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4 Improving the Resident Learning Environment The primary goal of graduate medical training is for residents to achieve sufficient competence to deliver safe and effective patient care when they enter into practice. The inherent inexperience of residents as they train need not affect patient safety if they are adequately supervised by more experienced physicians guiding them toward gradual independence. Re- duced work hours implemented in 00, some believe, pose a risk to the acquisition of competencies and to the continuity of care from both an educational and a patient safety perspective. The committee could not determine the full positive or negative effects of the 00 limits on educational outcomes because sufficient data on those outcomes are not yet available. However, substantial evidence about how people learn stresses the importance of having a reasonable workload, suf- ficient time for reflection, and the need for sleep to consolidate learning. New educational designs (e.g., curriculum restructuring, competency-based training, simulation-based training) along with workload and scheduling redesigns should be promoted to incorporate these approaches into the resident environment to maximize learning within fewer duty hours. Although residents are critically important to delivering direct patient care in teaching hospitals, the fundamental goal of residency training is edu- cation. It is through residency that physicians-in-training are transformed from novices into experienced professionals, providing society with compe- tent and compassionate healers for the future. The Association of American Medical Colleges (AAMC, 2006) has recently reaffirmed that residents are “first and foremost learners” and that “a resident’s educational needs should be the primary determinant of any assigned patient care services.” Similarly, 

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 RESIDENT DUTY HOURS the Accreditation Council for Graduate Medical Education (ACGME) has established in its requirements for all residency programs that (1) the learn- ing objectives of the program must not be compromised by excessive reli- ance on residents to fulfill service obligations, and (2) didactic and clinical education must have priority in the allotment of residents’ time and energy (ACGME, 2008b). Throughout the history of residency training, hospitals have insisted that trainees perform an extraordinary range and amount of ancillary responsibilities that are often noneducational in nature (Ludmerer, 1999). However, while education may be the primary objective of residency training, the nature of residency training—participating in direct patient care—requires that patient safety never be separated from that education. Residency programs implicitly assume responsibility for protecting the pa- tient during the educational experience, thus forming a “social contract” between patients and teaching care settings. In this setting, patients agree to have doctors in training at various milestones in their education, with variations in skills and competencies, provide their care in exchange for a social good—the production of future doctors. In order to better understand graduate medical education, this chapter looks at key educational principles underlying residency training, the way in which the 2003 duty hour limits have affected them, and at how residency training can be informed by the research literature on the way people learn. It concludes with a look at what is known about educational outcomes in residency programs as they have adapted to the 2003 duty hour limits and presents illustrative innovative educational approaches that may facilitate adaptations to resident duty hours and scheduling. EDUCATIONAL PRINCIPLES Three cardinal educational principles underlie residency education: (1) the gradual or graded assumption of responsibility for patient care while under supervision, (2) adequate time to engage in reflective learning, and (3) sufficient continuity in the care of individual patients to understand the natural evolution of illness and to reinforce professionalism and its obli- gations. Educationally, what matters most in residency training is not the number of duty hours but whether an adequate learning environment exists to satisfy these three principles during those hours (Ludmerer, 1999). In- stead of enhancing the learning environment for residents, implementation of the 2003 ACGME requirements is perceived by some educators to have weakened the educational environment in many programs (Charap, 2004; Fitzgibbons et al., 2006; Ludmerer and Johns, 2005; Ryan, 2005), pushing education away from key elements (e.g., adequate time for teaching and reflective learning) that would promote safety and better supervision. To change residency programs so that these positive elements can be enhanced

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 IMPROVING THE RESIDENT LEARNING ENVIRONMENT instead of diminished, the interplay of many organizational factors must be supported and reinforced for effective training to result (Salas and Can- non-Bowers, 2000, 2001). Graded Responsibility for Patient Care Under Supervision An intrinsic challenge of graduate medical education (GME) has been to find a balance between the educational needs of residents, who require increasing independence as they learn, and the safety needs of patients, who may benefit from being cared for by more experienced physicians. The ten- sion between these two aspects has become more obvious over the past few decades along with a growing attention to safety in medical care. Patients admitted to hospitals have been much sicker, and mistakes of omission and commission by any care provider may have more adverse consequences today than before (Ludmerer, 1999). A defining characteristic of GME is the assumption of progressively greater patient care responsibility by residents. This type of training is necessary, lest the country face the predicament of future patients’ being cared for by inadequately trained doctors (Kennedy et al., 2007). Residents can become effective independent physicians and assume full responsibility for patient care only after having acquired the competencies necessary to manage patients safely and well. To acquire this capacity, residents conduct initial evaluations of patients, make preliminary decisions about diagnosis and therapy, perform procedures, and administer treatments under the level of supervision appropriate for their developing competency—with the un- derstanding that all residents are accountable to attending physicians. The tension that results from the need of the resident to have gradual respon- sibility under appropriate supervision and the desire to provide optimal and safe care is always present and must be managed carefully to protect patients. Despite limited research on the use of on-the-job training (OJT) in health care, OJT has been widely used and validated in other fields as an effective training method (Barron et al., 1997; Becker, 1975; Mincer, 1962; Rothwell and Kazanas, 2004; Veum, 1999). In medicine, the validity of a graded responsibility model through in-hospital OJT has been grounded in its compelling inherent logic and rationale, and endorsed by generations of experienced teachers (Kennedy et al., 2005). However, it has not been eval- uated systematically against an alternative education model. Aspects of the graded responsibility model are supported in the psychological literature, in particular a five-stage model of skill acquisition: novice, advanced begin- ner, competent, proficient, and expert (Batalden et al., 2002; Dreyfus and Dreyfus, 1986). In the context of medical residency, the intent of in-hospital training is to deepen existing competencies and teach new ones in a man-

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 RESIDENT DUTY HOURS ner that moves residents further along the pathway from novice to expert (Jacobs, 2003; Rothwell and Kazanas, 2004). At times it can be difficult for attendings and faculty clinicians to assess the competency level of individual residents and determine the ideal degree of interaction that might suit them, but efforts to do so more effectively have been examined (Kennedy et al., 2007) and further development and learning of such methods may be useful in determining optimal supervision levels for individual residents. Role of Supervision in Providing Graded Responsibility Along the pathway of skill acquisition, supervision is the single most important element upon which this education model depends. In this con- text, supervision in medicine has been defined as (Kilminster and Jolly, 2000): The provision of monitoring, guidance and feedback on matters of per- sonal, professional and educational development in the context of the doctor’s care of patients. This would include the ability to anticipate a doctor’s strengths and weaknesses in particular clinical situations in order to maximize patient safety. Supervisory practices that enhance resident learning and performance are (1) the involvement of role models and mentors who demonstrate appro- priate professional practice (Hough, 2008); (2) specific learning objectives communicated to learners in advance of their interactions with patients; (3) periodic assessment of how well learners have met those objectives (Jacobs, 2003; Rothwell and Kazanas, 2004; Salas and Cannon-Bowers, 2000); and (4) timely and actionable feedback to residents (Arco, 2008). This report raises concerns regarding the current application of supervisory practices in the context of both learning and patient safety. Links Between Supervision and Patient Safety Supervision was a key issue when patient safety and long duty hours were examined in 1987 by the Bell Commission, which originally recom- mended the 80-hour duty limit for residents, and it remains so today. Even prior to the Bell Commission’s findings, the grand jury for the Zion case stated the following as part of its ruling (New York Supreme Court, 1986): A hospital is not the place for recently graduated doctors to grow and develop in isolation; rather it is a place where the learning process should continue under strict supervision. Thus, medical decisions, whether in an emergency room or on a hospital floor should not be made by inexperi-

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 IMPROVING THE RESIDENT LEARNING ENVIRONMENT enced interns and junior residents without in-person consultations with more senior physicians. Dr. Bell himself has subsequently written repeatedly that better supervision, not only regulation of hours, is the key to improving the quality of patient care (Bell, 1993, 2003, 2007). And since the time of the Zion case, the in- creasing complexity of patients’ illnesses and advancement of medical tools has strengthened the need for good supervision. After the 1984 Libby Zion case brought attention to the issue of resi- dent duty hours and fatigue on patient safety, several reports were published that examined the link between medical errors and resident supervision. A review of the effects of supervision by Kilminster and Jolly (2000) found that “supervision has a positive effect on patient outcomes and that lack of supervision is harmful for patients.” The authors view supervision as a distinct intervention with variable outcomes depending on the work and learning environment and its orientation toward teaching. A number of studies have found that closer resident supervision can lead to fewer errors and improved quality of care (Fallon et al., 1993; Gennis and Gennis, 1993; Singh et al., 2007; Sox et al., 1998). An attend- ing physician’s review of a resident’s report on a patient case is more likely to result in a change in patient management when the attending sees the patient directly (Gennis and Gennis, 1993), and the impact of better super- vision is likely to be more marked among less experienced residents (Fallon et al., 1993). Studies report higher death rates when residents are under poor supervision in surgery, anesthesia, emergency medicine, obstetrics, and pediatrics (McKee and Black, 1992), and report decreased complications and mortality rates when surgical residents are supported by the presence of attendings (Fallon et al., 1993). Residents’ compliance with care guidelines has been found to be greater under direct supervision (Sox et al., 1998). Di- rect supervision of residents can also help them acquire skills more quickly and increase their comfort level in performing invasive procedures (Huang et al., 2006; Osborn et al., 1993; Smith et al., 2004). Finally, residents tend to use more resources, such as test ordering, when they are less supervised (Griffith et al., 1996). Supervision in Practice Since the time of the Bell Commission, requirements for supervision have been strengthened in Medicare reimbursement policies and ACGME guidance. ACGME requires “sound supervision” policies from institutions and program directors (ACGME, 2007, 2008b). Under these principles, however, there is latitude in the way each program outlines how gradu- ated responsibility and supervision will interact, and how supervision is

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0 RESIDENT DUTY HOURS implemented in practice (ACGME, 2008b). For example, in an intensive care unit (ICU) the supervising attending might be onsite 24 hours a day, or be expected to be readily available by phone (e.g., within 5 minutes) and able to be at the bedside within a reasonable period (e.g., 20 minutes to 1 hour). For insurance payment purposes, attending physicians are required by Medicare’s 1996 Teaching Physician Presence Rules to include progress notes and documentation of their presence during operative procedures in a patient’s medical record.1 While residents are required to consult with their supervising attend- ing physician about their assessment of a patient, the proposed treatment plan, and any key decisions in the patient’s course of treatment, residents perform many of their duties without “over-the-shoulder” supervision. The degree of direct supervision varies by specialty, rotation, the tasks residents are undertaking, and the resident’s year of training. An example of graded responsibility is illustrated by first-year surgical residents gaining exposure to what are considered more fundamental skills, such as performing basic suturing skills and placing central and arterial lines, but being expected to master such procedures by their second year of residency. Likewise, a sec- ond-year surgical resident might be restricted to performing a laparascopic cholecystectomy from the left side of the operating table (where visibility of the operation is greater and access to the organ easier), but by their fourth year in training that resident would expected to know how to perform the procedure from both sides of the table (Brody School of Medicine, 2008). A supervisor is generally present or accessible in each of these instances, but the degree of supervision may depend on the competence level individual residents demonstrate for each acquired skill; with some residents requiring more hands-on guidance than others. Good Supervisory Practices Especially important in the supervisory relationship are the following: continuity in mentoring over time, the supervisor’s skill at providing over- sight and promoting intellectual autonomy among trainees, and the oppor- tunity for both trainee and supervisor to reflect on their work (Kilminster and Jolly, 2000). Of course, resident supervisors need to be clinically com- petent themselves as well as informed regarding effective learning processes. In particular, the way in which they communicate their knowledge is what matters to resident training. Trainees need clear feedback about their judg- ments; corrections must be conveyed unambiguously so that trainees are aware of potential mistakes and any weaknesses they may have (Kluger and 1 CMS (Centers for Medicare and Medicaid Services). 2005. 42 CFR 4172(a) evolution of Medicare billing regulations. Medicare Claims Processing Manual.

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 IMPROVING THE RESIDENT LEARNING ENVIRONMENT DeNisi, 1996). Helpful supervisory behaviors include giving direct guidance on clinical work; discussing links between theory and practice; participating in joint problem solving; and offering feedback, reassurance, and role mod- eling (Kilminster and Jolly, 2000). Rigidity, intolerance, lack of empathy, failure to offer support, lack of concern with teaching, and overemphasis on the evaluative aspects of supervision can have negative impacts by generat- ing defensive behaviors that interfere with learning (Kilminster and Jolly, 2000; Kluger and DeNisi, 1996). There has been no formal requirement for attendings to be trained to perform their supervisory role. However, faculty can be taught to be better teachers and supervisors. Pioneering work by Skeff and other colleagues (Litzelman et al., 1998; Skeff, 1998) has been instrumental in raising aware- ness of the need for supervisors to be instructed in their roles, as has work by other investigators (Bishop, 1998; Cote and Leclere, 2000; Kilminster and Jolly, 2000; Meyers et al., 2007; Williams and Webb, 1994). For bet- ter supervision to flourish, medical faculties need to place a higher priority on their educational mission. This entails greater institutional willingness to develop and promote clinician educators, the creation of “academies of medical educators,” mission-based budgeting, and related strategies to fund clinical teaching and supervision (Ludmerer, 2004). Return from investing in proper supervision can have a profound and long reach: the role model- ing that residents witness forms the basis for the effective supervision of future physicians and the potential for improved patient outcomes for years to come. Impact of 00 Duty Hour Rules on Faculty Availability A major concern stemming from the 2003 duty hour regulations is the effect they have had on the availability of faculty and senior residents for supervision and teaching with additional workload shifting to them (Arora et al., 2008; Coverdill et al., 2006a,b; Hutter et al., 2006). Some program responses to the 2003 duty hour limits indicate that the new regulations may have exacerbated preexisting shortcomings in the time for supervision and added new ones. Examples include reports of how reduced resident duty hours have shifted the workload to attendings and more senior resi- dents, leaving them less time for listening to resident presentations, asking them questions, providing advice, or allowing residents to make the primary diagnosis (Barden et al., 2002; Harrison and Allen, 2006; Shojania et al., 2006). Additionally, supervision has generally been less at night and dur- ing extended shifts when junior residents (and their patients) would benefit from more supervision, not less, since the risks for poor patient outcomes are known to be greater at these times (Huang et al., 2006; Kilminster and Jolly, 2000; Landrigan et al., 2004; Shojania et al., 2006; Shulkin, 2008).

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 RESIDENT DUTY HOURS In one study, the clinical internal medicine faculty reported their belief that they now spend more time on patient care than teaching and super- vising residents because of shifting workloads (see Figure 4-1). Almost 75 percent of key clinical faculty believed the duty hour regulations limited opportunities for both didactic and bedside teaching. The researchers noted the potential of the regulations for adverse consequences on faculty recruit- ment and retention due to potential increases in clinical responsibility (Reed et al., 2007). Another survey of attending physicians came to similar con- clusions: less time for teaching, less satisfaction with professional growth and development, and decreased educational stimulation from work. At- tending physicians reported a decline in the amount of time dedicated to didactic teaching, and residents missing educational conferences more often because more time was consumed by rounds (Arora and Meltzer, 2008). Removing Barriers to Communication In addition to lack of time, other barriers to good communication and supervision include lack of agreement on circumstances for consultation and institutional cultures that discourage communication. What needs to be supervised and when are often not clearly defined for most residencies, but this dialogue should occur. Farnan and colleagues (Farnan et al., 2007) examined the preferences of both internal medicine residents and their super- visors across four types of clinical scenarios involving specific critical deci- sion making on the part of residents. Residents and attendings agreed that immediate contact was necessary and should be required when there was a transfer of an existing patient into the ICU, when cardiac arrest occurred, and when a resident performed an invasive procedure. Attendings desired notification more often than residents wanted to contact them for transfers from the ICU (p = .0009), transfers from an outside facility (p = .001), patients’ receiving vasoactive medications for the first time (p = .02), or ini- tiation of intravenous antibiotics. Clarification of expectations for consulta- tions with supervisors in all programs would be beneficial. In some situations, teaching physicians humiliate residents who provide them with insufficient patient information or consider residents “weak,” insecure, and lacking in knowledge, skill, and judgment if they ask for help, thus suppressing needed discussion or calls for help even when resi- dents know they are over their heads (Hoff et al., 2006; Kilminster and Jolly, 2000; Shojania et al., 2006). Residents do not want to be seen as unable to make their own judgments without support or to be viewed as a nuisance by the attending, nor do they always want to admit to gaps in their knowledge and skills or give up their autonomy (Farnan et al., 2008). This avoidance of discussion with teachers undermines a critical role of supervision—to help residents become aware of their cognitive biases and

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Improved 100 No change 90 Worsened 80 70 60 50 40 30 Key Clinical Faculty, % 20 10 0 Time Supervising Time Providing Ability to Mentoring Teaching Satisfaction With Career Residents on Patient Care on Evaluate Relationships Satisfaction Personal-Professional Satisfaction Inpatient Services Inpatient Services Residents With Residents Life Balance Overall Figure 2. Views of 111 key clinical faculty on the effectfaculty on the effect of dutyfacultyregulations on satisfaction. Sign test, P �.001 for all outcomes. FIGURE 4-1 View of 111 key clinical of duty-hour regulations on hour workload and faculty workload satisfaction. NOTE: Sign test, p < .001 for all outcomes. SOURCE: Reed et al., 2007. Copyright © 2007, American Medical Association. All rights reserved. 

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4 RESIDENT DUTY HOURS to develop effective ways for gathering and interpreting patient information (Groopman, 2008). Furthermore, residents intimidated about asking ques- tions or requesting help can present a risk to patient safety (e.g., by taking undue time to reach decisions on courses of care). To promote patient safety, medical teaching environments must sup- port learners and the entire supervision and learning process. Teaching physicians must be ready to coach, back up, and aid a resident in providing quality patient care. It is the responsibility of house officers to call for help when they are unsure about what to do, but it is an attending’s responsibil- ity to foster conditions in which necessary consultations can take place. Su- pervisory behavior should include demonstrating how to act constructively upon recognizing a mistake. An effective teacher provides opportunity and sufficient time for learners to reflect on their own experiences (Langer, 1990). Furthermore, an effective residency program develops, rewards, and supports those physician supervisors who behave as appropriate role mod- els for residents. Training for supervisors may need to be provided to help instill a greater sense of supervisory leadership among them and develop skills that will help residents learn more effectively. The committee believes in the primacy of education in residency train- ing, the value of supervision to guide residents to gradual independence and ensure patient safety, and the importance of having well-trained faculty for that role. The committee agrees that support for teaching time and recog- nition of its importance in assessing professional development of faculty should be encouraged. In conjunction with the evidence on error and pa- tient safety in Chapter 6, the committee recommends the following: Recommendation 4-1: To increase patient safety and enhance educa- tion for residents, the ACGME should ensure that programs provide adequate, direct, onsite supervision for residents. The ACGME should require • Residency Review Committees, in conjunction with teaching insti- tutions and program directors, to establish measurable standards of supervision for each level of doctor in training, as appropriate to their specialty; and • First-year residents not to be on duty without having immedi- ate access to a residency program-approved supervisory physician in-house. There is no standard definition of whom or what level of “senior clini- cian” qualifies to act as a supervisor to residents, although any patient’s attending physician is ultimately responsible for the care received. The committee recognized that this definition can depend on the specialty being

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 IMPROVING THE RESIDENT LEARNING ENVIRONMENT pursued, the task being performed or taught, the competency level of indi- vidual residents, and the complexity of patient cases being cared for. While an attending-level supervisor is the ideal for all residents to be taught and guided under, for practical purposes and to avoid exacerbating the limited supply of supervising staff, the committee concluded that a senior resident (equivalent to a PGY-3) is an acceptable minimal level of experience to serve a supervisory role to more junior residents (PGY-1 and PGY-2 residents). For residents in their third year or higher of training, more senior clinicians (i.e., attendings, faculty, fellows) should provide supervision. In many cases, particularly in overseeing surgical procedures or dealing with highly com- plex cases such as interventional angiographic and intracranial procedures, an attending-level supervisor should always be required. Hospitalists and other senior-level staff can also serve to provide in-hospital resident super- vision when needed. The committee suggests that in-house supervisors be readily available to first-year residents, to help with any aspect of patient care duties, includ- ing on nights and weekends. It is hoped that these supervisors are not so overburdened with other clinical responsibilities such that their ability to supervise is compromised. Furthermore, supervisors need not necessarily be a member of the same team or service as the first year resident. It is ex- pected, however, that they be a senior resident or higher level physician in the same specialty training program as the first-year resident (i.e., internal medicine first-years should have an internal resident senior with whom they can consult, pediatrics with pediatrics, surgery with surgery, obstetrics- gynecology with obstetrics-gynecology, etc.). The committee believes that residency programs and specialties would benefit from creating their own supervisory guidelines to ensure adequate supervision is provided for all resident levels at all times. The committee also stresses the importance of enhancing supervisory leadership, by encouraging that supervisors at all levels (e.g., attendings and PGY-3s and above) be pro-active in their role: making conscientious efforts to contact their residents on a regular basis; providing feedback and constructive instruction (regarding diagnoses, treatment plans, professional behavior, or other attributes); and consistently helping residents identify areas to improve patient safety and their own patient care. Communica- tion should not be left solely to the discretion of residents to contact their supervisors to address concerns or clarify questions they may have. Supervi- sor-initiated contact, regardless of resident competency level, can serve to catch problems with treatment plans or handle unexpected events sooner than waiting for interns or residents to contact them, ultimately helping to prevent patient harm. As previously mentioned, faculty and other supervi- sors may need to be trained in this type of interaction to introduce it on a

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4 RESIDENT DUTY HOURS the duty hour constraints limiting their schedules, these techniques provide additional opportunities for residents to gain applicable clinical knowledge without risk to patient safety. Simulation-based training enables trainees to learn the necessary competencies (i.e., knowledge, skills, attitudes) (Salas et al., 2005) and has been shown to improve performance in clinical skills, such as procedural training (Lindquist et al., 2008; Medina et al., 2000; Sica et al., 1999; Wong, 2004), and in nonclinical skills, including com- munication, cooperation, leadership, and decision making (Medina et al., 2000; Østergaard, 2004; Sica et al., 1999). Simulation-based training is an effective training strategy when utilized properly (Salas et al., 2008). Practice must be guided (through crafted scenarios and timely, diagnostic feedback) to keep residents focused on learning key competencies (Salas and Burke, 2002). Allowing skills to be “practiced, assessed, diagnosed, remedied, and reinforced” all at once can create effective learning environments that require less time than real-life settings (Salas and Burke, 2002, p. 120). Both medical students and physi- cians have identified simulation-based training as a valuable tool for edu- cational purposes (Bond and Spillane, 2002; Bond et al., 2001; Gordon, 2000; Gordon et al., 2001; Halamek et al., 2000). Several electronic tools have also been shown to provide residents with learning opportunities in the absence of available faculty, helping them to learn more efficiently on their own (Cook et al., 2008). Assessing effectiveness of specific simulation courses or methods is be- yond the scope of this study. Numerous types and levels of simulation exist, each for different intents, purposes, and costs. The committee encourages examination and evaluation of the various simulation tools and methods that might serve to support educational redesign solutions, innovational training, and student evaluation. Long-Block Design In an effort to move away from service-oriented inpatient training toward education-oriented training, an Educational Innovations Project sponsored by ACGME was piloted by Warm and colleagues (2006) for ambulatory care training in internal medicine. A continuous year-long am- bulatory group practice, called a “long-block,” was created (beginning in a resident’s 17th month of training) and separated from traditional inpatient responsibilities. This long-block practice replaced sporadic ambulatory training rotations previously completed over 3 years and was scheduled to comply with duty hour limits. Results showed positive outcomes in multiple areas including increased resident and patient satisfaction and improve- ments in quality processes, outcome measures, and care continuity (Warm et al., 2008). Residents reported more time for learning and increased

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4 IMPROVING THE RESIDENT LEARNING ENVIRONMENT ability to focus in clinic with fewer interruptions in the long-block setting. They also reported better patient relationships and increased ownership of patient care (Warm et al., 2008). Quality Improvement Techniques Other redesign efforts, such as those based on teaching quality im- provement (QI) techniques to residents, have also been effective. For ex- ample, one internal medicine residency program sought to achieve one of ACGME’s new six core competencies—practice-based learning and improvement—which addresses “the need to teach and evaluate residents’ ability to apply quality improvement in their medical practice.” The faculty of this program chose to teach this competency by modifying the curricu- lum readings to focus on quality of care (which other programs have done), but also by having residents reflect on their work with faculty and evaluate their practice performances (Holmboe et al., 2005). The outcomes showed that residents involved in this education intervention were more likely to perform quality of care measures for their diabetic patients, which resulted in more positive patient outcomes and improved resident satisfaction with their education (Holmboe et al., 2005). A more recent study also aimed to teach internal medicine residents QI concepts and assessment techniques. Positive outcomes resulted after redesigning ambulatory block rotations and introducing a new curriculum specifically geared to achieve QI and assessment goals (Oyler et al., 2008). The authors note that teaching these skills can be difficult with limited staff availability or familiarity with the topics, but that using the American Board of Internal Medicine’s practice improvement module for preventive services was useful in overcoming these challenges. The new curriculum improved resident confidence with assessing QI and learning how to apply QI practices in their continuity clinics (Oyler et al., 2008). The educational redesign approaches presented above each has its strengths for teaching residents more effectively and efficiently. Additional innovations exist (Wong, 2006) and more are encouraged. It will be impor- tant to keep in mind the different needs of individual specialties, programs, and institutions when considering how best to redesign the educational content while complying with duty hour limits. CONCLUSION The committee concludes that the full effects of implementing the 2003 ACGME duty hour regulations on resident education remain unclear. The lack of published studies in most disciplines make assessments of educa- tional outcomes difficult. There seems to be a general impression from

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0 RESIDENT DUTY HOURS residents that their educational quality has remained relatively unchanged since the implementation of duty hour restrictions, while supervisors and faculty perceive that education has deteriorated in some instances. Look- ing at quantitative measures of educational outcomes, different programs and specialties have reported varying degrees of maintaining procedural volume or resident test scores since the 2003 duty hour limits. However, many of the more rigorous studies reported programs that managed either to sustain or improve these outcomes. With demanding workloads and less time in which to teach or learn, a new approach for graduate medical education—befitting the evolving medical landscape of the 21st century—is necessary. The committee’s approach has been to focus on the aspects of current resident work within the given duty hour limits that can have positive ef- fects on resident learning. Among those factors are redesigning residency program schedules so that they provide time needed for rest and recovery to consolidate learning, establishing appropriate workloads that allow time for reflection to enhance learning, strengthening supervision, and encour- aging approaches to curricula and training that improve overall learning environments. REFERENCES AAMC (Association of American Medical Colleges). 2006. Compact between postdoctoral appointees and their mentors December 00. http://www.aamc.org/research/postdoc compact/postdoccompact.pdf (accessed August 12, 2008). ———. 2008. Resident duty schedules and resident education. Presentation by Debra Weinstein to the Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety, May 8, 2008, Washington, DC. ABIM (American Board of Internal Medicine). 2008. Residency program pass rates 00- 00. Philadelphia, PA: American Board of Internal Medicine. ABMS (American Board of Medical Specialties). 2008a. Presentation by Kevin Weiss to the Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Sched- ules to Improve Patient Safety, May 8, 2008, Washington, DC. ———. 2008b. What board certification means. http://www.abms.org/About_Board_ Certification/means.aspx (accessed March 17, 2008). ACGME (Accreditation Council for Graduate Medical Education). 2007. ACGME institu- tional requirements: Checklist, effective: July , 00. http://www.acgme.org/acWebsite/ irc/IRCheckList-07.pdf (accessed 2/28/2008). ———. 2008a. CI–Committee on Innovation. http://www.acgme.org/acWebsite/ci/ci_welcome. asp (accessed October 22, 2008). ———. 2008b. Program director guide to the common program requirements. http://www. acgme.org/acWebsite/navPages/nav_commonpr.asp (accessed August 12, 2008). Arco, L. 2008. Feedback for improving staff training and performance in behavioral treatment programs. Behavioral Interventions 23(1):39-64. Arora, V., and D. Meltzer. 2008. Effect of ACGME duty hours on attending physician teaching and satisfaction. Archives of Internal Medicine 168(11):1226-1228.

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 IMPROVING THE RESIDENT LEARNING ENVIRONMENT Arora, V., S. Guardiano, D. Donaldson, I. Storch, and P. Hemstreet. 2005. Closing the gap between internal medicine training and practice: Recommendations from recent gradu- ates. American Journal of Medicine 118(6):680-685. Arora, V. M., E. Georgitis, J. N. Woodruff, H. J. Humphrey, and D. O. Meltzer. 2008. Improv- ing sleep hygiene—reply. Archives of Internal Medicine 168(11):1230. Barden, C. B., M. C. Specht, M. D. McCarter, J. M. Daly, and T. J. Fahey III. 2002. Effects of limited work hours on surgical training. Journal of the American College of Surgeons 195(4):531-538. Barron, J. M., M. C. Berger, and D. A. Black. 1997. How well do we measure training? Journal of Labor Economics 15(3):507-528. Basu, C. B., L. M. Chen, L. H. Hollier, Jr., and S. M. Shenaq. 2004. The effect of the Ac- creditation Council for Graduate Medical Education duty hours policy on plastic surgery resident education and patient care: An outcomes study. Plastic & Reconstructive Surgery 114(7):1878-1886. Batalden, P., D. Leach, S. Swing, H. Dreyfus, and S. Dreyfus. 2002. General competencies and accreditation in graduate medical education. Health Affairs 21(5):103-111. Becker, G. (1975). Human capital, 2nd ed. New York: Columbia University Press. Bell, B. M. 1993. Supervision, not regulation of hours, is the key to improving the quality of patient care. JAMA 269(3):403-404. ———. 2003. Reconsideration of the New York State laws rationalizing the supervision and the working conditions of residents. Einstein Journal of Biological Medicine 20(1):36-40. ———. 2007. Resident duty hour reform and mortality in hospitalized patients. JAMA 298(24):2865-2866. Bishop, V. 1998. Clinical supervision in practice. Some questions, answers and guidelines. Basingstoke: Macmillan Press. Bond, W. F., and L. Spillane. 2002. The use of simulation for emergency medicine resident assessment. Academic Emergency Medicine 9(11):1295-1299. Bond, W. F., M. Kostenbader, and J. F. McCarthy. 2001. Prehospital and hospital-based health care providers’ experience with a human patient simulator. Prehospital Emergency Care 5(3):284-287. Brody School of Medicine. 2008. Department of surgery: Residency curriculum. http://www. ecu.edu/cs-dhs/surgery/curriculum.cfm (accessed November 7, 2008). Brown, J. S., A. Collins, and P. Duguid. 1989. Situated cognition and the culture of learning. Educational Researcher 18(1):32-42. Charap, M. M. D. 2004. Reducing resident work hours: Unproven assumptions and unfore- seen outcomes. Annals of Internal Medicine 140(10):814-815. Chewning, E. G., and A. M. Harrell. 1990. The effect of information load on decision makers’ cue utilization levels and decision quality in a financial distress decision task. Accounting, Organizations and Society 15(6):527-542. Chi, M. T. H. 2000. Self-explaining expository texts: The dual processes of generating infer- ences and repairing mental models. In Advances in instructional psychology educa- tional design and cognitive science, Vol. 5, edited by R. Glaser. Mahwah, NJ: Lawrence Erlbaum Associates. Choo, F. 1995. Auditors’ judgment performance under stress: A test of the predicted rela- tionship by three theoretical models. Journal of Accounting, Auditing, and Finance 10(3):611-641. Clark, R., F. Nguyen, and J. Sweller. 2006. Efficiency in learning: Evidence-based guidelines to manage cognitive load. New York: John Wiley & Sons, Inc. Cohen-Gadol, A. A., D. G. Piepgras, S. Krishnamurthy, and R. D. Fessler. 2005. Resident duty hours reform: Results of a national survey of the program directors and residents in neurosurgery training programs. Neurosurgery 56(2):398-403.

OCR for page 125
 RESIDENT DUTY HOURS Cook, D., T. Beckman, K. Thomas, and W. Thompson. 2008. Adapting web-based instruc- tion to residents’ knowledge improves learning efficiency. Journal of General Internal Medicine 23(7):985-990. Cooper, G., S. Tindall-Ford, P. Chandler, and J. Sweller. 2001. Learning by imagining. Journal of Experimental Psychology: Applied 7(1):68-82. Cote, L., and H. Leclere. 2000. How clinical teachers perceive the doctor-patient relationship and themselves as role models. Academic Medicine 75(11):1117-1124. Coverdill, J. E., G. L. Adrales, W. Finlay, J. D. Mellinger, K. D. Anderson, B. W. Bonnell, J. B. Cofer, D. B. Dorner, C. Haisch, K. L. Harold, P. M. Termuhlen, and A. L. Webb. 2006a. How surgical faculty and residents assess the first year of the Accreditation Council for Graduate Medical Education duty-hour restrictions: Results of a multi-institutional study. American Journal of Surgery 191(1):11-16. Coverdill, J. E., W. Finlay, G. L. Adrales, J. D. Mellinger, K. D. Anderson, B. W. Bonnell, J. B. Cofer, D. B. Dorner, C. Haisch, K. L. Harold, P. M. Termuhlen, and A. L. B. Webb. 2006b. Duty-hour restrictions and the work of surgical faculty: Results of a multi- institutional study. Academic Medicine 81(1):50-56. de Virgilio, C. 2008. The 80-hour resident workweek: A perspective from a university- affiliated Los Angeles County surgical training program. Presentation to the Commit- tee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety, May 8, 2008, Irvine, CA. de Virgilio, C., A. Yaghoubian, R. J. Lewis, B. E. Stabile, and B. A. Putnam. 2006. The 80- hour resident workweek does not adversely affect patient outcomes or resident education. Journal of Surgical Education 63(6):435-439. Dreyfus, H. L., and S. E. Dreyfus. 1986. Five steps from novice to expert, edited by Mind over Machine. New York: The Free Press. Pp. 16-51. Durkin, E. T., R. McDonald, A. Munoz, and D. Mahvi. 2008. The impact of work hour restrictions on surgical resident education. Journal of Surgical Education 65(1): 54-60. Epstein, R. M. 1999. Mindful practice. JAMA 282(9):833-839. Ericsson, K. A. 2002. Attaining excellence through deliberate practice: Insights from the study of expert performance. In The pursuit of excellence through education, edited by M. E. Ferrari. Mahwah, NJ: Lawrence Erlbaum Associates. Pp. 21-56. Ericsson, K. A., and N. Charness. 1994. Expert performance: Its structure and acquisition. American Psychologist 49(8):725-747. Ericsson, K. A., and R. T. Krampe. 1993. The role of deliberate practice in the acquisition of expert performance. Psychological Review 100(3):363-406. Espey, E., T. Ogburn, and E. Puscheck. 2007. Impact of duty hour limitations on resident and student education in obstetrics and gynecology. Journal of Reproductive Medicine for the Obstetrician and Gynecologist 52(5):345-348. Fallon, W. F., Jr., R. L. Wears, and J. J. Tepas III. 1993. Resident supervision in the operat- ing room: Does this impact on outcome? Journal of Trauma-Injury Infection & Critical Care 35(4):556-560. Farnan, J. M., D. O. Meltzer, H. J. Humphrey, and V. Arora. 2007. Assessing supervision in internal medicine residency training. Paper read at Society of General Internal Medicine National Meeting, April 28, Toronto. Farnan, J. M., J. K. Johnson, D. O. Meltzer, H. J. Humphrey, and V. M. Arora. 2008. Resident uncertainty in clinical decision making and impact on patient care: A qualitative study. Quality and Safety in Health Care 17(2):122-126. Ferguson, C. M., K. C. Kellogg, M. M. Hutter, and A. L. Warshaw. 2005. Effect of work-hour reforms on operative case volume of surgical residents. Current Surgery 62(5):535-538.

OCR for page 125
 IMPROVING THE RESIDENT LEARNING ENVIRONMENT Fitzgibbons, J. P., D. R. Bordley, L. R. Berkowitz, B. W. Miller, and M. C. Henderson. 2006. Redesigning residency education in internal medicine: A position paper from the Association of Program Directors in Internal Medicine. Annals of Internal Medicine 144(12):920-926. Fletcher, K. E., W. Underwood III, S. Q. Davis, R. S. Mangrulkar, L. F. McMahon, Jr., and S. Saint. 2005. Effects of work hour reduction on residents’ lives: A systematic review. JAMA 294(9):1088-1100. Flexner, A. 1925. Medical education: A comparative study. New York: Macmillan Co. Gais, S., W. Plihal, U. Wagner, and J. Born. 2000. Early sleep triggers memory for early visual discrimination skills. Nature Neuroscience 3(12):1335-1339. Gennis, V. M., and M. A. Gennis. 1993. Supervision in the outpatient clinic: Effects on teach- ing and patient care. Journal of General Internal Medicine 8(7):378-380. Gordon, J. A. 2000. The human patient simulator: Acceptance and efficacy as a teaching tool for students. The medical readiness trainer team. Academic Medicine 75(5):522. Gordon, J. A., W. M. Wilkerson, D. W. Shaffer, and E. G. Armstrong. 2001. “Practicing” medicine without risk: Students’ and educators’ responses to high-fidelity patient simula- tion. Academic Medicine 76(5):469-472. Griffith III, C. H., N. S. Desai, J. F. Wilson, E. A. Griffith, K. J. Powell, and E. C. Rich. 1996. Housestaff experience, workload, and test ordering in a neonatal intensive care unit. Academic Medicine 71(10):1106-1108. Groopman, J. 2008. How doctors think. New York: Mariner Books. Halamek, L. P., D. M. Kaegi, D. M. Gaba, Y. A. Sowb, B. C. Smith, B. E. Smith, and S. K. Howard. 2000. Time for a new paradigm in pediatric medical education: Teaching neo- natal resuscitation in a simulated delivery room environment. Pediatrics 106(4):E45. Haney, E. M., C. Nicolaidis, A. Hunter, B. K. Chan, T. G. Cooney, and J. L. Bowen. 2006. Relationship between resident workload and self-perceived learning on inpatient medi- cine wards: A longitudinal study. BMC Medical Education 6:35. Harrison, R., and E. Allen. 2006. Teaching internal medicine residents in the new era. Inpatient attending with duty-hour regulations. Journal of General Internal Medicine 21(5):447-452. Hoff, T. J., H. Pohl, and J. Bartfield. 2006. Teaching but not learning: How medical residency programs handle errors. Journal of Organizational Behavior 27(7):869-896. Holmboe, E. S., L. M. Prince, and M. Green. 2005. Teaching and improving quality of care in a primary care internal medicine residency clinic. Academic Medicine 80(6):571-577. Horwitz, L. I., H. M. Krumholz, S. J. Huot, and M. L. Green. 2006. Internal medicine resi- dents’ clinical and didactic experiences after work hour regulation: A survey of chief residents. Journal of General Internal Medicine 21(9):961-965. Hough, M. C. 2008. Learning, decisions and transformation in critical care nursing practice. Nursing Ethics 15(3):322-331. Huang, G. C., C. C. Smith, C. E. Gordon, D. J. Feller-Kopman, R. B. Davis, R. S. Phillips, and S. N. Weingart. 2006. Beyond the comfort zone: Residents assess their comfort perform- ing inpatient medical procedures. American Journal of Medicine 119(1):71.e17-71.e24. Huber, R., M. F. Ghilardi, M. Massimini, and G. Tononi. 2004. Local sleep and learning. Nature 430(6995):78-81. Hutter, M. M., K. C. Kellogg, C. M. Ferguson, W. M. Abbott, and A. L. Warshaw. 2006. The impact of the 80-hour resident workweek on surgical residents and attending surgeons. Annals of Surgery 243(6):864-871. Immerman, I., E. N. Kubiak, and J. D. Zuckerman. 2007. Resident work-hour rules: A survey of residents’ and program directors’ opinions and attitudes. American Journal of Ortho- pedics 36(12):E172-E179. Jacobs, R. L. 2003. Structured on-the-job training: Unleashing employee expertise in the workplace, 2nd ed. San Francisco, CA: Berrett-Koehler Publishers, Inc.

OCR for page 125
4 RESIDENT DUTY HOURS Jagsi, R., and R. Surender. 2004. Regulation of junior doctors’ work hours: An analysis of British and American doctors’ experiences and attitudes. Social Science & Medicine 58(11):2181-2191. Jagsi, R., J. Shapiro, J. S. Weissman, D. J. Dorer, and D. F. Weinstein. 2006. The educational impact of ACGME limits on resident and fellow duty hours: A pre-post survey study. Academic Medicine 81(12):1059-1068. Kennedy, T. J., G. Regehr, G. R. Baker, and L. A. Lingard. 2005. Progressive independence in clinical training: A tradition worth defending? Academic Medicine 80(10 Suppl): S106-S111. Kennedy, T. J. T., L. Lingard, G. R. Baker, L. Kitchen, and G. Regehr. 2007. Clinical oversight: Conceptualizing the relationship between supervision and safety. Journal of General Internal Medicine 22(8):1080-1085. Kilminster, S. M., and B. C. Jolly. 2000. Effective supervision in clinical practice settings: A literature review. Medical Education 34(10):827-840. Kluger, A. N., and A. DeNisi. 1996. The effects of feedback interventions on performance: Historical review, a meta-analysis and a preliminary feedback intervention theory. Psy- chological Bulletin 119:254-284. Kort, K. C., L. A. Pavone, E. Jensen, E. Haque, N. Newman, and D. Kittur. 2004. Resident perceptions of the impact of work-hour restrictions on health care delivery and surgical education: Time for transformational change. Surgery 136(4):861-871. Kozak, L. J., C. J. DeFrances, and M. J. Hall. 2006. National Hospital Discharge Survey: 004 annual summary with detailed diagnosis and procedure data. Hyattsville, MD: National Center for Health Statistics. Landrigan, C. P., J. M. Rothschild, J. W. Cronin, R. Kaushal, E. Burdick, J. T. Katz, C. M. Lilly, P. H. Stone, S. W. Lockley, D. W. Bates, and C. A. Czeisler. 2004. Effect of reduc- ing interns’ work hours on serious medical errors in intensive care units. New England Journal of Medicine 351(18):1838-1848. Langer, E. J. 1990. The power of mindful learning. Cambridge, MA: Da Capo Press. Leung, W. C. 2002. Competency based medical training: Review. BMJ 325(7366):693-696. Lieberman, J. D., J. A. Olenwine, W. Finley, and G. G. Nicholas. 2005. Residency reform: Anticipated effects of ACGME guidelines on general surgery and internal medicine resi- dency programs. Current Surgery 62(2):231-236. Lin, G. A., D. C. Beck, and J. M. Garbutt. 2006. Residents’ perceptions of the effects of work hour limitations at a large teaching hospital. Academic Medicine 81(1):63-67. Lindquist, L., K. Gleason, M. McDaniel, A. Doeksen, and D. Liss. 2008. Teaching medication reconciliation through simulation: A patient safety initiative for second year medical students. Journal of General Internal Medicine 23(7):998-1001. Linn, M. C., H. S. Lee, R. Tinker, F. Husic, and J. L. Chiu. 2006. Inquiry learning: Teaching and assessing knowledge integration in science. Science 313(5790):1049-1050. Litzelman, D. K., G. A. Stratos, D. J. Marriott, and K. M. Skeff. 1998. Factorial validation of a widely disseminated educational framework for evaluating clinical teachers. Academic Medicine 73(6):688-695. Long, D. M. 2000. Competency-based residency training: The next advance in graduate medi- cal education. Academic Medicine 75(12):1178-1183. Ludmerer, K. M. 1999. Time to heal: American medical education from the turn of the century to the era of managed care. New York: Oxford University Press. ———. 2004. Learner-centered medical education. New England Journal of Medicine 351(12): 1163-1164. Ludmerer, K. M., and M. M. Johns. 2005. Reforming graduate medical education. JAMA 294(9):1083-1087.

OCR for page 125
 IMPROVING THE RESIDENT LEARNING ENVIRONMENT Malangoni, M. A., J. J. Como, C. Mancuso, and C. J. Yowler. 2005. Life after 80 hours: The impact of resident work hours mandates on trauma and emergency experience and work effort for senior residents and faculty. Journal of Trauma-Injury Infection & Critical Care 58(4):758-761. Martin, M., B. Vashisht, E. Frezza, T. Ferone, B. Lopez, M. Pahuja, R. K. Spence, F. Y. Bhora, and A. H. Harken. 1998. Competency-based instruction in critical invasive skills im- proves both resident performance and patient safety. Surgery 124(2):313-317. Mayer, R. E., W. Bove, A. Bryman, R. Mars, and L. Tapangco. 1996. When less is more: Mean- ingful learning from visual and verbal summaries of science textbook lessons. Journal of Educational Psychology 88(1):64-73. McKee, M., and N. Black. 1992. Does the current use of junior doctors in the United Kingdom affect the quality of medical care? Social Science & Medicine 34(5):549-558. Medina, L. S., J. M. Racadio, and H. A. Schwid. 2000. Computers in radiology. The sedation, analgesia, and contrast media computerized simulator: A new approach to train and eval- uate radiologists’ responses to critical incidents. Pediatric Radiology 30(5):299-305. Mendoza, K. A., and L. D. Britt. 2005. Resident operative experience during the transition to work-hour reform. Archives of Surgery 140(2):137-145. Meyers, F. J., S. E. Weinberger, J. P. Fitzgibbons, J. Glassroth, F. D. Duffy, and C. P. Clayton. 2007. Redesigning residency training in internal medicine: The consensus report of the Alliance for Academic Internal Medicine Education Redesign Task Force. Academic Medicine 82(12):1211-1219. Mincer, J. 1962. On-the-job training: Costs, returns, and some implications. Journal of Politi- cal Economy 70(5):50-79. New York Supreme Court. 1986. Report of the fourth grand jury for the April/May term of  concerning the care and treatment of a patient and the supervision of interns and ju- nior residents at a hospital in New York county. New York: New York Supreme Court. Osborn, L. M., J. R. Sargent, and S. D. Williams. 1993. Effects of time-in-clinic, clinic setting, and faculty supervision on the continuity clinic experience. Pediatrics 91(6):1089-1093. Østergaard, D. 2004. National medical simulation training program in Denmark. Critical Care Medicine 32(2 Suppl):S58-S60. Oyler, J., L. Vinci, V. Arora, and J. Johnson. 2008. Teaching internal medicine residents qual- ity improvement techniques using the ABIM’s practice improvement modules. Journal of General Internal Medicine 23. Plack, M. M., and L. Greenberg. 2005. The reflective practitioner: Reaching for excellence in practice. Pediatrics 116(6):1546-1552. Plihal, W., and J. Born. 1997. Effects of early and late nocturnal sleep on declarative and procedural memory. Journal of Cognitive Neuroscience 9(4):534-547. Pollock, E., P. Chandler, and J. Sweller. 2002. Assimilating complex information. Learning and Instruction 12(1):61-86. Reed, D. A., R. B. Levine, R. G. Miller, B. H. Ashar, E. B. Bass, T. N. Rice, and J. Cofrancesco, Jr. 2007. Effect of residency duty-hour limits: Views of key clinical faculty. Archives of Internal Medicine 167(14):1487-1492. Richardson, W. S. 2005. Teaching evidence-based practice on foot. Evidence-Based Medicine 8:100-103. Rothwell, W. J., and H. C. Kazanas. 2004. Improving on-the-job training: How to establish and operate a comprehensive OJT program. 2nd ed. New York: John Wiley and Sons. Ryan, J. 2005. Unintended consequences: The Accreditation Council for Graduate Medical Education work-hour rules in practice. Annals of Internal Medicine 143(1):82-83. Salas, E., and C. S. Burke. 2002. Simulation for training is effective when. . . . Quality and Safety in Health Care 11(2):119-120.

OCR for page 125
 RESIDENT DUTY HOURS Salas, E., and J. A. Cannon-Bowers. 2000. Designing training systems systematically. In The Blackwell handbook of principles of organizational behavior, edited by E. A. Locke. Malden, MA: Blackwell Publisher Ltd. Pp. 43-59. ———. 2001. The science of training: A decade of progress. Annual Review of Psychology 52:471-499. Salas, E., K. A. Wilson, C. S. Burke, and H. A. Priest. 2005. Using simulation-based training to improve patient safety: What does it take? Joint Commission Journal on Quality & Patient Safety 31(7):363-371. Salas, E., K. A. Wilson, E. H. Lazzara, H. B. King, J. S. Augenstein, D. W. Robinson, and D. J. Birnbach. 2008. Simulation-based training for patient safety: 10 principles that matter. Journal of Patient Safety 4(1):3-8. Satish, U., and S. Streufert. 2002. Value of a cognitive simulation in medicine: Towards op- timizing decision making performance of healthcare personnel. Quality and Safety in Health Care 11(2):163-167. Satish, U., S. Streufert, R. Marshall, J. S. Smith, S. Powers, P. Gorman, and T. Krummel. 2001. Strategic management simulations is a novel way to measure resident competencies. American Journal of Surgery 181(6):557-561. Sejits, G., and G. P. Latham. 2005. Learning versus performance goals: When should each be used? Academy of Management Executive 19:124-131. Shin, S., R. Britt, and L. D. Britt. 2008. Effect of the 80-hour work week on resident case cov- erage: Corrected article. Journal of the American College of Surgeons 207(1):148-150. Shojania, K. G., K. E. Fletcher, and S. Saint. 2006. Graduate medical education and patient safety: A busy—and occasionally hazardous—intersection. Annals of Internal Medicine 145(8):592-598. Shulkin, D. J. 2008. Like night and day—Shedding light on off-hours care. New England Journal of Medicine 358(20):2091-2093. Sica, G. T., D. M. Barron, R. Blum, T. H. Frenna, and D. B. Raemer. 1999. Computerized realistic simulation: A teaching module for crisis management in radiology. American Journal of Roentgenology 172(2):301-304. Singh, H., E. J. Thomas, L. A. Petersen, and D. M. Studdert. 2007. Medical errors involv- ing trainees: A study of closed malpractice claims from 5 insurers. Archives of Internal Medicine 167(19):2030-2036. Skeff, K. M. 1998. An educational framework for the analysis of teaching. Substance Abuse 9(2):61-75. Skeff, K. M., S. Ezeji-Okoye, P. Pompei, and S. Rockson. 2004. Benefits of resident work hours regulation. Annals of Internal Medicine 140(10):816-817. Smith, C. A., A. B. Varkey, A. T. Evans, and B. M. Reilly. 2004. Evaluating the performance of inpatient attending physicians: A new instrument for today’s teaching hospitals. Journal of General Internal Medicine 19(7):766-771. Sox, C. M., H. R. Burstin, E. J. Orav, A. Conn, G. Setnik, D. W. Rucker, P. Dasse, and T. A. Brennan. 1998. The effect of supervision of residents on quality of care in five university- affiliated emergency departments. Academic Medicine 73(7):776-782. Spencer, A. U., and D. H. Teitelbaum. 2005. Impact of work-hour restrictions on residents’ operative volume on a subspecialty surgical service. Journal of the American College of Surgeons 200(5):670-676. Stickgold, R., L. James, and J. A. Hobson. 2000. Visual discrimination learning requires sleep after training. Nature Neuroscience 3(12):1237-1238. Sweller, J., P. Chandler, P. Tierney, and M. Cooper. 1990. Cognitive load and selective atten- tion as factors in the structuring of technical matter. Journal of Experimental Psychology: General 119:176-192.

OCR for page 125
 IMPROVING THE RESIDENT LEARNING ENVIRONMENT USMLE (United States Medical Licensing Examination®). 2008. USLME performance data. http://www.usmle.org/Scores_Transcrtips/performance.html (accessed September 10, 2008). Vaughn, D. M., C. L. Stout, B. L. McCampbell, J. R. Groves, A. I. Richardson, W. K. Thompson, M. L. Dalton, and D. K. Nakayama. 2008. Three-year results of mandated work hour restrictions: Attending and resident perspectives and effects in a community hospital. American Surgeon 74(6):542-546. Veum, J. R. 1999. Training, wages and the human capital model. Southern Economic Journal 65(3):526-538. Vidyarthi, A. R., P. P. Katz, S. D. Wall, R. M. Wachter, and A. D. Auerbach. 2006. Impact of reduced duty hours on residents’ educational satisfaction at the University of California, San Francisco. Academic Medicine 81(1):76-81. Warm, E., D. Schauer, T. Diers, B. Mathis, Y. Neirouz, J. Boex, and G. Rouan. 2008. The ambulatory long-block: An Accreditation Council for Graduate Medical Education (ACGME) Educational Innovations Project (EIP). Journal of General Internal Medicine 23(7):921-926. Wiener, E. L., R. E. Curry, and M. L. Faustina. 1984. Vigilance and task load: In search of the inverted U. Human Factors 26(2):215-222. Williams, P. L., and C. Webb. 1994. Clinical supervision skills: A Delphi and critical incident technique study. Medical Teacher 16(2):139-157. Winslow, E. R., L. Berger, and M. E. Klingensmith. 2004. Has the 80-hour work week in- creased faculty hours? Current Surgery 61(6):602-608. Wong, A. K. 2004. Full scale computer simulators in anesthesia training and evaluation. Canadian Journal of Anesthesia 51(5):455-464. ———. 2006. Curriculum development in anesthesia: Basic theoretical principles. Canadian Journal of Anesthesia 53(9):950-960. Wong, J. G., E. S. Holmboe, and S. J. Huot. 2004. Teaching and learning in an 80-hour work week: A novel day-float rotation for medical residents. Journal of General Internal Medicine 19(5 Pt 2):519-523. Zuckerman, J. D., E. N. Kubiak, I. Immerman, and P. DiCesare. 2005. The early effects of Code 405 work rules on attitudes of orthopaedic residents and attending surgeons. Jour- nal of Bone and Joint Surgery—Series A 87(4):903-908.

OCR for page 125