In this simulation study, most anesthesiology residents acceded to an attending physician's order to transfuse blood to a patient who had explicitly refused transfusions for religious reasons. Subsequent interviews with the residents revealed that strict hierarchies persist within medical training, despite evidence that hierarchies impair communication and negatively affect safety. This study is reminiscent of one of the earliest studies of the impact of hierarchies on patient safety.

The Accreditation Council for Graduate Medical Education (ACGME) has progressively restricted resident physicians' duty hours since 2003, with the goal of improving patient safety and resident quality of life. Despite evidence that the 2003 regulations had no significant impact on patient outcomes and may have adversely affected resident education, further regulations implemented in 2011 placed new restrictions on the duty hours of first-year trainees. This randomized controlled trial, in which two 2011-compliant internal medicine resident schedules were compared with the existing schedule (which was compliant with the 2003 regulations), represents one of the first assessments of the new regulations. The investigators found that although residents slept more under the new schedules, the number of handoffs increased dramatically, residents' attendance at teaching conferences decreased, and both residents and nurses perceived that the quality of patient care worsened. An accompanying editorial calls for the ACGME to eliminate shift length restrictions and instead focus on reducing overall resident workload.

… nurses and attending physicians. … Sydor DT, Bould MD, Naik VN, et al. Br J Anaesth. 2013;110:463-471.  …

The use of simulation is increasing in medical training, in part due to its success in other industries such as aviation. Although studies of simulation training have found positive effects on team communication and adherence to recommended processes, the effect of simulation on subsequent patient outcomes remains unclear. This study represents a significant advance in the simulation literature, as it found that anesthesia residents who underwent high-fidelity simulation training performed better at weaning patients from cardiopulmonary bypass than residents who underwent standard classroom-based training. Studies such as this, demonstrating that simulation training improves real-life clinical performance, strengthen the case for integrating simulation into medical education in an era of restricted duty hours.

This commentary explores potential communication breakdowns that contribute to diagnostic errors and discusses information technology strategies to prevent them.