Weekly Updates - April 1, 2013

Monday, April 1, 2013

From the Director

Hola from Spain!

Thanks to everyone for their participation in MiniCEX madness! We completed a total of 37 MiniCEXs and 9 Ambulatory Pilot MiniCEXs! Congrats to Adam Garber as our week 4 winner. I hope everyone found this to be helpful and easy to do. Lets keep it up!  We are now able to start our ACGME survey. This is a CRITICAL part of our accreditation and provides us with helpful information to improve our program. Please look for instructions about how to log in - remember, it's anonymous !

I did hear that Jen Chung was awarded a gold star! Congrats Jen. She also got compliments from Lincoln clinic for excellent work. And congrats to our quality champions Rebecca  Sadun, Matt Chung and Kim Bryan. Rebecca did great work on CCU handoffs, Kim at the DOC and Matt for his SAR talk.  Pubmed from the program goes to Denise Duan Porter for her abstract accepted to ASH! Great job.

Looking forward to seeing you all on Tuesday!










QI Corner

Quality Improvement Noon Conference

A special thanks to Dr. Eric Peterson for his recent presentation on the national landscape of quality improvement.

Save the date for our next quality improvement noon conference on Wed 4/24 when Melissa King will be presenting a review of SRS reporting.

March Quality Champions

Please join me in congratulating this months Quality Champions

1) Matt Chung - VA cardiology project

2) Rebecca Sadun for her work on the OSH transfer project

3) Kim Bryan for her work with the DOC discharge clinic project

If you would like to nominate a QI champion for next month, please contact George Cheely, Ryan Schulteis, or Jon Bae


What Did I Read This Week

(submitted by Charles Hargett, MD)


This fun and interesting article came to my inbox via eTOC:  Desai SV, Feldman L, et. al.  Effect of the 2011 vs 2003 Duty Hour Regulation–Compliant Models on Sleep Duration, Trainee Education, and Continuity of Patient Care Among Internal Medicine House Staff.  JAMA Intern Med. 2013

Published online March 25, 2013:  http://archinte.jamanetwork.com/article.aspx?articleid=1672279


Beginning July 2011, the ACGME reduced the continuous-duty working hours of interns from 30 to 16 with the intention of decreasing fatigue in the least experienced trainees (anticipating a subsequent decrease in preventable adverse event (PAE) rates and improved educational environment).

Authors’ Clinical Question:

For internal medicine trainees, what are the comparative effects of the 2011 vs. 2003 ACGME duty hour regulations on trainees’ sleep duration, education, continuity of patient care, and perceived quality of care?


Design and Setting:  Prospective randomized trial with 3 month cross-over design (two 4-week blocks separated by a 4-week washout period) at a University Hospital (Johns Hopkins)

Population:  43 internal medicine interns (as members of 4 GenMed teams/firms)

Intervention(s):  2011-compliant schedules with 16-hour duty limits (includes two models: Q5 overnight call and a NF schedule)

Control:  2003-compliant schedule (Q4 overnight call with 30-hour duty limits)

Randomization and Blinding:  Teams were randomly assigned to one of the three models (2 firms to the 2003 control group, 1 firm to each of the 2 2011 schedule interventions).  Data handling and analysis were blinded.

Primary Outcome:  PGY-1 on-call period sleep duration (as measured by wristwatch actigraphy)

Secondary Outcomes:  Operations (LOS, 30d readmissions, D/C before 11AM), Educational (survey, admission volume, time in hospital, noon conference attendance), Continuity of Care (# handoffs, # different interns for each patient), Satisfaction (trainee and nurse survey based on 1-5 Likert rating)

Analysis:  ANOVA (F statistic), Wilcoxon rank sum test, or Pearson χ2 test to compare the differences across models.  Tests of significance were 2-tailed, with an α level of .05.  Based on the estimated sample size and number of sleep measurements, a power analysis estimated the minimal detectable effect size to be 3.2 hours.


Over the 8 study periods (4 control, 3 Q5, and 1 NF), interns worked a total of 560 control, 420 Q5, and 140 NF days.  There were 834 hospital admissions with similar patient severity of illness scores across the 3 models.  Trainee survey response rates were 73% for control firms, 77% for Q5, and 81% for NF.  The following table (WDIRTW_Table) summarizes the findings (though Figure 2 in the text provides a better sense of sleep variance and significance thereof).










Key Primary Outcome Results:

  • The mean duration of sleep an intern had on any day was the same regardless of the model
  • Compared with controls, interns on NF slept longer during the on call period
  • Compared with controls, interns on Q5 slept longer during the post-call period
  • Across 48-hour on call periods, there was a suggestion of increased average sleep time of 3 hours for Q5 and NF interns (though not statistically significant; see results and power analysis)
  • The variance in sleep duration was significantly reduced for all periods for Q5 and NF interns
  • Only 3 of 14 hours gained from Q5 or NF schedules were used for sleep

Key Secondary Outcome Results:

  • Compared with control schedules, the Q5 and NF schedules showed increased handoffs, reduced availability for teaching conferences, and reduced intern presence during daytime shifts
  • With Q5 and NF schedules, residents and nurses perceived reduced quality of care (actually resulting in early termination of NF arm and use of only the Q5 intervention after the wash-out period)


Although this study abounds with limitations I will only highlight a few to emphasize the complexity of this sort of research and suggest that they not unduly diminish the findings.  The most significant limitation is the reliance on self-reporting.  In addition to the potential for recall bias, educational perceptions may not necessarily reflect educational effectiveness.  Also, it’s difficult to know if participants expressed undue dislike for the new schedules merely because the schedules were unfamiliar and new.  In this vein, despite the advantages of a cross-over design, using experienced interns may have led to learning effects and carry-over between interventions and even order effects if they had previously experienced the control schedule earlier in the year.  Additionally, the effects of other concomitant changes instituted by the ACGME (e.g. PGY-2 and above limited to 24 + 4 call, 8 hours between shifts, etc.) were not accounted for in this study.  Also of note, roughly 20% of the actigraphy data was deemed “poor” (24 hour periods showing < 1200 minutes) and discarded.  Generalizability is limited by many factors such as the specific setting and rotation/team structures.  Likert-like scales are appropriate here but notably can be unidimensional, difficult to reproduce and validate, and are subject to potential biases (e.g. central tendency, acquiescence).  Overall, the study time and number of patient encounters was relatively small for some comparisons.


The future of health care delivery is, in large part, dependent upon the quality of graduate medical education and concerns over the effect of long duty hours on residents and their patients have produced fundamental changes in training.  Beginning with the duty hour reforms in New York in the late 1980’s and through the most recent changes in the ACGME program requirements, more than 100 studies have investigated the outcomes of these changes on both patients and residents.  It suffices to say that results of both individual studies and systematic reviews have been variable.  The current work by Desai and colleagues is interesting but most importantly adds to the evidence that the changes in ACGME training program requirements may have unintended consequences, chief among them being the possible adverse impact on resident education.  In a nutshell, are we simply trading old problems for some new ones?

Duty duty hour limits are here to stay, of course (as an aside, when I was a PGY3 extern at Oxford, they were pretty darn good doctors and their duty hours were limited to 52 hours/week).  One of the reasons I enjoy being part of the team that runs our training program is the challenge of preserving our core values of intellectual autonomy and curiosity, etc. in the on-the-ward, real world context of these changes in training.  Though the ACGME has offered fairly limited evidence for and support toward operationalizing the sum of changes (duty hour and competency-based education), the increasingly complex logistics of clinical care in a teaching hospital have fostered efficiencies in teaching, team management, quality improvement, and electronic information, among others.  At Duke, we’re actively engaged in rigorously studying the impact of these changes while rapidly adapting to the evolving educational landscape.  This includes higher-order efforts like resiliency training, safety and QI, and even seemingly more mundane (though central and practical) tasks like managing the education and care aspects during morning work rounds.  Our list goes on and on, including active studies involving patient handoffs, continuity of care, evidence-based teaching metrics and faculty development, milestone-based assessment and feedback, monitoring resident workload, implementation of short bursts of subspecialty co-attending teaching, etc.  In our current era of medical education, it’s essential to be mindful of potential issues, such as ensuring that trainees maintain experiences in following the trajectory of a patient’s illness, and that EHR innovations don’t dilute patient/trainee/attending interactions or adversely affect important cognitive steps in the development of clinical reasoning.

In summary, though well-intentioned and irrespective of their face validity, policy interventions in medical education may lead to unanticipated (and sometimes negative) consequences.  Given the complex relationships among variables affected by limits on resident duty hours, there remains a continuing need for efforts to maximize the safety and quality of care and the educational needs of trainees.  Strategies for managing such external regulatory change should be context-specific (e.g. Duke) and framed by priority and consensus.


Welcome to the (NEW) “All-in one” Ambulatory Evaluation Form for Resident Continuity Clinic

In keeping with the ACGME’s move to requiring milestone-based evaluations beginning in July 2013, and building on the extremely thoughtful work behind the scenes by Murat Arcasoy and Bill Hargett in coming up with such an evaluation for inpatient Gen Med (coming soon), a new ambulatory care evaluation form has been developed that will be pilot tested starting now until the end of the academic year.

The goal is to have more documented real-time observations of specific behaviors important in the practice of primary care medicine, in order to help inform comprehensive clinical evaluations and to provide immediate and focused feedback to housestaff.

This “all-in-one” form will be used for both spot observations and the three “classic” ambulatory Mini CEXs residents are currently required to complete each year as part of their procedure logs.  It will also double as the form for summative evaluations the program completes of residents’ performance in their continuity clinic settings.

Please note, corresponding levels in this new format are NOT grades, but show expected progression through milestones of residency training, to align with new standards for resident evaluation (e.g., the first few bubbles correspond to where a new intern might be expected to be).

WE WANT YOUR FEEDBACK!  Please send comments by email (Subject: Mini CEX- Ambulatory Feedback) to Alex Cho at alex.cho@duke.edu.

Preview Ambulatory Evaluation Form - MedHub

From the Chief Residents

Grand Rounds

Date Division Speaker Title
April 5 Infectious Disease-3 Dr. Christopher Woods Chronic Bartonella

Noon Conference

Date Topic Lecturer Vendor
4/1 Board Review ACRs Picnic Basket
4/2 Initial approach to a patient with a rheumatologic complaint Irene Witt Sushi
4/3 IM-ED Combined Conference Dr Holly Prigerson Rudinos
4/4 Visiting Professor from Harvard: Promoting the Quality of Life and Care of Patients Near Death Dr Holly Prigerson Dominos
4/5 Chair's Conference Chiefs Chick-fil-A


From the Residency Office

Congratulations to Sima Hodavance and her husband on the birth of their beautiful baby boy Connor!

hodavance baby_IMG_4499








Board Review Sessions held in the MedRes Library, Duke North, 8th Floor. Please contact Megan Diehl or Jeff Clarke if you would like to attend.  The schedule is as follows:

SAR Board Review Schedule

Date Topic Faculty Discussants
Tuesday, March 26 General Internal Medicine, EBM Drs. Zipkin, Cho, Phelps
Wednesday April 3 General Internal Medicine, EBM Drs. Greenblatt, Phelps, Simel
Tuesday April 9 ID Dr. Zaas
Wednesday April 17 Cardiology Dr. Jones
Tuesday April 23 Hem/Onc Drs. Riedel and Diehl
Tuesday April 30 Pulmonary Dr. Govert
Wednesday May 8 Gastroenterology Drs. Choi and Desai
Tuesday May 14 Endocrine Dr. Matt Crowley
Wednesday May 22 Renal Dr. Butterly
Tuesday May 28 Neurology Dr. Skeen
Wednesday June 5 Dermatology/Rheumatology Dr. Criscione
Tuesday June 11 Mixed Bag (Medical ethics, Palliative Medicine, Psych) Dr. Zaas, Chiefs

All sessions will be from 5-6pm in the Med Res Library.

Contact Information/Opportunities

Billings Clinic

Northeastern Colorado Internist

Utah Internist

Bingham Memorial Hospital

Upcoming Dates and Events

  • April 19:  Residency Program Pictures (rain date May 10)
  • April 28:  2nd Annual Stead Tread
  • June 4:  Resident Research Conference, Searle Center
  • June 8:  SAR Dinner, Hope Valley Country Club

Useful links