knowledge (OR, 1.9; 95% CI, 1.2-3.2), practice-based learning and improvement (OR, 2.7; 95% CI, 1.7-4.4), interpersonal and communication skills (OR, 1.9; 95% CI, 1.2-3.0), and professionalism (OR, 2.5; 95% CI, 1.5-4.0).
CONCLUSION: Residency program directors' reactions to ACGME duty hour recommendations demonstrate a marked degree of concern about educating a competent generation of future physicians in the face of increasing duty hour standards and regulation.
The reactions of residency program directors to the ACGME duty hour recommendations demonstrate a marked degree of concern about educating a competent generation of future physicians in the face of increasing duty hour standards and regulation.
Among medical educators, there are concerns that the 2003 Accreditation Council for Graduate Medical Education (ACGME) duty hour rules (DHR) has encouraged the development of a “shift work” mentality among residents while eroding professionalism by forcing residents to either abandon patients when they hit 80 hours or lie about hours worked. In this qualitative study, we explore how medical and surgical residents perceive and respond to DHR by examining the ‘local’ organizational culture in which their work is embedded.
In 2008, we conducted three months of ethnographic observation of internal medicine and general surgery residents as they went about their everyday work in two hospitals affiliated with the same training program. We also conducted in-depth interviews with seventeen residents. Field notes and interview transcripts were analyzed for perceptions and behaviors surrounding coming and leaving work, reporting of duty hours, and resident opinion about DHR.
Our respondents did not exhibit a “shift work” mentality in relation to their work. We found that residents: 1) occasionally stay in the hospital in order to complete patient care tasks even when, according to the clock, they were required to leave because the organizational culture stressed performing work thoroughly, 2) do not blindly embrace noncompliance with DHR but are thoughtful about the tradeoffs inherent in the regulations, and 3) express nuanced and complex reasons for erroneously reporting duty hours that suggest that reporting hours worked is not a simple issue of lying or truth telling.
Concerns about DHR and the erosion of resident professionalism via the development of a “shift work” mentality are likely to have been over-stated. At the institution we examined, residents did not behave as automatons punching in and out at prescribed times. Rather, they are mindful of the consequences and meaning surrounding the decisions they make to stay or leave work. When work hour rules are broken, residents do not perceive this behavior to be deviant but rather as a reflection of the higher priority that they place on providing patient care than on complying strictly with DHR. The influence of DHR on professionalism is more complex than conventional wisdom suggests and requires additional assessment.
internship and residency; duty hour regulations; professionalism
The Accreditation Council for Graduate Medical Education's (ACGME) new requirements raise multiple challenges for academic medical centers. We sought to evaluate career satisfaction, emotional states, positive and negative experiences, work hours and sleep among residents and faculty simultaneously in one academic medical center after implementation of the ACGME duty hour requirements.
Residents and faculty (1330) in the academic health center were asked to participate in a confidential survey; 72% of the residents and 66% of the faculty completed the survey.
Compared to residents, faculty had higher levels of satisfaction with career choice, competence, importance and usefulness; lower levels of anxiousness and depression. The most positive experiences for both groups corresponded to strong interpersonal relationships and educational value; most negative experiences to poor interpersonal relationships and issues perceived outside of the physician's control.
Approximately 13% of the residents and 14% of the faculty were out of compliance with duty hour requirements. Nearly 5% of faculty reported working more than 100 hours per week. For faculty who worked 24 hour shifts, nearly 60% were out of compliance with the duty-hour requirements.
Reasons for increased satisfaction with career choice, positive emotional states and experiences for faculty compared to residents are unexplained. Earlier studies from this institution identified similar positive findings among advanced residents compared to more junior residents. Faculty are more frequently at risk for duty-hour violations. If patient safety is of prime importance, faculty, in particular, should be compliant with the duty hour requirements. Perhaps the ACGME should contain faculty work hours as part of its regulatory function.
To assess the impact of work hours' limitations required by the Accreditation Council for Graduate Medical Education (ACGME) on residents' career satisfaction, emotions and attitudes.
A validated survey instrument was used to assess residents' levels of career satisfaction, emotions and attitudes before and after the ACGME duty hour requirements were implemented. The "pre" implementation survey was distributed in December 2002 and the "post" implementation one in December 2004. Only the latter included work-hour related questions.
The response rates were 56% for the 2002 and 72% for the 2004 surveys respectively. Although career satisfaction remained unchanged, numerous changes occurred in both emotions and attitudes. Compared to those residents who did not violate work-hour requirements, those who did were significantly more negative in attitudes and emotions.
With the implementation of the ACGME work hour limitations, the training experience became more negative for those residents who violated the work hour limits and had a small positive impact on those who did not violate them. Graduate medical education leaders must innovate to make the experiences for selected residents improved and still maintain compliance with the work hour requirements.
Increased focus on the number and type of physicians delivering health care in the United States necessitates a better understanding of changes in graduate medical education (GME). Data collected by the Accreditation Council for Graduate Medical Education (ACGME) allow longitudinal tracking of residents, revealing the number and type of residents who continue GME following completion of an initial residency. We examined trends in the percent of graduates pursuing additional clinical education following graduation from ACGME-accredited pipeline specialty programs (specialties leading to initial board certification).
Using data collected annually by the ACGME, we tracked residents graduating from ACGME-accredited pipeline specialty programs between academic year (AY) 2002–2003 and AY 2006–2007 and those pursuing additional ACGME-accredited training within 2 years. We examined changes in the number of graduates and the percent of graduates continuing GME by specialty, by type of medical school, and overall.
The number of pipeline specialty graduates increased by 1171 (5.3%) between AY 2002–2003 and AY 2006–2007. During the same period, the number of graduates pursuing additional GME increased by 1059 (16.7%). The overall rate of continuing GME increased each year, from 28.5% (6331/22229) in AY 2002–2003 to 31.6% (7390/23400) in AY 2006–2007. Rates differed by specialty and for US medical school graduates (26.4% [3896/14752] in AY 2002–2003 to 31.6% [4718/14941] in AY 2006–2007) versus international medical graduates (35.2% [2118/6023] to 33.8% [2246/6647]).
The number of graduates and the rate of continuing GME increased from AY 2002–2003 to AY 2006–2007. Our findings show a recent increase in the rate of continued training for US medical school graduates compared to international medical graduates. Our results differ from previously reported rates of subspecialization in the literature. Tracking individual residents through residency and fellowship programs provides a better understanding of residents' pathways to practice.
In 2003 the Accreditation Council for Graduate Medical Education mandated work hour restrictions. Violations can results in a residency program being cited or placed on probation. Recurrent violations could results in loss of accreditation. We wanted to determine specific intern and workload factors associated with violation of a specific mandate, the 30-hour duty period requirement.
Retrospective review of interns’ performance against the 30-hour duty period requirement during inpatient ward rotations at a pediatric residency program between June 24, 2008 and June 23, 2009. The analytical plan included both univariate and multivariable logistic regression analyses.
Twenty of the 26 (77%) interns had 80 self-reported episodes of continuous work hours greater than 30 hours. In multivariable analysis, noncompliance was inversely associated with the number of prior inpatient rotations (odds ratio: 0.49, 95% confidence interval (0.38, 0.64) per rotation) but directly associated with the total number of patients (odds ratio: 1.30 (1.10, 1.53) per additional patient). The number of admissions on-call, number of admissions after midnight and number of discharges post-call were not significantly associated with noncompliance. The level of noncompliance also varied significantly between interns after accounting for intern experience and workload factors. Subject to limitations in statistical power, we were unable to identify specific intern characteristics, such as demographic variables or examination scores, which account for the variation in noncompliance between interns.
Both intern and workload factors were associated with pediatric intern noncompliance with the 30-hour duty period requirement during inpatient ward rotations. Residency programs must develop information systems to understand the individual and experience factors associated with noncompliance and implement appropriate interventions to ensure compliance with the duty hour regulations.
An important expectation of pediatric education is assessing, resuscitating, and stabilizing ill or injured children.
To determine whether the Accreditation Council for Graduate Medical Education (ACGME) minimum time requirement for emergency and acute illness experience is adequate to achieve the educational objectives set forth for categorical pediatric residents. We hypothesized that despite residents working five 1-month block rotations in a high-volume (95 000 pediatric visits per year) pediatric emergency department (ED), the comprehensive experience outlined by the ACGME would not be satisfied through clinical exposure.
This was a retrospective, descriptive study comparing actual resident experience to the standard defined by the ACGME. The emergency medicine experience of 35 categorical pediatric residents was tracked including number of patients evaluated during training and patient discharge diagnoses. The achievability of the ACGME requirement was determined by reporting the percentage of pediatric residents that cared for at least 1 patient from each of the ACGME-required disorder categories.
A total of 11.4% of residents met the ACGME requirement for emergency and acute illness experience in the ED. The median number of patients evaluated by residents during training in the ED was 941. Disorder categories evaluated least frequently included shock, sepsis, diabetic ketoacidosis, coma/altered mental status, cardiopulmonary arrest, burns, and bowel obstruction.
Pediatric residents working in one of the busiest pediatric EDs in the country and working 1 month more than the ACGME-recommended minimum did not achieve the ACGME requirement for emergency and acute illness experience through direct patient care.
In 2003, the Accreditation Council for Graduate Medical Education (ACMGE) implemented a single duty hour standard nationwide. The evidence to date suggests that this neither improved nor worsened patient outcomes. In June 2010, the ACGME proposed a new set of duty hour standards for implementation in July 2011. The main disadvantage of this approach is that we will not be able to determine whether different standards would have worked better to reduce resident fatigue while improving patient safety. There are many unanswered questions as to how to design duty hour standards but relatively little evidence; in addition, the same approach may not work in all specialties and all hospitals. A more flexible, dynamic policy that emphasizes ongoing testing and evaluation would be more likely to achieve improvements in clinical and educational outcomes.
The Accreditation Council for Graduate Medical Education (ACGME) has announced revisions to the resident duty hour standards in light of a 2008 Institute of Medicine report that recommended further limits. Soliciting resident input regarding the future of duty hours is critical to ensure trainee buy-in.
To assess incoming intern perceptions of duty hour restrictions at 3 teaching hospitals.
We administered an anonymous survey to incoming interns during orientation at 3 teaching hospitals affiliated with 2 Midwestern medical schools in 2009. Survey questions assessed interns' perceptions of maximum shift length, days off, ACGME oversight, and preferences for a “fatigued post-call intern who admitted patient” versus “well-rested covering intern who just picked up patient” for various clinical scenarios.
Eighty-six percent (299/346) of interns responded. Although 59% agreed that residents should not work over 16 hours without a break, 50% of interns favored the current limits. The majority (78%) of interns desired ability to exceed shift limit for rare cases or clinical opportunities. Most interns (90%) favored oversight by the ACGME, and 97% preferred a well-rested intern for performing a procedure. Meanwhile, only 48% of interns preferred a well-rested intern for discharging a patient or having an end of life discussion. Interns who favored 16-hour limits were less concerned with negative consequences of duty hour restrictions (handoffs, reduced clinical experience) and more likely to choose the well-rested intern for certain scenarios (odds ratio 2.33, 95% confidence interval 1.42–3.85, P = .001).
Incoming intern perceptions on limiting duty hours vary. Many interns desire flexibility to exceed limits for interesting clinical opportunities and favor ACGME oversight. Clinical context matters when interns consider the tradeoffs between fatigue and discontinuity.
Work-hour limitations have been implemented by the Accreditation Council for Graduate Medical Education (ACGME) in July 2003 in order to minimize fatigue related medical adverse events. The effects of this regulation are still under intense debate. In this literature review, data of effects of limited work-hours on the quality of life, surgical education, and patient care was summarized, focusing on surgical subspecialities.
Studies that assessed the effects of the work-hour regulation published following the implementation of ACGME guidelines (2003) were searched using PubMed database. The following search modules were selected: work-hours, 80-hour work week, quality of life, work satisfaction, surgical education, residency training, patient care, continuity of care. Publications were included if they were completed in the United States and covered the subject of our review. Manuscrips were analysed to identify authors, year of publication, type of study, number of participants, and the main outcomes.
Twenty-one articles met the inclusion criteria. Studies demonstrate that the residents quality of life has improved. The effects on surgical education are still unclear due to inconsistency in studies. Furthermore, according to several objective studies there were no changes in mortality and morbidity following the implementation.
Further studies are necessary addressing the effects of surgical education and studying the objective methods to assess the technical skill and procedural competence of surgeons. In addition, patient surveys analysing their satisfaction and concerns can contribute to recent discussion, as well.
In 2003, the Accreditation Council for Graduate Medical Education standardized and regulated work hours for physicians in training in the United States. In December 2008, the Institute of Medicine (IOM) recommended further reductions in duty hours to ensure safer conditions for patients and residents and fellows. Significantly, the IOM committee acknowledged that there are barriers to implementing its recommendations.
In the wake of the IOM proposals, we chose to survey a reference closer to home: residency program directors, faculty, and residents. Our survey allowed them the opportunity to express their opinions regarding the IOM proposals.
The majority of the faculty oppose the proposed IOM changes, arguing that there is no definite evidence to support the hypothesis that fewer work hours mean better outcomes in patient safety and education. First-year residents and residents who moonlight were more likely to experience stress and to support decreased work hours.
The thoughts and opinions of faculty and residents collected through this survey, in combination with evidence-based studies from trial implementation of these standards, will contribute real answers to the challenging questions on resident work hours.
Prior studies of resident experience in gynecology looked only at the year before and after adoption of ACGME duty hour standards. This study sought to determine whether procedure volume differed after completion of a 4-year residency training program, before and after work hour reform.
Inpatient and outpatient procedures performed by MetroHealth Medical Center/Cleveland Clinic program residents from 1998 to 2006 were obtained from Annual Reports of Institutional and Resident Experience. Four-year experience before and after duty hour restrictions were compared: hours worked were collected from resident schedules, ambulatory hours and procedures were compared directly, surgical procedures and deliveries were compared using a 2-tailed t test. Data were also obtained for institutional volume changes, and a corrected value, based on the rates of resident cases per available cases, was analyzed.
Ambulatory hours worked per resident decreased after implementing work hour reform from 674 to 366 hours. The types of ambulatory and surgical procedures performed varied over time. Overall, basic surgical and obstetrical volume per resident did not change before and after work hour reform (mean before reform, 723 ± 117, mean after reform, 781 ± 200, P = .58 for gynecologic procedures; mean before reform, 611 ± 107, mean after reform, 535 ± 73, P = .18 for basic obstetrics and vaginal and cesarean deliveries). Institutional volume did not change significantly, although the percentage of the institutions' cases performed by residents did decrease for some procedures.
The ACGME duty hour restrictions do not limit the overall ambulatory or surgical procedural volume in an obstetrics and gynecology residency-training period.
There is growing interest in global health among medical trainees. Medical schools and residencies are responding to this trend by offering global health opportunities within their programs. Among United States (US) graduating pediatric residents, 40% choose to subspecialize after residency training. There is limited data, however, regarding global health opportunities within traditional post-residency, subspecialty fellowship training programs. The objectives of this study were to explore the availability and type of global health opportunities within Accreditation Council for Graduate Medical Education (ACGME)-accredited pediatric subspecialty fellowship training programs, as noted by their online report, and to document change in these opportunities over time.
The authors performed a systematic online review of ACGME-accredited fellowship training programs within a convenience sample of six US pediatric subspecialties. Utilizing two data sources, the American Medical Association-Fellowship and Residency Electronic Interactive Database Access (AMA-FREIDA) and individual program websites, all programs were coded for global health opportunities and opportunity types were stratified into predefined categories. Comparisons were made between 2008 and 2011 using Fisher exact test. All analyses were conducted using SAS Software v. 9.3 (SAS Institute Inc., Cary, NC).
Of the 355 and 360 programs reviewed in 2008 and 2011 respectively, there was an increase in total number of programs listing global health opportunities on AMA-FREIDA (16% to 23%, p=0.02) and on individual program websites (8% to 16%, p=0.004). Nearly all subspecialties had an increased percentage of programs offering global health opportunities on both data sources; although only critical care experienced a significant increase (p=0.04, AMA-FREIDA). The types of opportunities differed across all subspecialties.
Global health opportunities among ACGME-accredited pediatric subspecialty fellowship programs are limited, but increasing as noted by their online report. The availability and types of these opportunities differ by pediatric subspecialty.
Global health; Pediatrics; Graduate medical education; Subspecialty; Fellowship training
The Accreditation Council for Graduate Medical Education (ACGME) program requirements mandate “adequate supervision,” of residents, but there is little guidance for sports medicine fellowship directors regarding the transition from direct to indirect supervision of fellows covering football games.
We sought to gather evidence of current supervision practices in the context of injury outcomes.
Fellows and program directors of ACGME-accredited sports medicine fellowship programs were invited to complete an online survey regarding their experience and current supervision practice at football games. Criteria for transition to autonomy and desired changes in supervision practice were elicited. Player safety was quantified by noting the number of field-side emergencies, whether an attending was present, and whether better outcomes might have resulted from the presence of an attending.
A total of 80 fellows and 50 program directors completed the online survey. Direct supervision was lacking in about 50% of high school games and 20% of college games. A resulting cost in terms of player safety was estimated to apply to 5% of serious injuries by fellows' report but less than 0.5% by directors' report. Written criteria for transitioning from direct supervision to autonomy were the exception rather than the rule. The majority of fellows and directors expressed satisfaction with the current level of supervision, but 20% of fellows would prefer more supervision through postgame review.
Football games covered by fellows are often not directly supervised. Absence of an attending affected the outcomes of 5% or less of serious injuries. Transition to autonomy does not usually require meeting written criteria. Fellows might benefit from additional off-site supervision.
Educators have struggled with teaching and evaluation of the six Accreditation Council for Graduate Medical Education (ACGME) core competencies since their introduction in 1999. In addition, many authors have questioned the construct validity of the competencies. Concern has also arisen regarding the educational effects of the competencies and the subsequent limitation of resident duty hours, the combination of which have forced unprecedented changes in American graduate medical education. This article attempts to present an understanding of how these events have had direct and indirect effects on the education of residents in colon and rectal surgery, and to provide a framework for educators in colon and rectal surgery to adapt in their curricula.
ACGME competencies; colon and rectal surgery residency; technical competence; surgical judgment; effects of duty hour limits
In 2003, the Accreditation Council for Graduate Medical Education instituted common duty hour limits, and in 2008 the Institute of Medicine recommended additional limits on continuous duty hours. Using a night-float system is an accepted approach for adhering to duty hour mandates.
To determine the effect of an on-site night-float attending physician on resident education and patient care.
Night-float residents and daytime ward residents were surveyed at the end of their rotation about the impact of an on-site night-float attending physician on education and quality of patient care. Responses were provided on a 5-point Likert scale ranging from 1, strongly agree, to 5, strongly disagree.
Overall, 92 of the 140 distributed surveys were completed (66% response rate). Night-float residents found the night-float attending physician to be helpful with cross-cover issues (mean = 2.00), initial history and physical examination (mean = 1.56), choosing appropriate diagnostic tests (mean = 1.79), developing a treatment plan (mean = 1.74), and improving overall patient care (mean = 1.91). Daytime ward residents were very satisfied with the quality of the admission workups (mean = 1.78), tests and diagnostic procedures (mean = 1.76), and initial treatment plan (mean = 1.62) provided by the night-float service.
A night-float system that includes on-site attending physician supervision can provide a valuable opportunity for resident education and may help improve the quality of patient care.
The American Board of Internal Medicine Certification Examination (ABIM-CE) is one of several methods used to assess medical knowledge, an Accreditation Council for Graduate Medical Education (ACGME) core competency for graduating internal medicine residents. With recent changes in graduate medical education program directors and internal medicine residents are seeking evidence to guide decisions regarding residency elective choices. Prior studies have shown that formalized elective curricula improve subspecialty ABIM-CE scores. The primary aim of this study was to evaluate whether the number of subspecialty elective exposures or the specific subspecialties which residents complete electives in impact ABIM-CE scores.
ABIM-CE scores, elective exposures and demographic characteristics were collected for MedStar Georgetown University Hospital internal medicine residents who were first-time takers of the ABIM-CE in 2006–2010 (n=152). Elective exposures were defined as a two-week period assigned to the respective subspecialty. ABIM-CE score was analyzed using the difference between the ABIM-CE score and the standardized passing score (delta-SPS). Subspecialty scores were analyzed using percentage of correct responses. Data was analyzed using GraphPad Prism version 5.00 for Windows.
Paired elective exposure and ABIM-CE scores were available in 131 residents. There was no linear correlation between ABIM-CE mean delta-SPS and the total number of electives or the number of unique elective exposures. Residents with ≤14 elective exposures had higher ABIM-CE mean delta-SPS than those with ≥15 elective exposures (143.4 compared to 129.7, p=0.051). Repeated electives in individual subspecialties were not associated with significant difference in mean ABIM-CE delta-SPS.
This study did not demonstrate significant positive associations between individual subspecialty elective exposures and ABIM-CE mean delta-SPS score. Residents with ≤14 elective exposures had higher ABIM-CE mean delta-SPS than those with ≥15 elective exposures suggesting there may be an “ideal” number of elective exposures that supports improved ABIM-CE performance. Repeated elective exposures in an individual specialty did not correlate with overall or subspecialty ABIM-CE performance.
Resident education; Gender; Elective; Subspecialty; Graduate medical education
The Accreditation Council for Graduate Medical Education (ACGME) requires physicians in training to be educated in 6 competencies considered important for independent medical practice. There is little information about the experiences that residents feel contribute most to the acquisition of the competencies.
To understand how residents perceive their learning of the ACGME competencies and to determine which educational activities were most helpful in acquiring these competencies.
A web-based survey created by the graduate medical education office for institutional program monitoring and evaluation was sent to all residents in ACGME-accredited programs at the David Geffen School of Medicine, University of California-Los Angeles, from 2007 to 2010. Residents responded to questions about the adequacy of their learning for each of the 6 competencies and which learning activities were most helpful in competency acquisition.
We analyzed 1378 responses collected from postgraduate year-1 (PGY-1) to PGY-3 residents in 12 different residency programs, surveyed between 2007 and 2010. The overall response rate varied by year (66%–82%). Most residents (80%–97%) stated that their learning of the 6 ACGME competencies was “adequate.” Patient care activities and observation of attending physicians and peers were listed as the 2 most helpful learning activities for acquiring the 6 competencies.
Our findings reinforce the importance of learning from role models during patient care activities and the heterogeneity of learning activities needed for acquiring all 6 competencies.
In December 2008 the Institute of Medicine (IOM) released a report recommending limits on resident hours that are considerably more restrictive than the current Accreditation Council for Graduate Medical Education duty hour standards.
In March 2009, a large pediatric residency program implemented a 1-month trial of a schedule and team structure fully congruent with the IOM recommendations to study the implications of such a schedule.
Comparison of the interns' experience in the trialed intervention schedule was made to interns working a traditional schedule with every fourth night call.
The residents on the intervention schedule averaged 7.8 hours of sleep per 24-hour period compared to 7.6 hours for interns in a traditional schedule. Participation in bedside rounds and formal didactic conferences was decreased in the intervention schedule. Several factors contributed to increased perceived work intensity for interns in the intervention schedule. Redistribution of work during busy shifts altered the role of senior residents and attending physicians which may have a negative effect on senior residents' ability to develop skills as supervisors and educators.
The trial implementation suggests it is possible to implement the proposed duty hour limits in a pediatric residency, but it would require a significant increase in the resident workforce (at least 25% and possibly 50%) to care for the same number of patients. Furthermore, the education model would need to undergo significant changes. Further trials of the IOM recommendations are needed prior to widespread implementation in order to learn what works best and causes the least harm, disruption, and unnecessary cost to the system.
The Accreditation Council of Graduate Medical Education’s (ACGME) Data Accreditation System indicates 124 of 152 orthopaedic surgery residency program directors have 5 or fewer years of tenure. The qualifications and responsibilities of the position based on the requirements of orthopaedic surgery residency programs, the institutions that support them, and the ACGME Outcome Project have evolved the role of the program coordinator from clerical to managerial. To fill the void of information on the coordinators’ expanding roles and responsibilities, the 2006 Association of Residency Coordinators in Orthopaedic Surgery (ARCOS) Career survey was designed and distributed to 152 program coordinators in the United States. We had a 39.5% response rate for the survey, which indicated a high level of day-to-day managerial oversight of all aspects of the residency program; additional responsibilities for other department or division functions for fellows, rotating medical students, continuing medical education of the faculty; and miscellaneous business functions. Although there has been expansion of the role of the program coordinator, challenges exist in job congruence and position reclassification. We believe use of professional groups such as ARCOS and certification of program coordinators should be supported and encouraged.
The nationwide decline in pediatric admissions to community hospitals threatens the sustainability of small pediatric residency programs. Little is known about the response of small programs to this challenge.
We report on the design and evaluation of an innovative, collaborative model for pediatric inpatient training between an academic community medical center and a children's hospital.
We describe the operational, academic, and financial features of the model. Outcome measures include patient volume and subspecialty mix, resident and faculty perceptions as reported in an anonymous survey, and Accreditation Council for Graduate Medical Education Residency Review Committee (RRC) review.
In 2003, Albert Einstein Medical Center (Einstein) closed its pediatric inpatient unit and established an independent teaching service at St Christopher's Hospital for Children (St Christopher's) in Philadelphia, Pennsylvania. Under the new model, patient volume and subspecialty mix more than tripled. Einstein residents and faculty identified 5 major strengths: level of responsibility and decision making, caring for medically complex children, quality of teaching, teamwork, and opportunity to participate in academic activities at a children's hospital. St Christopher's leadership reported increased volume, no disruption of their residency program, and no dilution of clinical teaching material. The Einstein program was reaccredited by the RRC in 2006 for 2 years and in 2009 for 4 years.
A collaborative model for inpatient training was successful in maintaining a community hospital–based pediatric residency program. Positive outcomes were documented for the residency program, the parent community hospital, and the collaborating children's hospital.
Earlier work demonstrated that ACGME duty hour reform did not adversely affect mortality, with slight improvement noted among specific subgroups.
To determine whether resident duty hour reform differentially affected the mortality risk of high severity patients or patients who experienced post-operative complications (failure-to-rescue).
Observational study using interrupted time series analysis with data from July 1, 2000 - June 30, 2005. Fixed effects logistic regression was used to examine the change in the odds of mortality or failure-to-rescue (FTR) in more versus less teaching-intensive hospitals before and after duty hour reform.
All unique Medicare patients (n = 8,529,595) admitted to short-term acute care non-federal hospitals and all unique VA patients (n = 318,636 patients) with principal diagnoses of acute myocardial infarction, congestive heart failure, gastrointestinal bleeding, stroke or a DRG classification of general, orthopedic or vascular surgery.
Measurements and Main Results
We measured mortality within 30 days of hospital admission and FTR, measured by death among patients who experienced a surgical complication. The odds of mortality and FTR generally changed at similar rates for higher and lower risk patients in more vs. less teaching intensive hospitals. For example, comparing the mortality risk for the 10% of Medicare patients with highest risk to the other 90% of patients in post-reform year 1 for combined medical an OR of 1.01 [95% CI 0.90, 1.13], for combined surgical an OR of 0.91 [95% CI 0.80, 1.04], and for FTR an OR of 0.94 [95% CI 0.80, 1.09]. Findings were similar in year 2 for both Medicare and VA. The two exceptions were a relative increase in mortality for the highest risk medical (OR 1.63 [95% CI 1.08, 2.46]) and a relative decrease in the high risk surgical patients within VA in post-reform year 1 (OR 0.52 [95% CI 0.29, 0.96]).
ACGME duty hour reform was not associated with any consistent improvements or worsening in mortality or failure-to-rescue rates for high risk medical or surgical patients.
medical errors internship and residency; education, medical, graduate; personnel staffing and scheduling; continuity of patient care
The Accreditation Council for Graduate Medical Education (ACGME) requires an annual evaluation of all ACGME-accredited residency and fellowship programs to assess program quality. The results of this evaluation must be used to improve the program. This manuscript describes a metric to be used in conducting ACGME-mandated annual program review of ACGME-accredited anesthesiology residencies and fellowships.
A variety of metrics to assess anesthesiology residency and fellowship programs are identified by the authors through literature review and considered for use in constructing a program "report card."
Metrics used to assess program quality include success in achieving American Board of Anesthesiology (ABA) certification, performance on the annual ABA/American Society of Anesthesiology In-Training Examination, performance on mock oral ABA certification examinations, trainee scholarly activities (publications and presentations), accreditation site visit and internal review results, ACGME and alumni survey results, National Resident Matching Program (NRMP) results, exit interview feedback, diversity data and extensive program/rotation/faculty/curriculum evaluations by trainees and faculty. The results are used to construct a "report card" that provides a high-level review of program performance and can be used in a continuous quality improvement process.
An annual program review is required to assess all ACGME-accredited residency and fellowship programs to monitor and improve program quality. We describe an annual review process based on metrics that can be used to focus attention on areas for improvement and track program performance year-to-year. A "report card" format is described as a high-level tool to track educational outcomes.
In a recent report, the Institute of Medicine recommended more restrictions on residents' working hours. Several problems exist with a system that places a weekly limit on resident duty hours: (1) it assumes the presence of a linear relationship between hours of work and patient safety; (2) it fails to consider differences in intensity among programs; and (3) it does not address increases in the scientific content of medicine, and it places the burden of enforcing the duty hour limits on the Accreditation Council for Graduate Medical Education.
An innovative method of calculating credit hours for graduate medical education would shift the focus from “years of residency” to “hours of residency.” For example, internal medicine residents would be requested to spend 8640 hours of total training hours (assuming 60 hours per week for 48 weeks annually) instead of the traditional 3 years. This method of counting training hours is used by other professions, such as the Intern Development Program of the National Council of Architectural Registration Boards. The proposed approach would allow residents and program directors to pace training based on individual capabilities. Standards for resident education should include the average number of patients treated in each setting (inpatient or outpatient). A possible set of “multipliers” based on these parameters, and possibly others such as resident evaluation, is devised to calculate the “final adjusted accredited hours” that count toward graduation.
Substituting “years of training” with “hours of training” may resolve many of the concerns with the current residency education model, as well as adapt to the demands of residents' personal lives. It also may allow residents to pace their training according to their capabilities and learning styles, and contribute to reflective learning and better quality education.