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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 2003, 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 2003 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 âfirst and foremost learnersâ and that âa residentâs educational needs should be the primary determinant of any assigned patient care services.â Similarly, 125
126 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 residentsâ 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 trainingâparticipating in direct patient careârequires 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 âsocial contractâ 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 goodâthe 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
IMPROVING THE RESIDENT LEARNING ENVIRONMENT 127 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 patientsâ 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 competencyâwith 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-
128 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 doctorâs care of patients. This would include the ability to anticipate a doctorâs 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 Commissionâs 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-
IMPROVING THE RESIDENT LEARNING ENVIRONMENT 129 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 patientsâ 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 âsupervision has a positive effect on patient outcomes and that lack of supervision is harmful for patients.â 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; G Â ennis and Gennis, 1993; Singh et al., 2007; Sox et al., 1998). An attend- ing physicianâs review of a residentâs 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). Residentsâ 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 âsound supervisionâ 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
130 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 Medicareâs 1996 Teaching Physician Presence Rules to include progress notes and documentation of their presence during operative procedures in a patientâs medical record. 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 patientâs course of treatment, residents perform many of their duties without âover-the-shoulderâ supervision. The degree of direct supervision varies by specialty, rotation, the tasks residents are undertaking, and the residentâs 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 supervisorâs 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 â CMS (Centers for Medicare and Medicaid Services). 2005. 42 CFR 4172(a) evolution of Medicare billing regulations. Medicare Claims Processing Manual.
IMPROVING THE RESIDENT LEARNING ENVIRONMENT 131 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 âacademies of medical educators,â 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 2003 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).
132 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 superÂvised 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 superÂ 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), patientsâ 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 âweak,â 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 supervisionâto help residents become aware of their cognitive biases and
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 ï¿½.001 for all outcomes. FIGURE 4-1â 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 Â© 2007, American Medical Association. All rights reserved. 133
134 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 attendingâs 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 â¢ 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 â¢ 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 âsenior clini- cianâ qualifies to act as a supervisor to residents, although any patientâs attending physician is ultimately responsible for the care received. The committee recognized that this definition can depend on the specialty being
IMPROVING THE RESIDENT LEARNING ENVIRONMENT 135 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
136 RESIDENT DUTY HOURS broad scale throughout residency programs and help make it a part of the training and safety culture. Ensuring a Workload That Allows Adequate Time for Reflective Learning A second cardinal educational principle of graduate medical training is having time for reflective learning. This manifests in the regular pacing of mindful reflection in a physicianâs practice, during diagnosis, in the process of treatment, and upon case completion. From the beginning of the modern residency, medical educators have emphasized the importance to learning of allowing residents sufficient time to reflect on their workâalthough the re- ality of practice today does not always exhibit this ideal. Mindful reflection involves openness to new information and implicit awareness of multiple perspectives and possibilities (Langer, 1990). It is far better for the intel- lectual growth of residents, educators have argued, to have house officers study fewer patients in depth rather than many patients superficially. The pioneering medical educator Abraham Flexner spoke to this point: Medi- cine is best learned through the âintensive and thorough study of relatively few patientsâ (Flexner, 1925, p. 270). To allow residents the opportunity to reflect, medical educators strove to ensure that the âcaseloadâ of house officers was not too burdensome, leaving them more time to read, contem- plate, attend conferences and rounds, and monitor their patients carefully (Ludmerer, 1999). Impact of 2003 Duty Hour Rules on Workload and Learning For most of the 20th century, this cardinal educational principle that residents should have time for reflection was honored. However, in 1984, along with the implementation of prospective payment for hospitals and the need to control costs, the already decreasing average length of hospital stay continued to fall by one-third of what it had been before (7.3 days in 1980 to 4.8 in 2004) (Kozak et al., 2006). As more cases shifted to outpa- tient care, the remaining inpatients had a greater severity and complexity of health care needs. Although residents have managed an escalating number of admissions and discharges for the past two decades, thereby allowing hospital âthroughputâ to be maintained at a high level, the educational costs to their training have been significant (Ludmerer, 1999). The regulations implemented in 2003 limiting resident duty hours have had the unintended consequence of worsening the situation in many pro- grams (Hutter et al., 2006; Vidyarthi et al., 2006). By not decreasing resi- dentsâ workload along with their work hours (Charap, 2004; Fitzgibbons et al., 2006; Ludmerer and Johns, 2005; Ryan, 2005), the already hectic pace at which residents worked has become faster than ever. One resident
IMPROVING THE RESIDENT LEARNING ENVIRONMENT 137 described the âfrantic mentalityâ that engulfed the wards, with residents and interns ârushing from task to task and then out of the hospitalâ (Ryan, 2005, p. 82). He also described âthe marginalization of learningâ that resulted from this intense pace, âSuccess in the medical wards, mov- ing patients along, and getting things done often require efficiency above all else.ââ.ââ.ââ. [This] makes education about the diagnosis and management of disease feel like a hindrance, a drag on the steady progress through the dayâ (Ryan, 2005, p. 83). The patient load confronting residents during the era of âthroughputâ has raised concerns for patientsâ safety and the quality of their care. In organizational research generally, extremely difficult performance de- mands yield dysfunctional consequences unless there is substantial support to make the demands manageable. Consequences include extreme stress, pressures on personal time, burnout, and in some cases, inappropriate or unethical behavior (Sejits and Latham, 2005). Teaching hospitals need to address the question: Have residents been given the means to succeed at maximizing learning while providing quality patient care? Cognitive Load Theory To fully understand how workload affects resident learning and per- formance, it is important to appreciate the implications of cognitive load theory. This theory deals with the amount of cognitive information a person is able to absorb, process, and retain from any given task. Some forms of cognitive load are useful in achieving goals while others waste mental re- sources. In learning, the goal is to minimize the inefficient or wasteful forms of cognitive load and maximize its useful forms. Cognitive load theory represents a universal set of learning principles demonstrated to result in efficient educational environments when designed with human cognitive learning processes in mind (Clark et al., 2006). Controlled experimental research studies are the basis for these principles (e.g., Mayer et al., 1996; Sweller et al., 1990). Three types of cognitive information (or load) are relevant to train- ing: intrinsic, germane, and extraneous. Intrinsic load is the mental work imposed by the complexity of the learning content (e.g., units of knowl- edge to be acquired). Germane or relevant load is mental work imposed by instructional activities that benefit learning (e.g., constructing a report to express what the learner has understood after completing task). Extra- neous or irrelevant load is mental work that is irrelevant to the learning goal (e.g., âscutâ work), usually under the control of the managers of the learning environment. Therefore, cognitive load is the mental work that a task or situation imposes. Humans are known to have limited cognitive capacity, which is why efficient instruction substitutes for the noviceâs lack
138 RESIDENT DUTY HOURS of sophisticated knowledgeÂâby segmenting and sequencing content in ways that reduce the amount of new information novices must process at one time (e.g., by controlling the complexity of tasks novices perform; by guiding their attention to critical information). The traditional educational principle, that house officers should study problems in depth, has received substantial theoretical and empirical sup- port from education and psychology research (Langer, 1990; Pollock et al., 2002). Experts in these disciplines have coined the terms âreflective learn- ingâ and âmindfulnessâ to describe the most important requirements for learning, which align with the principles of cognitive load theory. Reflection means deliberate recall and review of an event, typically an event in which the learner is actively involved. Mindfulness is systematic, careful attention, a heightened awareness. (The opposite of mindfulness is the automatic pro- cessing of information in routine habit-based ways.) Both reflective learning and mindfulness require that learning be paced, giving the learner time to engage in these critical intellectual activities. This goes hand-in-hand with segmenting cognitive load in order to optimize the information a learner retains. The supervisor or instructorâs role in this process is to focus residentsâ attention on appropriate content. For example, when talking about a case, there is a reflective discussion of possible alternatives for patient treatment. By questioning and modeling how he or she thinks and showing how the time is structured to do this, the instructor creates an active information processing on the part of the resident, showing him or her how to consider alternatives systematically and weigh what is most important (Clark et al., 2006; Langer, 1990; Richardson, 2005; Smith et al., 2004). This may oc- cur more easily in inpatient settings, where patient visits can be longer and allow more time for reflection than in outpatient settings, where visits are typically 15 minutes long. However, since a residentsâ service is to be edu- cational for them, time should be made to discuss cases and allow residents to reflect on decisions made and actions taken whether in the inpatient or outpatient setting. Integration of what has just happened with prior knowl- edge is important and should occur as close in time to the event as possible (Clark et al., 2006; Linn et al., 2006). This process of reflection permits residents to consolidate pieces of information into a bigger, richer under- standing they can recall and apply (Chi, 2000; Cooper et al., 2001), and the importance of the role a supervisor plays in this cannot be overstated. Therefore, the design of the learning environment itselfâlargely dic- tated by the structure of a hospitalâs systemâaffects how residents learn. Learning takes place best in the context of activityâthat is, learning by doing. Resident learning is enhanced by ongoing collaborative social inter- action and ready access to knowledgeable colleagues (Brown et al., 1989), reasons why onsite training and supervision are important for residents.
IMPROVING THE RESIDENT LEARNING ENVIRONMENT 139 If faculty have modeled appropriate ways of learning by doing, then resi- dents can learn to generate alternative courses of action for consideration based on prior modeling demonstrated by the attending (Clark et al., 2006; Groopman, 2008). Training programs that mingle activities unrelated to learning place additional burdens on the working memory of would-be learners (Clark et al., 2006). The result is slower, inefficient, and potentially reduced or inap- propriate learning (e.g., short cuts, poorly executed procedures). Learning is enhanced when the tasks that people perform (those that go into their working memory) focus on content that is relevant and germane to what they are trying to learn. For example, doing patient intakes and perform- ing surgical procedures are relevant to learning about patient care. Patient transport, scheduling, or certain kinds of paperwork are not. The notion of cognitive load theory is to build a learning environment that helps active processing and avoids placing tasks in the environment that might hinder it (Clark et al., 2006; Sweller et al., 1990). The more relevant the content is, the more efficient is the learning, so that less time is needed to learn the same amount of material (Clark et al., 2006). Optimizing Workload to Improve Learning In addition to feedback from instructors, time for reflection, and rel- evant content, behavioral and brain research has demonstrated that work- load is related to performance as well. For any given task, an optimal level of workload exists that yields the highest level of performance. On a graph, this relationship between learning on the y-axis and census and workload on the x-axis would appear as an inverted U function. A departure in either direction off the plateau of the inverted U is expected to result in lower performance (Chewning and Harrell, 1990; Choo, 1995; Wiener et al., 1984). Too little work stimulates less learning, and work overload undermines a residentâs ability to absorb new information. Thought pro- cesses become fragmented, and judgment deteriorates. One can be the most responsible, knowledgeable, and thoughtful resident, but if the system gives a resident responsibility for too many patients, stress develops and learning does not take place, placing safe care at risk. The optimal level of workload varies with individual expertise, so a novice can absorb less workload than an expert. Haney and colleagues (2006) have explored this well-known principle for its applicability to medical residency. They find that for new learners (i.e., interns) the peak of this curve is sensitive to the total number of patients in their census. In contrast, for more experienced learners, the peak is sensitive to case variety and the severity of illness in new admissions. Translated to residency education, these concepts validate the idea that residentsâ caseloads should be of manageable size and variety
140 RESIDENT DUTY HOURS so that residents may learn most effectively (Epstein, 1999; Ericsson, 2002; E Â ricsson and Charness, 1994; Ericsson and Krampe, 1993; Langer, 1990; Plack and Greenberg, 2005). Less attention has been paid to workload than regulation of hours. Workload is affected not only by patient demands but also by enabling societal, educational, and hospital structures. Compressing the volume of work that residents must do into less time after the 2003 ACGME duty hour limits might have been done in the hopes that the level of educational outcomes would not decline. However, cognitive thresholds exist beyond which additional workload becomes counterproductive to learning and performance. Hence, the committee recommends in Chapter 3 that nonedu- cational work be minimized, that Residency Review Committees develop workload guidance that is specialty-specific by year of residency, and that residents be given enough time to conduct thorough evaluations of patients and to engage in reflective learning based on their clinical experiences. Additionally, sleep is necessary to consolidate memory to help people retrieve what they have learned (Gais et al., 2000; Huber et al., 2004; Plihal and Born, 1997; Stickgold et al., 2000). Learning is much less effec- tive without adequate sleep, substantially decreasing the ability to retrieve information from oneâs long-term memory. Finding the Balance Between Continuity of Care and Educational Opportunities Continuity of care is the third principle of quality resident education. Residents require continuity in the care of their patients to understand the normal course of illness and to act in the best interest of patients. By fol- lowing patients from admission to discharge, residents see the results of their treatments, learn how to respond to complications or complexities that arise from treatment, and better understand how to treat the âwholeâ patient. Decades of experience in preparing residents for independent prac- tice have convinced medical educators that residents must have multiple op- portunities, under supervision, to participate directly in the care of âtheirâ patients from the inception of an illness through the entire course of diag- nosis, treatment, and recovery. In underscoring the importance of continuity of care in resident edu- cation, a clear distinction must be made between continuity of care in the hours or days of an acute illness, and continuity over the weeks, months, and years of a chronic disease or disability. The acute care circumstance is particularly an issue in the context of resident duty hours as certain special- ties advocate for retention of the 30-hour extended duty period for at least a portion of their trainees. The committee has taken this into account in recommending adjustments to duty hours in Chapter 7. Like fully trained
IMPROVING THE RESIDENT LEARNING ENVIRONMENT 141 physicians in practice, residents clearly cannot be on duty 24/7; handovers to competent colleagues at appropriate intervals are essential. Indeed, en- suring effective handover of patient care responsibility is another critical skill that residents must acquire and is addressed in Chapter 8. The committee concludes that societal concern about the adverse ef- fects of resident fatigue during extended duty periods can be addressed by providing protected time for sleep and preserving the long-term societal benefits that stem from residents having ample continuity of care experi- ences during their training. IMPACT OF 2003 LIMITS ON EDUCATIONAL OUtcomes This section addresses how the 2003 ACGME duty hour limits have affected the quality of the resident learning experience as determined by resident and faculty perceptions of education being provided, measured exposure to procedural cases, time available for didactic sessions and study, and test performance. Limitations of many studies from which the evidence is drawn make a wider generalization of conclusions difficult. Nonethe- less, this body of research calls attention to how resident education may be affected by changes caused by duty hour limits. Overall, studies tend to suggest that individual programs were able to adjust to the new duty hour rules while still upholding educational standards. Note that programs struggling with maintaining standards are unlikely to be represented in the literature. Perceptions of Effects on Education Surveys of resident education represent perceptions of residents, fac- ulty members, and program directors regarding the impact of duty hour regulations on resident education. These surveys vary in their sample sizes, ranging from single institutions to multiple institutions in a particular specialty. In several surveys, residents did not report improved educational satisfaction as a result of duty hour changes, nor did they report significant decreases in the volume of key clinical experiences or in traineesâ percep- tions of âpreparednessâ (AAMC, 2008; Jagsi and Surender, 2004; Jagsi et al., 2006; Vidyarthi et al., 2006). These resident reports essentially convey the perception that duty hour regulations had little or no change in the quality of their education or their satisfaction with it. In one single insti- tution survey of plastic surgeons, however, residents reported increased satisfaction with their educational experience, stating that they were more alert, more satisfied with their time for didactics and study, and that they believed patient care had improved since implementing the new duty hours (Basu et al., 2004).
142 RESIDENT DUTY HOURS Surveys of faculty perceptions tend to yield more negative reports. The prevailing belief of faculty in these studies from a few institutions and across various specialties is that resident education has been compromised (Cohen-Gadol et al., 2005; Espey et al., 2007; Immerman et al., 2007; Lieberman et al., 2005; Vaughn et al., 2008; Winslow et al., 2004). In contrast, authors of one study note that residency programs were indeed able to maintain their standards by reinventing their approach to presenting educational content (de Virgilio et al., 2006). Effects on Procedure Volume and Case Mix The volume of procedures performed is one quantitative measure of resident training, particularly for surgical specialties, and is often used as a quality measure for physicians in practice. Most of the studies evaluated the numbers of procedures performed in single institutions and are largely specific to one or two medical specialties. Effects on Procedure Volume for Residents A systematic review of 54 studies examined the effects of the duty hour regulations on residents in internal medicine, pediatrics, OB/GYN, surgery, and family medicine, psychiatry, and radiology. Of these studies, only OB/GYN and surgery assessed procedure volume. Results showed that numbers of procedures remained relatively unchanged for residents in 3 of the OB/GYN studies. In the 25 surgical studies, however, the effect of duty hour regulations on volume was unclear: some found operative volume to increase, whereas others found that volume decreased (Fletcher et al., 2005). Research that employed surveys or other methods for resident self- report of case volume more often found that trainees perceived no change or a decline in operating time since the implementation of duty hour limits (Barden et al., 2002; Kort et al., 2004; Zuckerman et al., 2005). One study reported both actual case counts and perceptions; this pediatric surgery unit maintained the number of procedures performed 1 year before implement- ing duty hour changes and 1 year after (47 and 44 procedures, respectively), with matching perceptions among residents of steady caseload and main- tenance of patient management skills (Spencer and Teitelbaum, 2005). A majority of the studies examined that relied on available surgical case logs and databases also showed no significant change in resident case volume or time in the operating room, maintaining numbers and hours from previ- ous years (Durkin et al., 2008; Ferguson et al., 2005; Shin et al., 2008). One such study, however, showed a significant increase in total procedural volume for graduating residents (de Virgilio et al., 2006). Regarding the surgical exposure of senior residents, one study found an increase in case volume specifically for PGY-5 residents (a 51-case in-
IMPROVING THE RESIDENT LEARNING ENVIRONMENT 143 crease post duty hour implementation: 339 vs. 390, p = .05) while volume remained stable for more junior residents (Ferguson et al., 2005). Another survey specific to chief residents also reported an increase in the total number of yearly operations they participated in, despite the finding of no volume change for more junior residents (Barden et al., 2002). Other studies examining the surgical volume for senior residents affirm no sig- nificant change in the number of cases performed as a result of duty hour regulations (Malangoni et al., 2005; Mendoza and Britt, 2005; Spencer and Teitelbaum, 2005). The authors in one of the studies concluded that no relationship existed between duty hours and procedure volume (Mendoza and Britt, 2005). Effects on Case Mix for Residents Case mix exposure has also been a concern of specialty boards (ABMS, 2008a). The more often routine cases are performed, the less opportunity residents have of expanding their educational base to learn new procedures or treatment steps. The teaching value of operative cases lies in the com- plexity or uniqueness of cases in addition to case volume. Impact of duty hour limits on case mix varies across assessments. In a national survey of neurosurgical training programs, 41 percent of residents and 74 percent of program directors believed that chief residents operated on less complex cases post-implementation (Cohen-Gadol et al., 2005). Regarding the case mix of surgical procedures assessed in the studies above, senior residents in one report were found to perform more endoscopic and vascular access procedures than before (Spencer and Teitelbaum, 2005), while senior residents in the other study reported that the types of cases they performed remained essentially the same (Malangoni et al., 2005). Along with volume and complexity of operative cases, important lessons are also learned from postoperative patient care by following treatment outcomes and learning how to treat potential complications. Less periop- erative exposure for residents in general has been observed, although this has not been well quantified. Overall, the focus of the literature has been more on procedural vol- ume and less on appropriate case mix, perioperative time and nonoperative didactic opportunities, quality of instruction, or success of competencies attained, which several educators have claimed may have equal or greater impact on a residentâs learning capacity. Effects on Time for Didactic Sessions and Study The research addressing the impact of duty hour regulation on didactic education suggests that resident attendance at formal didactic sessions is down, either because they are not available when sessions are offered or
144 RESIDENT DUTY HOURS because workload precludes their attendance (Arora and Meltzer, 2008; Reed et al., 2007). Responses by chief residents to a survey conducted by Horwitz and colleagues (2006) indicated that despite no change in the num- ber of hours scheduled for educational activities there appeared to be âa decrease in intern attendance at conferences, and many reduced third-year elective time.â Some reports have found that time for independent study, reading, and case preparation has increased (Basu et al., 2004; Vaughn et al., 2008; Zuckerman et al., 2005), perhaps replacing time lost for confer- ence attendance (Lin et al., 2006). Although residents may compensate during separate time now available for independent reading and study, this is not universally observed. Licensing Exam, Board Certification, and In-Training Exam Results Residency training can take 3 to 7 years to complete depending on the degree of specialization or subspecialization pursued. The first cohort of 3-year residents trained entirely under 2003 ACGME limits finished in June 2006 so it is not surprising that educational outcomes data are just beginning to emerge. Examination pass rates provide a readily available objective mea- sure of such outcomes, and data from these measures are presented below. The U.S. Medical Licensing Exam Step 3, generally taken at the end of the first year of residency, assesses whether a medical doctor has suffi- cient knowledge and clinical decision-making skills to deliver medical care independently. Scores on this test have remained at fairly consistent levels for U.S. graduates of allopathic medical schools before and after the 2003 ACGME duty hour rules. First-time takers between 1999 and 2003 had a 94-95 percent pass rate, whereas 96 percent of first-time takers from these schools passed in 2004-2006 (n = 16,395 in 2006) (USMLE, 2008). After completing accredited residencies and fellowships, graduate medi- cal trainees take additional exams if they choose to become board certified (ABMS, 2008b). Data on board certification rates are not publicly available for each specialty. Only non-surgical specialties have had a resident cohort complete all of its training since the 2003 work limits were put in place. First-time taker pass rates for the American Board of Internal Medicine certifying exam were 92 percent for 2003, 92 percent for 2004, 92 percent for 2005, 91 percent for 2006, and 94 percent for 2007 (ABIM, 2008). Previous yearsâ scores were 86 percent for 2000, 88 percent for 2001, and 87 percent for 2002. Changes in board pass rates are susceptible to vari- ous factors, such as the number of U.S. medical school graduates entering a specific specialty, making it difficult to conclude whether resident duty hour â Personal communication, L. J. Grosso, Director of Psychometric Operations, American Board of Internal Medicine, April 29, 2008.
IMPROVING THE RESIDENT LEARNING ENVIRONMENT 145 adjustments had a direct impact. Testimony to the committee reported that there are declines in pediatric board pass rates and thoracic and orthopedic surgery, but there have been no detailed analyses of the factors that might have contributed to these declines (ABMS, 2008a). A few institution-specific studies of surgical programs (e.g., trauma surgeons) report on their success in maintaining procedural volume and their scores on the American Board of Surgery In-Training Examination (ABSITE). To assess resident ABSITE scores before and after the imple- mentation of duty hours, researchers surveyed general surgical residents in a New York program and found that scores increased on average for all 29 respondents to the survey. This increase was statistically significant for junior but not senior residents (Barden et al., 2002). In response to duty hour regulations, a trauma care program of 46 residents employed different schedules, made curriculum changes, and increased the number of residents in the program. Anticipating that residents would not do more reading on their own time, the program also added new meetings, tests, weekly assignments, and mock oral exams geared toward helping residents achieve high ABSITE scores. While ABSITE scores and pass rates did not change significantly between the two time periods, substantial financial and faculty resources were required to support these program changes (de Virgilio, 2008; de Virgilio et al., 2006). One study that reviewed resident ABSITE scores and operative logs before and after duty hour limits showed no change in case volume and a significant increase in overall ABSITE per- formance largely due to improved scores on its basic science component (Durkin et al., 2008). The American Board of Medical Specialties (ABMS) anticipates training repercussions under the current 80-hour limit for certain types of training programs (e.g., emergency, trauma) because of less exposure to patients with unusual complexity of illnesses, long surgical cases, or management of postoperative complications. The ABMS notes that further reduction of to- tal weekly duty hours may result in the need to lengthen the training period of various specialties (ABMS, 2008a). However, with the recommendations of this report, the committee has attempted to avoid having to extend train- ing duration for medical and surgical residents by maintaining the 80-hour limit to provide flexibility for programs that need those hours. Redesign of curriculums, schedules, medical teams, caseload, and staffing are all factors to consider when attempting to reorganize training programs in a manner that will meet residentsâ educational needs within duty hour limits. Redesigning Education and Educational Innovations Educators in the medical field have acknowledged that changes in duty hour rules provide an opportune time to redefine educational practices and
146 RESIDENT DUTY HOURS improve overall resident learning environments (Skeff et al., 2004; Wong et al., 2004). Indeed, regardless of changes in duty hours, educational redesign may be the only reasonable response to statements made by other leaders in the field suggesting that aspects of current training systems for residents fail to reflect the constant changes taking place in medical practice (Arora et al., 2005). Redesign presents an opportunity to take the 20th-century model of GME training and transform it into a 21st-century model suited to the increasingly demanding needs of patients and the healthcare system. The new era of GME can continue to make greater use of new educational technologies, which have driven so much of the change in practice over the past few decades, innovative approaches to curricula, and greater training in systems strategies. Several interventions have been mentioned already (e.g., adjusting schedules and workload, reformatting curricula, increasing practice tests, reorganizing staff). This section illustrates other interven- tions that could be employed in response to duty hours and changing prac- tice. ACGME itself has encouraged innovative new practices that would serve this purpose, supporting them through its Committee on Innovation ( Â ACGME, 2008a). Educational Redesign Interventions The following educational redesign interventions demonstrate inno- vation in targeting the content of what residents learn and incorporating techniques that enhance learning (e.g., contextual learning, supervisory feedback) discussed earlier in this chapter. Using techniques to help resi- dents learn more efficiently became increasingly important when programs adapted to the 2003 duty hour limits and had less time in which to teach residents. Competency-Based Design As a way to maintain educational outcomes given the reduced hour limits, some residency programs are focusing on a competency-based ap- proach to their medical training. Competency-based teaching is a concept that proposes to replace the current time-based educational model of resi- dency, which requires residents to complete their learning in a fixed number of years, with a model in which the completion of training is determined by the demonstration of required competencies. In this way, residents can progress and acquire knowledge and skills in a manner that is more attuned to their individual abilities at any given time. To help enhance the effective- ness of this approach, educators should be encouraged to utilize better tools for measuring skill acquisition (Satish and Streufert, 2002; Satish et al., 2001) and advance trainees according to their individual progress.
IMPROVING THE RESIDENT LEARNING ENVIRONMENT 147 A competency-based training curriculum was implemented in one in- stitutionâs neurosurgical department. Evaluation of its effectiveness yielded promising results. Not only did the residents succeed in mastering the pre- scribed neurosurgical skills, but the time taken to master the procedures was reduced by several months compared to traditional time requirements (Long, 2000). Similar results were achieved using competency-based teach- ing interventions for invasive skills to a small number of general surgery interns. The authors of this study acknowledged that residents in their pro- gram often lacked basic invasive skills until asked to perform on patients. To better prepare them to perform such procedures the interns were taken to the cadaver laboratory where faculty instructed them directly, provid- ing hands-on direction and feedback, as they conducted endotracheal tube insertions, chest tube insertions, and venous cutdowns. The goal was for interns to correctly perform these procedures within 120 seconds. Prior to instruction, seven of the eight interns failed the tasks of endotracheal tube insertion and venous cutdown, and five out of eight failed the chest tube insertion (Martin et al., 1998). After instruction, there were no failures, no complications, and the time taken to complete each task was significantly reduced. These skills were transferable to the clinical setting where these interns performed these procedures multiple times with minimal complica- tions (Martin et al., 1998). Different simulated settings have been shown to improve resident practice in other specialties as well, such as anesthesiology and radiology (Sica et al., 1999; Wong, 2004). Long (2000) acknowledged that such training may be easier to deter- mine in procedural fields, since outcomes can be more clearly defined, but widely used skills such as accurate history taking, physical examination, interpreting diagnostic data, and sound patient management were also included. Shifting attention to milestones of learning, rather than time in place, can promote the integration of proper learning experiences. Further- more, reduction in actual time taken to acquire competencies is particularly beneficial in light of reduced duty hours, indicating that more time for train- ing may not be necessary for residents to learn their needed clinical skills. Further evaluations in other specialties would be helpful in assessing the extent to which such training is practical or beneficial across different resi- dency programs and specialties, recognizing that competency-based training âis just one of many potentially useful approaches that may have a role at various stages of the educational processâ (Leung, 2002). Simulation-Based Training to Support Educational Designs Simulation, both high and low tech, has been increasingly studied to train residents more efficiently and has been gaining acceptance as a method through which to teach and measure competency-based education. With
148 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; Ãstergaard, 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 âpracticed, assessed, diagnosed, remedied, and reinforcedâ 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 âlong-block,â was created (beginning in a residentâs 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
IMPROVING THE RESIDENT LEARNING ENVIRONMENT 149 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 ACGMEâs new six core competenciesâpractice-based learning and improvementâwhich addresses âthe need to teach and evaluate residentsâ ability to apply quality improvement in their medical practice.â 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 Medicineâs 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
150 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 educationâbefitting the evolving medical landscape of the 21st centuryâis necessary. The committeeâs 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 2006. http://www.aamc.org/research/postdoc compact/postdoccompact.pdf (accessed August 12, 2008). âââ. 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 2005- 2007. 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. âââ. 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 1, 2007. http://www.acgme.org/acWebsite/ irc/IRCheckList-07.pdf (accessed 2/28/2008). âââ. 2008a. CIâCommittee on Innovation. http://www.acgme.org/acWebsite/ci/ci_welcome. asp (accessed October 22, 2008). âââ. 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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