Resident Duty Hours Enhancing Sleep, Supervision, and Safety (2009) / Chapter Skim
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4 Improving the Resident Learning Environment
4 Improving the Resident Learning Environment
Pages 125-158
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From page 125... ...
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 education.
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From page 126... ...
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.
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From page 127... ...
. Graded Responsibility for Patient Care Under Supervision An intrinsic challenge of graduate medical education (GME)
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From page 128... ...
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 recommended 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)
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From page 129... ...
After the 1984 Libby Zion case brought attention to the issue of resident 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)
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From page 130... ...
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.
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From page 131... ...
Examples include reports of how reduced resident duty hours have shifted the workload to attendings and more senior residents, 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)
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From page 132... ...
. Almost 75 percent of key clinical faculty believed the duty hour regulations limited opportunities for both didactic and bedside teaching.
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From page 133... ...
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.
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From page 134... ...
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 training, 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.
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From page 135... ...
; and consistently helping residents identify areas to improve patient safety and their own patient care. Communication should not be left solely to the discretion of residents to contact their supervisors to address concerns or clarify questions they may have.
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From page 136... ...
. The regulations implemented in 2003 limiting resident duty hours have had the unintended consequence of worsening the situation in many programs (Hutter et al., 2006; Vidyarthi et al., 2006)
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From page 137... ...
Cognitive Load Theory To fully understand how workload affects resident learning and performance, 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.
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, and the importance of the role a supervisor plays in this cannot be overstated. Therefore, the design of the learning environment itself -- largely dictated by the structure of a hospital's system -- affects how residents learn.
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From page 139... ...
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)
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From page 140... ...
In underscoring the importance of continuity of care in resident education, 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 specialties advocate for retention of the 30-hour extended duty period for at least a portion of their trainees.
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From page 141... ...
In one single institution 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)
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From page 142... ...
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.
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From page 143... ...
. The authors in one of the studies concluded that no relationship existed between duty hours and procedure volume (Mendoza and Britt, 2005)
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medical school graduates entering a specific specialty, making it difficult to conclude whether resident duty hour Personal communication, L
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. To assess resident ABSITE scores before and after the implementation 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.
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From page 146... ...
. 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)
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From page 147... ...
Shifting attention to milestones of learning, rather than time in place, can promote the integration of proper learning experiences. Furthermore, reduction in actual time taken to acquire competencies is particularly beneficial in light of reduced duty hours, indicating that more time for training may not be necessary for residents to learn their needed clinical skills.
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From page 148... ...
. 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.
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From page 149... ...
It will be important 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.
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From page 150... ...
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 effects 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 encouraging approaches to curricula and training that improve overall learning environments.
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From page 151... ...
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.
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Presentation to the Commit tee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety, May 8, 2008, Irvine, CA.
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1993. Supervision in the outpatient clinic: Effects on teach ing and patient care.
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2006. The educational impact of ACGME limits on resident and fellow duty hours: A pre-post survey study.
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2005. Unintended consequences: The Accreditation Council for Graduate Medical Education work-hour rules in practice.
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2006. Graduate medical education and patient safety: A busy -- and occasionally hazardous -- intersection.
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2006. Impact of reduced duty hours on residents' educational satisfaction at the University of California, San Francisco.
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