Patient-centered care includes involving patients and their families in self-management of chronic diseases. Identifying and addressing barriers to self-management, including those related to health literacy and vision limitations, may enhance one’s ability to self-manage. A set of brief verbal screening questions (BVSQ) that does not rely on sufficient vision to assess health literacy was developed by Chew and colleagues in the outpatient setting. We sought to evaluate the utility of this tool for hospitalized patients and to determine the prevalence of poor vision among inpatients. In a prospective study, the BVSQ and the Rapid Estimate of Adult Learning in Medicine–Revised (REALM-R; among participants with sufficient vision, ≥20/50 Snellen) were administered to general medicine inpatients. Of 893 participants, 79% were African-American, and 57% were female; the mean age was 53 years. Among 668 participants who completed both tools, the proportion with low health literacy was 38% with the BVSQ versus 47% with the REALM-R (p = .0001). Almost one fourth of participants had insufficient vision; participants with insufficient vision were more likely to be identified as having low health literacy by the BVSQ, compared to those with sufficient vision (59% vs. 38%, p < .001).
Prior studies suggest that terminally ill patients who use religious coping are less likely to have advance directives and more likely to opt for heroic end-of-life measures. Yet, no study to date has examined whether end-of-life practices are associated with measures of religiosity and spirituality.
To assess the relationship between general measures of patient religiosity and spirituality and patients’ preferences for care at the end of life.
We examined data from the University of Chicago Hospitalist Study, which gathers sociodemographic and clinical information from all consenting general internal medicine patients at the University of Chicago Medical Center. Primary outcomes were whether the patient had an advance directive, a do-not-resuscitate (DNR) order, a durable power of attorney for health care, and an informally designated decision maker. Primary predictors were religious attendance, intrinsic religiosity, and self-rated spirituality.
The sample population (n=8,308) was predominantly African American (73%) and female (60%). In this population, 1.5% had advance directives and 10.4% had DNR orders. Half (51%) of patients had specified a decision maker. White patients were more likely than African-American patients to have an advance directive (adjusted odds ratio [OR] 2.1; 95% confidence interval [CI] 1.1, 4.0) and a DNR order (OR 1.7; 95% CI 1.0, 2.9). Patients reporting high intrinsic religiosity were more likely to have specified a decision maker than those with low intrinsic religiosity (OR 1.3; CI 1.1, 1.6). The same was true for those with high compared to low spirituality (OR 1.3; CI 1.1, 1.5). Religious characteristics were not significantly associated with having an advance directive or DNR order.
Among general medicine inpatients at an urban academic medical center, those who were highly religious and/or spiritual were more likely to have a designated decision-maker to help with end-of-life decisions, but did not differ from other patients in their likelihood of having an advance directive or DNR order.
Advance directive; DNR order; religiosity; spirituality; end-of-life care; medical inpatient
Many patients nationwide change their primary care physician (PCP) when internal medicine (IM) residents graduate. Few studies have examined this handoff.
To assess patient outcomes and resident perspectives after the year-end continuity clinic handoff
Patients who underwent a year-end clinic handoff in July 2010 and a comparison group of all other resident clinic patients from 2009–2011. PGY2 IM residents surveyed from 2010–2011.
Percent of high-risk patients after the clinic handoff scheduled for an appointment, who saw their assigned PCP, lost to follow-up, or had an acute visit (ED or hospitalization). Perceptions of PGY2 IM residents surveyed after receiving a clinic handoff.
Thirty graduating residents identified 258 high-risk patients. While nearly all patients (97 %) were scheduled, 29 % missed or cancelled their first new PCP visit. Only 44 % of patients saw the correct PCP and six months later, one-fifth were lost to follow-up. Patients not seen by a new PCP after the handoff were less likely to have appropriate follow-up for pending tests (0 % vs. 63 %, P < 0.001). A higher mean no show rate (NSR) was observed among patients who missed their first new PCP visit (22 % vs. 16 % NSR, p < 0.001) and those lost to follow-up (21 % vs. 17 % NSR, p = 0.019). While 47 % of residents worried about missing important data during the handoff, 47 % reported that they do not perceive patients as “theirs” until they are seen by them in clinic.
While most patients were scheduled for appointments after a clinic handoff, many did not see the correct resident and one-fifth were lost to follow-up. Patients who miss appointments are especially at risk of poor clinic handoff outcomes. Future efforts should improve patient attendance to their first new PCP visit and increase PCP ownership.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-012-2100-y) contains supplementary material, which is available to authorized users.
outpatient handoffs; signout; resident continuity clinic; year-end transfer; transitions of care
Hospitalized patients frequently misuse their respiratory inhalers, yet it is unclear what the most effective hospital-based educational intervention is for this population.
To compare two strategies for teaching inhaler use to hospitalized patients with asthma or chronic obstructive pulmonary disease (COPD).
A Phase-II randomized controlled clinical trial enrolled hospitalized adults with physician diagnosed asthma or COPD.
Hospitalized adults (age 18 years or older) with asthma or COPD.
Participants were randomized to brief intervention [BI]: single-set of verbal and written step-by-step instructions, or, teach-to-goal [TTG]: BI plus repeated demonstrations of inhaler use and participant comprehension assessments (teach-back).
The primary outcome was metered-dose inhaler (MDI) misuse post-intervention (<75% steps correct). Secondary outcomes included Diskus® misuse, self-reported inhaler technique confidence and prevalence of 30-day health-related events.
Of 80 eligible participants, fifty (63%) were enrolled (BI n = 26, TTG n = 24). While the majority of participants reported being confident with their inhaler technique (MDI 70%, Diskus® 94%), most misused their inhalers pre-intervention (MDI 62%, Diskus® 78%). Post-intervention MDI misuse was significantly lower after TTG vs. BI (12.5 vs. 46%, p = 0.01). The results for Diskus® were similar and approached significance (25 vs. 80%, p = 0.05). Participants with 30-day acute health-related events were less common in the group receiving TTG vs. BI (1 vs. 8, p = 0.02).
TTG appears to be more effective compared with BI. Patients over-estimate their inhaler technique, emphasizing the need for hospital-based interventions to correct inhaler misuse. Although TTG was associated with fewer post-hospitalization health-related events, larger, multi-centered studies are needed to evaluate the durability and clinical outcomes associated with this hospital-based education.
respiratory inhalers; teach-to-goal; hospitalized patients; health literacy; asthma; COPD
To systematically review the literature to characterize interventions with potential to improve outcomes for minority patients with asthma.
Medline, PsycINFO, CINAHL, Cochrane Trial Databases, expert review, reference review, meeting abstracts.
STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTEVENTIONS
Medical Subject Heading (MeSH) terms related to asthma were combined with terms to identify intervention studies focused on minority populations. Inclusion criteria: adult population; intervention studies with majority of non-White participants.
STUDY APPRAISAL AND SYNTHESIS OF METHODS
Study quality was assessed using Downs and Black (DB) checklists. We examined heterogeneity of studies through comparing study population, study design, intervention characteristics, and outcomes.
Twenty-four articles met inclusion criteria. Mean quality score was 21.0. Study populations targeted primarily African American (n = 14), followed by Latino/a (n = 4), Asian Americans (n = 1), or a combination of the above (n = 5). The most commonly reported post-intervention outcome was use of health care resources, followed by symptom control and self-management skills. The most common intervention-type studied was patient education. Although less-than half were culturally tailored, language-appropriate education appeared particularly successful. Several system–level interventions focused on specialty clinics with promising findings, although health disparities collaboratives did not have similarly promising results.
Publication bias may limit our findings; we were unable to perform a meta-analysis limiting the review’s quantitative evaluation.
CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS
Overall, education delivered by health care professionals appeared effective in improving outcomes for minority patients with asthma. Few were culturally tailored and one included a comparison group, limiting the conclusions that can be drawn from cultural tailoring. System-redesign showed great promise, particularly the use of team-based specialty clinics and long-term follow-up after acute care visits. Future research should evaluate the role of tailoring educational strategies, focus on patient-centered education, and incorporate outpatient follow-up and/or a team-based approach.
asthma; disparities; interventions; culturally tailored
Physicians may counsel patients who leave against medical advice (AMA) that insurance will not pay for their care. However, it is unclear whether insurers deny payment for hospitalization in these cases.
To review whether insurers denied payment for patients discharged AMA and assess physician beliefs and counseling practices when patients leave AMA.
Retrospective cohort of medical inpatients from 2001 to 2010; cross-sectional survey of physician beliefs and counseling practices for AMA patients in 2010.
Patients who left AMA from 2001 to 2010, internal medicine residents and attendings at a single academic institution, and a convenience sample of residents from 13 Illinois hospitals in June 2010.
Percent of AMA patients for which insurance denied payment, percent of physicians who agreed insurance denies payment for patients who leave AMA and who counsel patients leaving AMA they are financially responsible.
Of 46,319 patients admitted from 2001 to 2010, 526 (1.1%) patients left AMA. Among insured patients, payment was refused in 4.1% of cases. Reasons for refusal were largely administrative (wrong name, etc.). No cases of payment refusal were because patient left AMA. Nevertheless, most residents (68.6%) and nearly half of attendings (43.9%) believed insurance denies payment when a patient leaves AMA. Attendings who believed that insurance denied payment were more likely to report informing AMA patients they may be held financially responsible (mean 4.2 vs. 1.7 on a Likert 1–5 scale, in which 5 is “always” inform, p < 0.001). This relationship was not observed among residents. The most common reason for counseling patients was “so they will reconsider staying in the hospital” (84.8% residents, 66.7% attendings, p = 0.008)
Contrary to popular belief, we found no evidence that insurance denied payment for patients leaving AMA. Residency programs and hospitals should ensure that patients are not misinformed.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-012-1984-x) contains supplementary material, which is available to authorized users.
patient discharge; financial responsibility; hospital reimbursement
To assess internal medicine (IM) and surgery program directors’ views of the likely effects of the 2011 Accreditation Council for Graduate Medical Education duty hours regulations.
In fall 2010, investigators surveyed IM and surgery program directors, assessing their views of the likely impact of the 2011 duty hours standards on learning environment, workload, education opportunities, program administration, and patient outcomes.
Of 381 IM program directors, 287 (75.3%) responded; of 225 surgery program directors, 118 (52.4%) responded. Significantly more surgeons than internists indicated that the new regulations would likely negatively impact learning climate, including faculty morale and residents’ relationships (P < 0.001). Most leaders in both specialties (80.8% IM, 80.2% surgery) felt that the regulations would likely increase faculty workload (P = .73). Both IM (82.2%) and surgery (96.6%) leaders most often rated, of all education opportunities, first-year resident clinical experience to be adversely affected (P < .001). Respondents from both specialties indicated that they will hire more nonphysician/midlevel providers (59.5% IM, 89.0% surgery, P < .001) and use more nonteaching services (66.8% IM, 70.1% surgery, P = .81). Respondents expect patient safety (45.1% IM, 76.9% surgery, P < .001) and continuity of care (83.6% IM across all training levels, 97.5% surgery regarding first-year residents) to decrease.
IM and surgery program directors agree that the 2011 duty hours regulations will likely negatively affect the quality of the learning environment, workload, education opportunities, program administration, and patient outcomes. Careful evaluation of actual impact is important.
While early reports highlight the benefits of tablet computing in hospitals, introducing any new technology can result in inflated expectations.
The aim of the study is to compare anticipated expectations of Apple iPad use and perceptions after deployment among residents.
115 internal medicine residents received Apple iPads in October 2010. Residents completed matched surveys on anticipated usage and perceptions after distribution 1 month prior and 4 months after deployment.
In total, 99% (114/115) of residents responded. Prior to deployment, most residents believed that the iPad would improve patient care and efficiency on the wards; however, fewer residents “strongly agreed” after deployment (34% vs 15% for patient care, P<.001; 41% vs 24% for efficiency, P=.005). Residents with higher expectations were more likely to report using the iPad for placing orders post call and during admission (71% vs 44% post call, P=.01, and 16% vs 0% admission, P=.04). Previous Apple iOS product owners were also more likely to use the iPad in key areas. Overall, 84% of residents thought the iPad was a good investment for the residency program, and over half of residents (58%) reported that patients commented on the iPad in a positive way.
While the use of tablets such as the iPad by residents is generally well received, high initial expectations highlight the danger of implementing new technologies. Education on the realistic expectations of iPad benefits may be warranted.
iPad; mobile tablet computing; technology; expectation dynamics; hype
In 2010, the Accreditation Council for Graduate Medical Education released its resident duty hours restrictions, requiring that faculty monitor their residents’ patient handoffs to ensure that residents are competent in handoff communications. Although studies have reported the need to improve the effectiveness of the handoff and a variety of curricula have been suggested and implemented, a common method for teaching and evaluating handoff skills has not been developed. Also in 2010, engineers, informaticians, and physicians interested in patient handoffs attended a symposium in Savannah, Georgia, hosted by the Association for Computing Machinery, entitled Handovers and Handoffs: Collaborating in Turns. As a result of this symposium, a workgroup formed to develop practical and readily implementable educational materials for medical educators involved in teaching patient handoffs to residents. In this article, the result of that yearlong collaboration, the authors aim to provide clarity on the definition of the patient handoff, to review the barriers to performing effective handoffs in academic health centers, to identify available solutions to improve handoffs, and to provide a structured approach to educating residents on handoffs via a curricular blueprint. The authors’ blueprint was developed to guide educators in customizing handoff education programs to fit their specific, local needs. Hopefully, it also will provide a starting point for future research into improving the patient handoff. Increasingly complex patient care environments require both innovations in handoff education and improvements in patient care systems to improve continuity of care.
Handoffs are ubiquitous to Hospital Medicine and considered a vulnerable time for patient safety.
To develop recommendations for hospitalist handoffs during shift change and service change.
PubMed (through January 2007), AHRQ Patient Safety Network, white papers, and hand search of article bibliographies.
Controlled studies evaluating interventions to improve in-hospital handoffs (n = 10).
Studies were abstracted for design, setting, target, outcomes (including patient, staff, or system level outcomes), and relevance to hospitalists.
Although there were no studies of hospitalist handoffs, the existing literature from related disciplines and expert opinion support the use of a verbal handoff supplemented with written documentation in a structured format or technology solution. Technology solutions were associated with a reduction in preventable adverse events, improved satisfaction with handoff quality, and improved provider identification. Nursing studies demonstrate that supplementing verbal exchange with a written medium leads to improved retention of information. White papers characterized effective verbal exchange as focusing on ill patients and actions required, with time for questions and minimal interruptions. In addition, content should be updated daily to ensure communication of the latest clinical information. Using this literature, recommendations for hospitalist handoffs are presented with corresponding levels of evidence.
Recommendations were reviewed by hospitalists at the Society of Hospital Medicine (SHM) Annual Meeting and by an interdisciplinary team of expert consultants and were endorsed by the SHM governing Board.
The systematic review and resulting recommendations provide hospitalists a starting point from which to improve in-hospital handoffs.
In the years following reduced resident work hours, single resident accountability for patient care has disappeared and replaced by frequent care transitions and shared responsibility between residents as the necessary paradigm for delivery of care in acute care settings. With this change, there has been increasing patient acuity and complexity as well as increased cognitive demands for clinicians, potential for miscommunication at care transitions, and preventable errors. Importantly, forgetting to transmit needed information during handoffs is a major contribution to overall suboptimal care processes including: delays in diagnosis and treatment, task omissions, work redundancies and near misses. To address these quality and safety problems, electronic tools embedded in the electronic health record are beginning to emerge. These tools when designed to provide cognitive support for intradisciplinary sharing of care can play a role in reducing information overload, miscommunication, and omission of patient care tasks. Less common are electronic tools that are designed for interdisciplinary information sharing. These interdisciplinary tools have greater potential for decreasing system inefficiencies and improving the overall quality of care delivery than intra-disciplinary tools. This presentation will provide an overview of existing electronic handoff tools and the design implications for future tools.
Little is known about how often patients desire and experience discussions with hospital personnel regarding R/S (religion and spirituality) or what effects such discussions have on patient satisfaction.
Objective, Design and Participants
We examined data from the University of Chicago Hospitalist Study, which gathers sociodemographic and clinical information from all consenting general internal medicine patients at the University of Chicago Medical Center.
Primary outcomes were whether or not patients desired to have their religious or spiritual concerns addressed while hospitalized, whether or not anyone talked to them about religious and spiritual issues, and which member of the health care team spoke with them about these issues. Primary predictors were patients’ ratings of their religious attendance, their efforts to carry their religious beliefs over into other dealings in life, and their spirituality.
Forty-one percent of inpatients desired a discussion of R/S concerns while hospitalized, but only half of those reported having such a discussion. Overall, 32% of inpatients reported having a discussion of their R/S concerns. Religious patients and those experiencing more severe pain were more likely both to desire and to have discussions of spiritual concerns. Patients who had discussions of R/S concerns were more likely to rate their care at the highest level on four different measures of patient satisfaction, regardless of whether or not they said they had desired such a discussion (odds ratios 1.4–2.2, 95% confidence intervals 1.1–3.0).
These data suggest that many more inpatients desire conversations about R/S than have them. Health care professionals might improve patients’ overall experience with being hospitalized and patient satisfaction by addressing this unmet patient need.
patient satisfaction; physician/patient communication; quality of care; religion; spirituality
Older Hospitalized Patients; Sleep Quality; Blood Pressure
While there is growing interest among residents in participating in international health experiences, it is unclear whether this interest will translate into intentions to pursue a global health career. We aimed to describe overall interest in and career intentions toward global health among interns.
We administered an anonymous survey to incoming interns in all specializations during graduate medical education orientation at 3 teaching hospitals affiliated with 2 Midwestern US medical schools in June 2009. Survey domains included demographics, previous global health experiences, interest in and barriers to participating in global health experiences during residency, and plans to pursue a future global health career.
Response rate was 87% (299 of 345 residents). The most commonly reported barriers to participating in global health experiences were scheduling (82%) and financial (80%) concerns. Two-thirds of interns (65%) reported they were likely to focus on global health in their future career. Of those envisioning a global health career, 77% of interns reported interest in participating in short, occasional trips in the future; and 23% of interns intended to pursue a part-time or full-time career abroad. Interns committed to a career abroad were more willing to use vacation time (73% vs. 40% of all others, respectively; P < .001) or to personally finance the trip (58% vs. 27% of all others, respectively; P = < .001), and were less concerned about personal safety than interns not committed (9% vs. 26% of all others, respectively; P = .01).
Although a large proportion of incoming interns report interest in global health careers, few are committed to a global health career. Medical educators could acknowledge career plans in global health when developing global health curricula.
The ACGME-released revisions to the 2003 duty hour standards.
To review the impact of the 2003 duty hour reform as it pertains to resident and patient outcomes.
Medline (1989–May 2010), Embase (1989–June 2010), bibliographies, pertinent reviews, and meeting abstracts.
We included studies examining the relationship between the pre- and post-2003 time periods and patient outcomes (mortality, complications, errors), resident education (standardized test scores, clinical experience), and well-being (as measured by the Maslach Burnout Inventory). We excluded non-US studies.
One rater used structured data collection forms to abstract data on study design, quality, and outcomes. We synthesized the literature qualitatively and included a meta-analysis of patient mortality.
Of 5,345 studies identified, 60 met eligibility criteria. Twenty-eight studies included an objective outcome related to patients; 10 assessed standardized resident examination scores; 26 assessed resident operative experience. Eight assessed resident burnout. Meta-analysis of the mortality studies revealed a significant improvement in mortality in the post-2003 time period with a pooled odds ratio (OR) of 0.9 (95% CI: 0.84, 0.95). These results were significant for medical (OR 0.91; 95% CI: 0.85, 0.98) and surgical patients (OR 0.86; 95% CI: 0.75, 0.97). However, significant heterogeneity was present (I2 83%). Patient complications were more nuanced. Some increased in frequency; others decreased. Outcomes for resident operative experience and standardized knowledge tests varied substantially across studies. Resident well-being improved in most studies.
Most studies were observational. Not all studies of mortality provided enough information to be included in the meta-analysis. We used unadjusted odds ratios in the meta-analysis; statistical heterogeneity was substantial. Publication bias is possible.
Since 2003, patient mortality appears to have improved, although this could be due to secular trends. Resident well-being appears improved. Change in resident educational experience is less clear.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-011-1657-1) contains supplementary material, which is available to authorized users.
Patients are asked to assume greater responsibility for care, including use of medications, during transitions from hospital to home. Unfortunately, medications dispensed via respiratory inhalers to patients with asthma or chronic obstructive pulmonary disease (COPD) can be difficult to use.
To examine rates of inhaler misuse and to determine if patients with asthma or COPD differed in their ability to learn how to use inhalers correctly.
A cross-sectional and pre/post intervention study at two urban academic hospitals.
Hospitalized patients with asthma or COPD.
A subset of participants received instruction about the correct use of respiratory inhalers.
Use of metered dose inhaler (MDI) and Diskus® devices was assessed using checklists. Misuse and mastery of each device were defined as <75% and 100% of steps correct, respectively. Insufficient vision was defined as worse than 20/50 in both eyes. Less-than adequate health literacy was defined as a score of <23/36 on The Short Test of Functional Health Literacy in Adults (S-TOFHLA).
One-hundred participants were enrolled (COPD n = 40; asthma n = 60). Overall, misuse was common (86% MDI, 71% Diskus®), and rates of inhaler misuse for participants with COPD versus asthma were similar. Participants with COPD versus asthma were twice as likely to have insufficient vision (43% vs. 20%, p = 0.02) and three-times as likely to have less-than- adequate health literacy (61% vs. 19%, p = 0.001). Participants with insufficient vision were more likely to misuse Diskus® devices (95% vs. 61%, p = 0.004). All participants (100%) were able to achieve mastery for both MDI and Diskus® devices.
Inhaler misuse is common, but correctable in hospitalized patients with COPD or asthma. Hospitals should implement a program to assess and teach appropriate inhaler technique that can overcome barriers to patient self-management, including insufficient vision, during transitions from hospital to home.
asthma; pulmonary disease; chronic disease; hospital medicine; health literacy
A two-year quality improvement campaign at a single teaching hospital was launched to improve the identification, documentation, and treatment of pressure ulcers (PUs) after Centers for Medicare & Medicaid Services (CMS) declared severe hospital-acquired PUs are “never-events.”
The campaign included (1) reference materials, (2) new documentation templates, (3) staff education, and (4) hospital-wide mattress replacement. An ongoing retrospective chart review of frail older patients determined the presence of PU documentation, which provider (nurse or physician) documented the PU, and which descriptors (stage, size, or location) were used.
The campaign significantly increased the proportion of PUs completely documented by nurses from 27% to 55% following mattress replacement and resident education (OR 3.68, p = 0.001, 95% CI: 1.68–8.08). A similar improvement was observed for physician documentation increasing from 12% to 36% following the same interventions however this change was not statistically significant (OR 2.11, p = 0.12, 95% CI: 0.82–5.39).
These improvements were short-lived due to the implementation of electronic medical records (EMR) for nursing notes. Although the percentage of PUs completely documented by nurses decreased following EMR implementation, it increased in the following months, above the pre-campaign baseline as nurses adapted to the new documentation system. However, after EMR implementation, complete PU documentation by physicians fell to a nadir of 0% and did not recover.
A multi-component campaign to improve the quality of PU documentation by both physicians and nurses can yield positive gains. However, these improvements were short-lived due to EMR implementation, which acutely worsened documentation of PUs. This emphasizes the importance of frequent and repeated interventions to sustain quality improvement successes.
Although sustainability is a key component in the evaluation of continuous quality improvement (CQI) projects, medicine resident CQI projects are often evaluated by immediate improvements in targeted areas without addressing sustainability.
To assess the sustainability of resident CQI projects in an ambulatory university-based clinic.
During their ambulatory rotation, all second year internal medicine residents use the American Board of Internal Medicine’s Clinical Preventive Services (CPS) Practice Improvement Modules (PIM) to complete chart reviews, patient surveys, and a system survey. The residents then develop a group CQI project and collect early post data. Third year residents return to evaluate their original CQI project during an ambulatory rotation two to six months later and complete four plan-do-study-act (PDSA) cycles on each CQI project.
From July 2006 to June 2009, 64 (100%) medicine residents completed the CQI curriculum. Residents completed six group projects and examined their success using early (2 to 6 weeks) and late (2 to 6 months) post-intervention data. Three of the projects demonstrated sustainable improvement in the resident continuity clinic.
When residents are taught principles of sustainability and spread and asked to complete multiple PDSA cycles, they are able to identify common themes that may contribute to success of QI projects over time.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-010-1547-y) contains supplementary material, which is available to authorized users.
resident education; quality improvement; sustainability; practice-based learning and improvement; system-based practice
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.