ABSTRACT

Background

Despite 25 years of implementation and a sizable amount of research, the impact of resident duty hour restrictions on patients and residents still is unclear. Advocates interpret the research as necessitating immediate change; opponents draw competing conclusions.

Objective

This study updates a systematic review of the literature on duty hour restrictions conducted 1 year prior to the implementation of the Accreditation Council for Graduate Medical Education's 2011 regulations.

Methods

The review draws on reports catalogued in MEDLINE and PreMEDLINE from 2010 to 2013. Interventions that dealt with the duty hour restrictions included night float, shortened shifts, and protected time for sleep. Outcomes were patient care, resident well-being, and resident education. Studies were excluded if they were not conducted in patient care settings.

Results

Twenty-seven studies met the inclusion criteria. Most frequently, the studies concluded that the restrictions had no impact on patient care (50%) or resident wellness (47%), and had a negative impact on resident education (64%). Night float was the most frequent means of implementing duty hour restrictions, yet it yielded the highest proportion of unfavorable findings.

Conclusions

This updated review, including 27 recent applicable studies, demonstrates that focusing on duty hours alone has not resulted in improvements in patient care or resident well-being. The added duty hour restrictions implemented in 2011 appear to have had an unintended negative impact on resident education. New approaches to the issue of physician fatigue and its relationship to patient care and resident education are needed.

ABSTRACT

Background

Trainees are responsible for conducting advance care discussions but are often stressed by this role.

Objective

We developed an instrument to determine whether residents could identify a clinical scenario that necessitated an examination of a patient's goals and preferences as they pertain to clinical care, and subsequently measured their readiness to engage in such discussions.

Methods

Participants responded verbally to open-ended case presentations and completed survey items. We scored responses according to proximity to idealized answers.

Results

The sample consisted of 44 internal medicine residents, 12 students, 5 hospitalists, and 3 palliative care attendings, all of whom volunteered for the study and participated in standard interviews. Residents had widely varying scores (range 0–12, maximum score of 15) on the scored open response items. For eliciting values, mean score increased with training, and students, trainees, and attending physicians had mean scores of 3.7, 5.7, and 8.7, respectively (P = .01). For recommending care, mean scores were 3.0, 6.5, and 9.3, respectively (P < .001). Scores were correlated closely with increasing clinical experience and inversely with self-reported stress when conducting a goals-of-care discussion. The Kuder-Richardson Formula 20 reliability for the instrument was 0.52. Interrater reliability for sections about eliciting and recommending care were 0.64 (P < .001) and 0.50 (P < .001), respectively. The 1-week test-retest reliability was 0.91 for open response items and 0.76 for Likert responses.

Conclusions

A verbally administered instrument can readily and rapidly characterize a trainee's readiness to participate in advance care planning with patients.

ABSTRACT

Background

In 2003, the Accreditation Council for Graduate Medical Education limited resident duty hours to 80 hours per week. More than a decade later, the effect of the limits on resident clinical competence is not fully understood.

Objective

We sought to assess the effect of duty hour restrictions on resident performance of an uncomplicated cesarean delivery.

Methods

We reviewed unlabored primary cesarean deliveries at Duke University Hospital after 34 weeks gestation, between 2003 and 2011. Descriptive statistics and linear regression were used to compare total operative time with incision to delivery time as a function of years since institution of the 80-hour workweek. Resident training level, subject body mass index, estimated blood loss, and skin closure method were controlled for in the regression model.

Results

We identified 444 deliveries that met study criteria. The mean (SD) total operative time in 2003–2004 was 43.3 (14.3) minutes and 59.6 (10.7) minutes in 2010–2011 (P < .001). Multivariable regression demonstrated an increase in total operative time of 1.9 min/y (P < .001) but no change in incision to delivery time (P = .05). The magnitude of increased operative time was seen among junior residents (2.0 min/y, P < .001) compared to that of senior residents (1.2 min/y, P = .06).

Conclusions

Since introduction of the 2003 duty hour limits, there has been an increase of nearly 20 minutes in the time required for a routine cesarean delivery. It is unclear if the findings are due to a change in residency duty hours or to another aspect of residency training.

The Challenge

A journal club provides an opportunity to critically appraise the medical literature and apply it to clinical practice. Traditional, in-person journal clubs face challenges of scheduling participants and facilitators, recruiting local experts, and having a limited, local impact.

Residency programs sometimes struggle with documenting interactions between faculty and trainees, including educational interventions. One approach we find useful is to ask residents to summarize a conversation with a member of the faculty via a confidential e-mail. Faculty may then reply, reinforcing or expanding concepts, or clarifying misinterpretations.

Sometimes this approach is used after discussing theoretical concepts or clinical issues related to the specialty. On other occasions, it is used to address core competencies, such as those related to attitude, professionalism, and interpersonal skills.

The advantages of this strategy include prompting the learner to reflect and distill the key points