duty hours debate: does promoting patient safety necessarily mean further reductions in duty hours?

In December of 2008, the Institute of Medicine published a report titled: Resident Duty Hours: Enhancing Sleep, Supervision and Safety. I have to admit that I have only read the Report Brief and the table of recommendations found on their website, however, it appears clear that the report suggests modification of current ACGME rules for shift length (although not theoretically reducing the overall 80 hours), and tightening of monitoring processes by the ACGME are needed.

The report was published almost a year ago, why bring it up now? One of the Staff here at the Cleveland Clinic brought the open letter from Dr. Thomas Nasca (CEO for ACGME) to my attention yesterday. I was so impressed by Dr. Nasca's thoughtful response to the report that I decided to scrap the topic planned for November and bring your attention to this document. After reading Dr. Nasca's letter, I wondered what our community was thinking about the IOM report and the ACGME response.

It would be hard to imagine that any physician group would argue against patient safety. The primacy of keeping patients' safe is one of the foundational principles of the social contract that physicians have with the public. After reading Dr. Nasca's letter, I can see that there are many contributing factors to a safe clinical environment. Sometimes these 'competing goods' are in conflict. A well rested resident is a good thing. Fewer staff hand-offs during care is also a good thing. If you haven't read Dr Nasca's letter and you teach residents, I suggest you take the time. I hope you also take the time to share your opinions on this vitally important issue.

http://acgme.org/acWebsite/home/NascaLetterCommunity10_27_09.pdf

SEPTEMBER/OCTOBER SUMMARY

Strong opinions were voiced by our respondents to the question: Are Academic RVU's the Answer to Making Time for Teaching? It appeared that either the respondent was strongly in favor or strongly opposed. Those in favor thought that, although not perfect, academic RVU systems provide a way to "account for and recognize" academic efforts. A few of those opposed, seemed "opposed in principle", not really articulating a rationale. However, a small number cited the problem of reducing a highly complex activity (teaching, advising, mentoring) into an artificial formula. In fact, one reader stated that "going down this "slippery slope" could be likened to "pandering to the bean counters". Whether or not Academic RVU's surface again as an option, we know that there will be strong opinions on both sides.

ARE ACADEMIC RVUs THE ANSWER TO MAKING TIME FOR TEACHING?

The problem of finding time for teaching and having that time “honored” as valuable to the institution has been an ongoing concern for academic medical departments; but perhaps never more than now. Some departments have begun exploring adapting the familiar clinical metric, RVU’s or relative value units as a way to place comparable value on time taken by physicians in their roles as teachers and researchers.

In a 2007 article in J Am Coll Radiol (see link below) the authors state: "Despite the importance of teaching, research, and related activities to the mission of academic medical departments, no useful and widely agreed-on metrics exist with which to assess the value of individual faculty members’ contributions in these areas.

They go on to describe the use of RVUs as a common metric. In their model, all academic activity is quantified and weighted based on "estimates of effort, impact, and value to the department" (Mezrich,R & Nagy, PG. 2007). In the category of teaching, for example, classroom teaching and student feedback are factored into the equation, while clinical teaching is factored into clinical productivity. It is an article well worth reading if you are considering an RVU-based system. Their experience details the complexity of the process and the importance of linking departmental goals to the weighting system

In theory it sounds good, but how do you truly account for time spent preparing new interactive seminars, case-based teaching sessions, facilitating PBL or the development of innovations like online teaching modules. How do you account for time for providing feedback, writing evaluations and mentoring students and residents? Can we deconstruct teaching into RVUs… Should we? What do you think?

For ohiolink users

For citation and abstract

AUGUST 2009 SUMMARY

The concept of introducing or expanding online learning in medical education stimulated a good discussion. Some of our readers described their experience with online learning as boring, painful, and passive, while others described their experiences as interactive, satisfying and effective. How do you account for the disparity of experience and opinion? One reader suggested that the question was phrased too simply. Like most questions in medicine and medical education, the answer usually begins with "it depends". Our readers thought that "it depended" on the purpose of the instruction, the learning style and motivation of the students, the skill of the teacher and the ability of the technology used to create interaction. One reader thought that the generation of the student cohort might also influence the effectiveness of the instruction. Neil, on September 2 (see comments) really did a nice job of addressing the complexity of the question He concluded, as did others, that a blend of online and face-to-face methods may be the best approach. For more information see link below:

http://www.ed.gov/rschstat/eval/tech/evidence-based-practices/finalreport.pdf

IS ONLINE LEARNING READY FOR PRIME TIME IN MEDICINE?

Everyone who uses a computer learns online. We learn when we Google a topic and sort and read the resulting hits. We gather new information and use it immediately (time of a movie) or reflect on it and weave it into our understanding of a new or familiar theme.

What about using online learning as the primary method for learning about medicine? Can our students, residents and fellows (as well as ourselves) effectively learn what we need to know through online classes? Numerous studies have clearly indicated that some people can learn very effectively online. Other studies indicate that the effectiveness of online learning is dependant on the subject matter, the skill of the teacher to create online learning environments, and the learning style and personal characteristics of the learner.

In response to reduced duty hours, the introduction or expansion of online or distance education classes seems to make good sense. Online CME offerings also become more attractive as travel restrictions due to the lingering recession limit CME choices.

Sometime in the next year someone is going to ask you about online learning. What do you think? Is it ready for PRIME TIME?

Should we forget about lectures and get the very best teachers to create online courses that our students and residents can access day or night?

Are there topics that can not be taught online?

Are there types of learners that you think will have problems with online learning?

If you have taken an online CME course, or taught an online course, what type of experience was it for you? If you have no experience but have an opinion, let us know. Let’s see what the collective wisdom is about integrating online learning into our medical schools and hospitals.

JUNE/JULY SUMMARY

REMEDIATION – WHAT WORKS

We only received 8 responses to this question, but those who responded had a lot to share. All of the responders recognized that solid remediation takes work; work in planning and work in follow-through. Planning without follow-through is just plain not worth the effort and can leave the resident feeling even more hopeless. A couple of our responders indicated that hardly anyone has the time to do this right. Another thread of the discussion looked at our ability to listen and diagnose problems correctly. As we all know a “prescription” based on a faulty diagnosis is unlikely to be effective. Read the attached article for some ideas on developing good remediation plans.

http://ovidsp.tx.ovid.com/spa/ovidweb.cgi?&S=DDDJFPDCGDDDNHOHMCFLCBOKGOAHAA00&Link+Set=S.sh.38%7c4%7csl_10

REMEDIATION - WHAT WORKS

Teaching is pretty easy when we have bright, motivated students and residents who share our values and “hang on our every word”. But that is not always the case.

I was facilitating a group of faculty at a conference this spring where the topic was “the problem student/resident.” One member of the group was describing the terrible time she was having with a certain resident and how she “had to come down hard on him” and how she didn’t see much hope of him improving his clinical performance as he had a “rotten attitude” and a “poor work ethic”. She was quick to let our group know that she never had any trouble with “good residents”.

As our group tried to help her explore her main issues, it struck me that I had heard that many times before – “I never have trouble with the good student or good resident”. Well the truth is, NOBODY DOES. Those students and residents would learn no matter what we did. They make us feel like good teachers and so we become better!

Our real challenge as teachers comes when the student or resident 1) is working at top mental capacity and just barely making it, 2) does not share our values or social mores, and/or 3) does not share our expectations for work productivity. At some point, we identify students or residents who need some “special action” on our part. That “special action” is often called remediation. Remediation can be a simple learning plan designed by the resident or student and monitored by a faculty member, or it can be a formal learning plan that is designed by the faculty, approved by a committee and monitored closely with specific consequences attached to not meeting benchmarks.

The issue for discussion for June/July is REMEDIATION ACTIVITIES. What has been your experience? What works? What doesn’t work? Are their specific types of student or resident issues that are more amenable to change through a specific type of remediation? Should we try, as a community, to formalize a series of “remediation steps” that all programs within an institution would follow depending on the severity of the problem? I’ve posed lots of questions,… Now let’s hear what you think.

MAY 2009 SUMMARY

We had an interesting discussion about "problem residents" and whether one can really know whether a resident is just getting a slow start, or will not realistically be able to become a competent physician. As you might have guessed, no one had a definative "formula" that we could follow. Two readers commented on the interview process and its limitations in exploring values and work ethic. Others commented that "substance use" should always be explored when faced with undesireable behavior. Three readers mentioned two characteristics that had been good predictors of success. The first predictor was a willingness by the resident to acknowledge the problem and the second was an ability to reflect on the feedback given and pose a plan. Finally, one readers posed a rule to follow - "always be working in the best interest of the resident".

CUT YOUR LOSSES or LATE BLOOMER???

New residency program directors have limited experiences and face multiple problems each day. One new PD has recently had a challenging time managing two residents, one a third year and one an intern. The third year had posed a professionalism problem from his first year along with some problems integrating into the system and organizational challenges. Things had not gotten too much better over the course his training and lots of time and energy had been invested in getting this resident through the program. Now a new intern was showing the same beginning pattern. He wondered if he should just cut his losses on this intern now rather than waiting three years. His "sample of 1", indicated that he was taking on a 3 year problem. But we all can think of examples of residents who begin with problems and end up being "STARS". So his question: What percent of new residents who show both professionalism problems and knowledge problems in their first year ever turn it around and become contributing members of the residency program? What is your experience?

APRIL 2009 SUMMARY

The topic for April, THE MILLENIUM GENERATION IN HEALTH CARE, struck a cord with a few of our readers. The responses seemed to be divided between those who indicated that making a generalization about a whole generation seemed somehow "flawed" and others who seemed to believe that there was merit in the premise and that there was adequate evidence of differences to warrant discussion. Both are reasonable. I doubt that we will ever be able to conclude this debate with hard evidence. However, we have noted generational trends in the past and this one might be worth watching.

Millennium Generation in Health Care

For the past few months, I have heard more references to the Millennium Generation than I had in the last year. In giving workshops on teaching techniques, the subject has come up. At a recent meeting, a respected leader asked whether the incentive packages needed to be changed to factor in the values of the Millennium Generation. So being the dutiful “baby boomer” that I am, I felt the responsibility to learn more (and bring you all in on the lesson).

The Millennium Generation or Generation Y (approx. 1980 – 2000) are just entering our graduate schools, medical schools and residencies and they are making an impact. According to experts, we can expect a different set of values and expectations from this group of young people and potential conflict with older “baby booming” authority figures.

Some of the common characteristics of the Millennium Generation noted by observers are:

• Tech savvy – They grew up with computers and relate to the world through technology. This characteristic can also lead to the tendency to be impatient and expect instant gratification
  
• Image driven, sometimes called “trophy children”. They grew up being told they were “special”. This belief can sometimes lead to a false sense of entitlement.
  
• Value personal time and time for family, they believe they should be able to “have it all”
  
• Efficient multi-taskers (see tech savvy)
  
• Adaptable. Some attribute this to their early entry into “day care”, “early team sports” and doting parents who included children in all types of activities and travel. Whatever the reason, the Generation “Y”ers believe they can “get it done”
  

Do we change the system to adapt to this new generation? Or should we change at all?

What kind of educational systems will appeal to the best and brightest of this generation?

Have any of you thought this through?

Have you noted any differences in the last few classes that have entered your graduate schools, medical schools or residency programs? Or is this all "psycho-babble"?

Do you have any advice for the rest of us? We would love to hear what you think!

February-March Summary (Technology and Teaching)

The topic of Technology and Teaching did bring out some strong feelings and some really great ideas. The article that sparked this discussion suggested that “skills in critical thinking and analysis” had declined as a result of the use of technology in learning environments. Now that is a pretty bold statement and a very general one. Are all forms of technology to blame? That hardly seems likely as technology is a multifaceted tool that has many applications. So what could it be about technology that could result in these findings? Our readers commented and their comments fell into 3-4 categories.

• Five of the 17 responders believed that their residents and students had “lost skill”. Three of the responder thought this might be attributed to “speed” of connectivity and searches. According to our readers’ thinking, students and residents quickly search using key words and don’t think things through or critically analyze. They have an answer before they have really thought out the question. I tend to agree with this point of view. Google anything and you will receive multiple answers. Analyzing the quality of those answers is another story. This however does not mean that technology is a villain. The tool is not to blame. Could we as teachers expect more from our learners? Should we teach them how to use the technology tools that science has given the? Yes, of course.


• Another group seemed generally “miss-trustful” of too much technology.


• The third group of responders really explored technology as a tool. As Neil so aptly stated, “technology gets bad press when it might just be the teaching method that is at fault” Often, technology is just a “delivery method”. Of course it can be more and we have to monitor how we use technology as a part of our repertoire of methods and tools. If critical thinking is what we want, then we need to consider how best to stimulate our learners to analyze.

DOES TECHNOLOGY HAVE A PRICE?

Every innovation has both an intended effect and other effects that are unintended. Technology is no different. ScienceDaly recently published an article titled "Is Technology Producing a Decline In Critical Thinking and Analysis?" that summarized a study that recently appeared in "Science". In this article, Dr. Patricia Greenwood from UCLA reviewed over 50 studies. One conclusion from this review was that while visual intelligence had gone up, "skills in critical thinking and analysis have declined."

Another interesting finding, particularly relevant to schools that provide and promote the use of laptops, was that "students who were given access to the internet during class did not process what the speaker said as well as student who did not have access". Although many of the studies reviewed were completed with children, the results are no less important for those of us who teach students and residents in the health professions.

Click on the link http://www.sciencedaily.com/releases/2009/01/090128092341.htm and check out the summary and find the citation for the full "Science" article.

What are your thoughts about these findings? Does this disturb you? Is it just a predictable evolution of man? Do we need to change our expectations? Should we offer more opportunities for discussion and problem solving? Should we reduce the number of computer simulations? Is it too late by the time students come to us to make a difference? It would be great to hear from readers who grew up in the technology age and also from those of us who grew up with "books". Respond to any of these questions or just react to the findings of this study.

JANUARY/FEBRUARY SUMMARY

Our January “Education Item from the News” from The New York Times, titled “At MIT, Large Lectures Are Going The Way Of The Blackboard” really seemed to spark some interesting conversation. The vast majority of the 18 posts seemed interested in rethinking Grand Rounds to make it more engaging, while a few others thought that Grand Rounds was OK, and described it as a unique educational venue in which experts presented interesting findings on topics of interest. The perhaps missed point was that “Grand Rounds” was just an example of a teaching venue that might benefit from “rehab”. Individuals do not learn unless they are engaged and teaching formats that rely on “listening” alone as the means of engagement disadvantage many learners.

One of our readers suggested the use of the Audience Response System (ARS) as a means of promoting engagement in large groups. ARS has been found to increase attention on the part of participants and may be a great way to encourage engagement. A few other ideas from our BLOGGERS were to:

• “Allow invitees to large lectures to submit questions to the speaker a few days PRIOR to the session to allow them to customize their presentations.”
• “Archive the presentations in a way that can be accessed later by non-attendees and attendees who would like to review.”
• "Grand Rounds"-- when given by residents and fellows and arranged properly so that feedback can be given-- can serve the very important function of allowing trainees to hone their public speaking skills. It is important for doctors... as teachers... to possess such communication skills.”
• “Teaching to smaller groups provides an opportunity to engage all participants in a discussion that presumably, enhances an active learning; the lecturer, acting as a moderator, can gauge the level of understanding and effectively ensure the learning of the information”

WHAT'S SO GRAND ABOUT GRAND ROUNDS?

A recent article in The New York Times Education Section
http://www.nytimes.com/2009/01/13/us/13physics.html?partner=permalink&exprod=permalink described an enormous change in the way the introductory science courses are taught at MIT; yes, Massachusetts Institute of Technology! Rather than the traditional crowded lecture hall, small groups of students explore the problems of science by interacting with peers and using faculty as resources and facilitators. The “50 minute expert lecture” is dead; instead, professors engage students in small group work while clarifying key concepts as they roam from table to table.

How’s it working out?

“Last fall, after years of experimentation and debate and resistance from students, who initially petitioned against it, the department made the change permanent. Already, attendance is up and the failure rate has dropped by more than 50 percent.”

What does this have to do with Medical Education and Grand Rounds?

Everything!! For years, many of the Basic Science and Clinical teachers in medical schools and residency programs across the country have been “bucking” the “case-based and/or collaborative teaching” trends by saying that there is simply too much to “cover” to use these more interactive concept-based teaching approaches. It is true that you can cover more ground with a lecture, but if no one is awake, much less learning, what is the point?

Will medical and residency education be “brave enough” to follow the example of MIT? Can we resurrect interaction, clinical reasoning discussions and vigorous debate at some of our education meetings?

Can we change “Grand Rounds” into something really GRAND? Click on the link above and read the whole article. It is fascinating. We want to hear what your think?