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Search results for "Residents and Fellows"

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Cases & Commentaries

Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees

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Olle ten Cate, PhD; November 2018

An ICU patient with head and spine trauma was sent for an MRI. Due his critical condition, hospital policy required a physician and nurse to accompany the patient to the MRI scanner. The ICU attending assigned a new intern, who felt unprepared to handle any crises that might arise, to transport the patient along with the nurse. While in a holding area awaiting the MRI, the patient's heart rate fell below 20 beats per minute, and the experienced ICU nurse administered atropine to recover his heart rate and blood pressure. The intern worried he had placed the patient's life at risk because of his inexperience, but he also felt uncomfortable speaking up.

Journal Article > Study

Pediatric anesthesiology fellows' perception of quality of attending supervision and medical errors.

Benzon HA, Hajduk J, De Oliveira G Jr, et al. Anesth Analg. 2018;126:639-643.

This survey study of pediatric anesthesiology fellows found a high rate of self-reported medication errors overall. The rate of reported errors did not differ among respondents with varying levels of supervision. The authors highlight the need to investigate and reduce the high rates of reported perioperative medication errors.

Journal Article > Study

Clinical reasoning education at US medical schools: results from a national survey of internal medicine clerkship directors.

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Rencic J, Trowbridge RL Jr, Fagan M, Szauter K, Durning S. J Gen Intern Med. 2017;32:1242-1246.

In recent years, diagnostic error has gained widespread attention as a major patient safety issue. Addressing cognitive biases as part of medical education may help reduce diagnostic error. Researchers sought to characterize clinical reasoning educational programs at United States medical schools and to understand the attitudes of internal medicine clerkship directors around the instruction of clinical reasoning. Survey responses were received from 91 out of 123 members of the Clerkship Directors in Internal Medicine. Respondents generally felt that clinical reasoning should be formally taught throughout medical education and that more time should be set aside for doing so. More than 50% of the respondents indicated that their institution did not have dedicated time for teaching clinical reasoning. Both limited curricular time and lack of faculty capable of teaching in this area were cited as barriers. The authors suggest that additional resources should be dedicated to teaching clinical reasoning in medical education. A PSNet perspective provides an update on diagnostic error.

Journal Article > Review

Understanding the multidimensional effects of resident duty hours restrictions: a thematic analysis of published viewpoints in surgery.

Devitt KS, Kim MJ, Gotlib Conn L, et al. Acad Med. 2018;93:324-333.

Duty hour limitations have been controversial due to inconclusive evidence regarding their impact on care outcomes. This review examined the effect of work hour restrictions on surgical residents. The authors found that duty hour restrictions have fallen short of their goals, discuss unintended consequences of the strategy that diminish safety, and call for amended policy solutions to address concerns.

Journal Article

Three perspectives on changes in resident work environment and duty hours.

Bilimoria KY, Meyers MO, Mouawad NJ, et al. JAMA Surg. 2017;152:903-908.

In July 2017, the ACGME modified resident physician duty hour policies, lifting several of the restrictions initially implemented in 2011. This series of editorials presents perspectives of surgical residents, researchers, and surgical residency program directors on the recent changes.

Journal Article > Commentary

Root cause analysis and actions for the prevention of medical errors: quality improvement and resident education.

Charles R, Hood B, DeRosier JM, et al. Orthopedics. 2017;40:e628-e635.

This commentary highlights the importance of engaging residents in root cause analysis of errors and near misses. The authors discuss how participation in root cause analysis can educate trainees about process analysis and augment skill development.

Journal Article > Study

Comparison of appendectomy outcomes between senior general surgeons and general surgery residents.

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Siam B, Al-Kurd A, Simanovsky N, et al. JAMA Surg. 2017;152:679-685.

Balancing supervision and autonomy for trainee physicians is a contested area in patient safety. This analysis of medical record data at a single institution compared complication rates following acute appendectomy between surgical resident physicians and attending surgeons. As measured by a composite score, the complication rate did not differ between trainees and attending surgeons. There was no difference in the rate of follow-up imaging, length of stay, or duration of antibiotics following surgery. On average, trainees took about 9 minutes longer to complete the surgery. The authors conclude that trainees do not require attending supervision to safely perform appendectomies. A related editorial calls for greater surgical resident autonomy and notes the importance of real-life experience with procedures to prepare residents for independent practice. A past PSNet perspective explored this tension between supervision and autonomy in medical education.

Journal Article > Study

Performance of vascular exposure and fasciotomy among surgical residents before and after training compared with experts.

Mackenzie CF, Garofalo E, Puche A, et al.; Retention and Assessment of Surgical Performance (RASP) Group of Investigators. JAMA Surg. 2017;152:1-8.

Surgeons' technical skills are associated with surgical patient outcomes. This evaluation of an educational simulation intervention found that training procedural skills measurably but variably improved surgical performance. Increased experience with procedures following the training led to residents retaining these skills for up to 18 months. These results demonstrate the critical role of procedure volume in building surgical skill and safety. A related editorial focuses on the subset of learners who did not meet technical proficiency, among whom patient safety problems could occur.

Journal Article > Commentary

Making residents part of the safety culture: improving error reporting and reducing harms.

Fox MD, Bump GM, Butler GA, Chen LW, Buchert AR. J Patient Saf. 2017 Jan 30; [Epub ahead of print].

Medical residents are increasingly exposed to patient safety concepts during their training. This commentary describes the implementation of a longitudinal curriculum to augment resident physicians' error reporting at a pediatric hospital. The project team found the program to be effective in improving the rates of reporting by both residents and other clinicians at the organization.

Journal Article > Study

Increasing trainee reporting of adverse events with monthly, trainee-directed review of adverse events.

Smith A, Hatoun J, Moses J. Acad Pediatr. 2017;17:902-906.

This pre–post study aimed to increase error reporting by pediatric resident physicians and medical students. Residents and medical students reported more errors after implementation of a monthly educational conference in which event reports were reviewed. The authors conclude that trainee-led adverse event review conferences can increase event reporting.

Journal Article > Study

Association between end-of-rotation resident transition in care and mortality among hospitalized patients.

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Denson JL, Jensen A, Saag HS, et al. JAMA. 2016;316:2204-2213.

Handoffs are ubiquitous in hospital care and a recognized risk factor for adverse events. Most research on handoffs has focused on care transitions from the primary clinician to a covering clinician, but studies have also demonstrated the potential for harm associated with changes in the entire team of care (such as at the end of the academic year). In academic hospitals, clinician teams switch on a predictable schedule, often at the end of the month, when residents complete a rotation. This study analyzed the outcomes of more than 200,000 inpatients at Veterans Affairs hospitals to determine if end-of-rotation team changes were associated with clinical harm. Investigators found a striking increase in in-hospital mortality among patients whose hospitalization spanned the end of a rotation (and thus were exposed to a resident team change during their hospital stay), which persisted for up to 90 days after discharge. The accompanying editorial notes that some of the mortality increase may be accounted for by the fact that patients who are more seriously ill and have longer hospitalizations may have been at higher risk of death independent of the team change. Nevertheless, since there are no standards for patient handoffs at the end of a rotation, poor information transfer or cognitive heuristics (such as anchoring bias) may have led to preventable adverse events. The editorial authors advocate for more research into the mechanisms of this mortality increase and the development of standards analogous to the I-PASS signout format for end-of-rotation handoffs.

Journal Article > Commentary

Education for the next frontier in patient safety: a longitudinal resident curriculum on diagnostic error.

Ruedinger E, Olson M, Yee J, Borman-Shoap E, Olson APJ. Am J Med Qual. 2017;32:625-631.

Diagnostic error has yet to be formally integrated into graduate medical education. This commentary describes the design, implementation, and evaluation of a resident curriculum on diagnostic errors that explored medical decision making, critical thinking skills, and how to provide feedback and support for second victims.

Journal Article > Study

Integrating patient safety in the OMFS curriculum: survey of 4-year residency programs.

Buhrow SM, Buhrow JA. J Patient Saf. 2016;12:197-203.

Spurred in part by requirements put forth by the ACGME, graduate medical education programs have become increasingly focused on engaging residents in patient safety and quality improvement efforts. This study found that formal training in patient safety has been integrated into the curriculum of many 4-year oral and maxillofacial surgery residency programs, suggesting that patient safety is an increasingly important focus within dental education as well.

Journal Article

Latest Results From the "FIRST" Trial.

J Am Coll Surg. 2017;224:103-159.

The Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial examined residency program response to duty hour rules. This special issue features studies exploring effects of the initial trial including perceptions on the impact of a flexible 80-hour workweek on continuity of care and on physician well-being.

Legislation/Regulation

Summary of Proposed Changes to ACGME Common Program Requirements Section VI.

Accreditation Council for Graduate Medical Education.

Implementation of resident duty hours, meant to address fatigue in health care, has long been a subject of patient safety discussions. This website provides a summary of proposed changes to the current ACGME residency Common Program Requirements that shape working hours, offers rationale for the revisions.

Book/Report

National Report of Findings 2016: Issue Brief No. 2: Patient Safety.

Clinical Learning Environment Review. Chicago, IL: Accreditation Council for Graduate Medical Education; 2016.

Integrating patient safety concepts into graduate medical education addresses an unmet need. This report draws from the results of a multidimensional review of learner perspectives to gain insights regarding how their education has prepared them for safe practice. The analysis highlights the current status of patient safety in resident and fellow education, reporting and incident review, and monitoring outcomes of safety interventions in the experiential learning environment.

Journal Article > Commentary

Ethical considerations in the development of the Flexibility in Duty Hour Requirements for Surgical Trainees trial.

Minami CA, Odell DD, Bilimoria KY. JAMA Surg. 2017;152:7-8.

Patient safety research has generated some concern regarding ethical implications involved in implementing changes that affect patient care. This commentary discusses ethical challenges related to a large trial that explored the effects of duty hour flexibility. The authors discuss policy changes, institutional review board roles, and informed consent as tactics to address concerns.

Book/Report

Bipartisan Consensus: The Public Wants Well-Rested Medical Residents to Help Ensure Safe Patient Care.

Almashat S, Carome M, Wolfe S, Landrigan CP, Czeisler C. Washington, DC: Public Citizen; September 13, 2016.

Duty-hour limitations have been implemented as a strategy to address resident fatigue, but they remain controversial. This report summarizes the results of a national poll that sought to assess public opinion regarding removing 16-hour shift restrictions and transparency around clinician work time.

Journal Article > Commentary

Advancing interprofessional patient safety education for medical, nursing, and pharmacy learners during clinical rotations.

Thom KA, Heil EL, Croft LD, Duffy A, Morgan DJ, Johantgen M. J Interprof Care. 2016;30:819-822.

Interprofessional education can augment student development and teamwork. This commentary describes how one institution designed and implemented a multidisciplinary course to educate learners about core concepts in patient safety and interprofessional practice. The program includes modules on key areas such as failure analysis, teamwork, and error reporting.

Newspaper/Magazine Article

A better safety net for young doctors.

Landro L. Wall Street Journal. August. 8, 2016.

First-year residents may be reluctant to ask for assistance due to factors such as peer pressure to demonstrate competency. This newspaper article reports on one hospital's strategy to enhance communication among residents and attendings, which encourages residents to ask questions of senior clinicians who are coached to welcome learning conversations.

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