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4
Improving the Resident
Learning Environment
The primary goal of graduate medical training is for residents to achieve
sufficient competence to deliver safe and effective patient care when they
enter into practice. The inherent inexperience of residents as they train
need not affect patient safety if they are adequately supervised by more
experienced physicians guiding them toward gradual independence. Re-
duced work hours implemented in 00, some believe, pose a risk to the
acquisition of competencies and to the continuity of care from both an
educational and a patient safety perspective.
The committee could not determine the full positive or negative effects of
the 00 limits on educational outcomes because sufficient data on those
outcomes are not yet available. However, substantial evidence about how
people learn stresses the importance of having a reasonable workload, suf-
ficient time for reflection, and the need for sleep to consolidate learning.
New educational designs (e.g., curriculum restructuring, competency-based
training, simulation-based training) 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 edu-
cation. It is through residency that physicians-in-training are transformed
from novices into experienced professionals, providing society with compe-
tent and compassionate healers for the future. The Association of American
Medical Colleges (AAMC, 2006) has recently reaffirmed that residents are
“first and foremost learners” and that “a resident’s educational needs should
be the primary determinant of any assigned patient care services.” Similarly,
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RESIDENT DUTY HOURS
the Accreditation Council for Graduate Medical Education (ACGME) has
established in its requirements for all residency programs that (1) the learn-
ing objectives of the program must not be compromised by excessive reli-
ance on residents to fulfill service obligations, and (2) didactic and clinical
education must have priority in the allotment of residents’ time and energy
(ACGME, 2008b). Throughout the history of residency training, hospitals
have insisted that trainees perform an extraordinary range and amount of
ancillary responsibilities that are often noneducational in nature (Ludmerer,
1999). However, while education may be the primary objective of residency
training, the nature of residency training—participating in direct patient
care—requires that patient safety never be separated from that education.
Residency programs implicitly assume responsibility for protecting the pa-
tient during the educational experience, thus forming a “social contract”
between patients and teaching care settings. In this setting, patients agree
to have doctors in training at various milestones in their education, with
variations in skills and competencies, provide their care in exchange for a
social good—the production of future doctors.
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.
EDUCATIONAL PRINCIPLES
Three cardinal educational principles underlie residency education: (1)
the gradual or graded assumption of responsibility for patient care while
under supervision, (2) adequate time to engage in reflective learning, and
(3) sufficient continuity in the care of individual patients to understand the
natural evolution of illness and to reinforce professionalism and its obli-
gations. Educationally, what matters most in residency training is not the
number of duty hours but whether an adequate learning environment exists
to satisfy these three principles during those hours (Ludmerer, 1999). In-
stead of enhancing the learning environment for residents, implementation
of the 2003 ACGME requirements is perceived by some educators to have
weakened the educational environment in many programs (Charap, 2004;
Fitzgibbons et al., 2006; Ludmerer and Johns, 2005; Ryan, 2005), pushing
education away from key elements (e.g., adequate time for teaching and
reflective learning) that would promote safety and better supervision. To
change residency programs so that these positive elements can be enhanced
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IMPROVING THE RESIDENT LEARNING ENVIRONMENT
instead of diminished, the interplay of many organizational factors must
be supported and reinforced for effective training to result (Salas and Can-
non-Bowers, 2000, 2001).
Graded Responsibility for Patient Care Under Supervision
An intrinsic challenge of graduate medical education (GME) has been
to find a balance between the educational needs of residents, who require
increasing independence as they learn, and the safety needs of patients, who
may benefit from being cared for by more experienced physicians. The ten-
sion between these two aspects has become more obvious over the past few
decades along with a growing attention to safety in medical care. Patients
admitted to hospitals have been much sicker, and mistakes of omission and
commission by any care provider may have more adverse consequences
today than before (Ludmerer, 1999).
A defining characteristic of GME is the assumption of progressively
greater patient care responsibility by residents. This type of training is
necessary, lest the country face the predicament of future patients’ being
cared for by inadequately trained doctors (Kennedy et al., 2007). Residents
can become effective independent physicians and assume full responsibility
for patient care only after having acquired the competencies necessary to
manage patients safely and well. To acquire this capacity, residents conduct
initial evaluations of patients, make preliminary decisions about diagnosis
and therapy, perform procedures, and administer treatments under the level
of supervision appropriate for their developing competency—with the un-
derstanding that all residents are accountable to attending physicians. The
tension that results from the need of the resident to have gradual respon-
sibility under appropriate supervision and the desire to provide optimal
and safe care is always present and must be managed carefully to protect
patients.
Despite limited research on the use of on-the-job training (OJT) in
health care, OJT has been widely used and validated in other fields as an
effective training method (Barron et al., 1997; Becker, 1975; Mincer, 1962;
Rothwell and Kazanas, 2004; Veum, 1999). In medicine, the validity of a
graded responsibility model through in-hospital OJT has been grounded in
its compelling inherent logic and rationale, and endorsed by generations of
experienced teachers (Kennedy et al., 2005). However, it has not been eval-
uated systematically against an alternative education model. Aspects of the
graded responsibility model are supported in the psychological literature,
in particular a five-stage model of skill acquisition: novice, advanced begin-
ner, competent, proficient, and expert (Batalden et al., 2002; Dreyfus and
Dreyfus, 1986). In the context of medical residency, the intent of in-hospital
training is to deepen existing competencies and teach new ones in a man-
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RESIDENT DUTY HOURS
ner that moves residents further along the pathway from novice to expert
(Jacobs, 2003; Rothwell and Kazanas, 2004). At times it can be difficult for
attendings and faculty clinicians to assess the competency level of individual
residents and determine the ideal degree of interaction that might suit them,
but efforts to do so more effectively have been examined (Kennedy et al.,
2007) and further development and learning of such methods may be useful
in determining optimal supervision levels for individual residents.
Role of Supervision in Providing Graded Responsibility
Along the pathway of skill acquisition, supervision is the single most
important element upon which this education model depends. In this con-
text, supervision in medicine has been defined as (Kilminster and Jolly,
2000):
The provision of monitoring, guidance and feedback on matters of per-
sonal, professional and educational development in the context of the
doctor’s care of patients. This would include the ability to anticipate a
doctor’s strengths and weaknesses in particular clinical situations in order
to maximize patient safety.
Supervisory practices that enhance resident learning and performance are
(1) the involvement of role models and mentors who demonstrate appro-
priate professional practice (Hough, 2008); (2) specific learning objectives
communicated to learners in advance of their interactions with patients; (3)
periodic assessment of how well learners have met those objectives (Jacobs,
2003; Rothwell and Kazanas, 2004; Salas and Cannon-Bowers, 2000); and
(4) timely and actionable feedback to residents (Arco, 2008). This report
raises concerns regarding the current application of supervisory practices
in the context of both learning and patient safety.
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 recom-
mended 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):
A hospital is not the place for recently graduated doctors to grow and
develop in isolation; rather it is a place where the learning process should
continue under strict supervision. Thus, medical decisions, whether in an
emergency room or on a hospital floor should not be made by inexperi-
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IMPROVING THE RESIDENT LEARNING ENVIRONMENT
enced interns and junior residents without in-person consultations with
more senior physicians.
Dr. Bell himself has subsequently written repeatedly that better supervision,
not only regulation of hours, is the key to improving the quality of patient
care (Bell, 1993, 2003, 2007). And since the time of the Zion case, the in-
creasing complexity of patients’ illnesses and advancement of medical tools
has strengthened the need for good supervision.
After the 1984 Libby Zion case brought attention to the issue of resi-
dent 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) found
that “supervision has a positive effect on patient outcomes and that lack
of supervision is harmful for patients.” The authors view supervision as a
distinct intervention with variable outcomes depending on the work and
learning environment and its orientation toward teaching.
A number of studies have found that closer resident supervision can
lead to fewer errors and improved quality of care (Fallon et al., 1993;
Gennis and Gennis, 1993; Singh et al., 2007; Sox et al., 1998). An attend-
ing physician’s review of a resident’s report on a patient case is more likely
to result in a change in patient management when the attending sees the
patient directly (Gennis and Gennis, 1993), and the impact of better super-
vision is likely to be more marked among less experienced residents (Fallon
et al., 1993). Studies report higher death rates when residents are under
poor supervision in surgery, anesthesia, emergency medicine, obstetrics, and
pediatrics (McKee and Black, 1992), and report decreased complications
and mortality rates when surgical residents are supported by the presence of
attendings (Fallon et al., 1993). Residents’ compliance with care guidelines
has been found to be greater under direct supervision (Sox et al., 1998). Di-
rect supervision of residents can also help them acquire skills more quickly
and increase their comfort level in performing invasive procedures (Huang
et al., 2006; Osborn et al., 1993; Smith et al., 2004). Finally, residents tend
to use more resources, such as test ordering, when they are less supervised
(Griffith et al., 1996).
Supervision in Practice
Since the time of the Bell Commission, requirements for supervision
have been strengthened in Medicare reimbursement policies and ACGME
guidance. ACGME requires “sound supervision” policies from institutions
and program directors (ACGME, 2007, 2008b). Under these principles,
however, there is latitude in the way each program outlines how gradu-
ated responsibility and supervision will interact, and how supervision is
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0 RESIDENT DUTY HOURS
implemented in practice (ACGME, 2008b). For example, in an intensive
care unit (ICU) the supervising attending might be onsite 24 hours a day,
or be expected to be readily available by phone (e.g., within 5 minutes) and
able to be at the bedside within a reasonable period (e.g., 20 minutes to 1
hour). For insurance payment purposes, attending physicians are required
by Medicare’s 1996 Teaching Physician Presence Rules to include progress
notes and documentation of their presence during operative procedures in
a patient’s medical record.1
While residents are required to consult with their supervising attend-
ing physician about their assessment of a patient, the proposed treatment
plan, and any key decisions in the patient’s course of treatment, residents
perform many of their duties without “over-the-shoulder” supervision. 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. Likewise, a sec-
ond-year surgical resident might be restricted to performing a laparascopic
cholecystectomy from the left side of the operating table (where visibility of
the operation is greater and access to the organ easier), but by their fourth
year in training that resident would expected to know how to perform the
procedure from both sides of the table (Brody School of Medicine, 2008).
A supervisor is generally present or accessible in each of these instances, but
the degree of supervision may depend on the competence level individual
residents demonstrate for each acquired skill; with some residents requiring
more hands-on guidance than others.
Good Supervisory Practices
Especially important in the supervisory relationship are the following:
continuity in mentoring over time, the supervisor’s skill at providing over-
sight and promoting intellectual autonomy among trainees, and the oppor-
tunity for both trainee and supervisor to reflect on their work (Kilminster
and Jolly, 2000). Of course, resident supervisors need to be clinically com-
petent themselves as well as informed regarding effective learning processes.
In particular, the way in which they communicate their knowledge is what
matters to resident training. Trainees need clear feedback about their judg-
ments; corrections must be conveyed unambiguously so that trainees are
aware of potential mistakes and any weaknesses they may have (Kluger and
1 CMS (Centers for Medicare and Medicaid Services). 2005. 42 CFR 4172(a) evolution of
Medicare billing regulations. Medicare Claims Processing Manual.
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IMPROVING THE RESIDENT LEARNING ENVIRONMENT
DeNisi, 1996). Helpful supervisory behaviors include giving direct guidance
on clinical work; discussing links between theory and practice; participating
in joint problem solving; and offering feedback, reassurance, and role mod-
eling (Kilminster and Jolly, 2000). Rigidity, intolerance, lack of empathy,
failure to offer support, lack of concern with teaching, and overemphasis on
the evaluative aspects of supervision can have negative impacts by generat-
ing defensive behaviors that interfere with learning (Kilminster and Jolly,
2000; Kluger and DeNisi, 1996).
There has been no formal requirement for attendings to be trained to
perform their supervisory role. However, faculty can be taught to be better
teachers and supervisors. Pioneering work by Skeff and other colleagues
(Litzelman et al., 1998; Skeff, 1998) has been instrumental in raising aware-
ness of the need for supervisors to be instructed in their roles, as has work
by other investigators (Bishop, 1998; Cote and Leclere, 2000; Kilminster
and Jolly, 2000; Meyers et al., 2007; Williams and Webb, 1994). For bet-
ter supervision to flourish, medical faculties need to place a higher priority
on their educational mission. This entails greater institutional willingness
to develop and promote clinician educators, the creation of “academies of
medical educators,” mission-based budgeting, and related strategies to fund
clinical teaching and supervision (Ludmerer, 2004). Return from investing
in proper supervision can have a profound and long reach: the role model-
ing that residents witness forms the basis for the effective supervision of
future physicians and the potential for improved patient outcomes for years
to come.
Impact of 00 Duty Hour Rules on Faculty Availability
A major concern stemming from the 2003 duty hour regulations is the
effect they have had on the availability of faculty and senior residents for
supervision and teaching with additional workload shifting to them (Arora
et al., 2008; Coverdill et al., 2006a,b; Hutter et al., 2006). Some program
responses to the 2003 duty hour limits indicate that the new regulations
may have exacerbated preexisting shortcomings in the time for supervision
and added new ones. Examples include reports of how reduced resident
duty hours have shifted the workload to attendings and more senior resi-
dents, 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). Additionally, supervision has generally been less at night and dur-
ing extended shifts when junior residents (and their patients) would benefit
from more supervision, not less, since the risks for poor patient outcomes
are known to be greater at these times (Huang et al., 2006; Kilminster and
Jolly, 2000; Landrigan et al., 2004; Shojania et al., 2006; Shulkin, 2008).
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RESIDENT DUTY HOURS
In one study, the clinical internal medicine faculty reported their belief
that they now spend more time on patient care than teaching and super-
vising residents because of shifting workloads (see Figure 4-1). Almost 75
percent of key clinical faculty believed the duty hour regulations limited
opportunities for both didactic and bedside teaching. The researchers noted
the potential of the regulations for adverse consequences on faculty recruit-
ment and retention due to potential increases in clinical responsibility (Reed
et al., 2007). Another survey of attending physicians came to similar con-
clusions: less time for teaching, less satisfaction with professional growth
and development, and decreased educational stimulation from work. At-
tending physicians reported a decline in the amount of time dedicated to
didactic teaching, and residents missing educational conferences more often
because more time was consumed by rounds (Arora and Meltzer, 2008).
Removing Barriers to Communication
In addition to lack of time, other barriers to good communication and
supervision include lack of agreement on circumstances for consultation
and institutional cultures that discourage communication. What needs to
be supervised and when are often not clearly defined for most residencies,
but this dialogue should occur. Farnan and colleagues (Farnan et al., 2007)
examined the preferences of both internal medicine residents and their super-
visors across four types of clinical scenarios involving specific critical deci-
sion making on the part of residents. Residents and attendings agreed that
immediate contact was necessary and should be required when there was a
transfer of an existing patient into the ICU, when cardiac arrest occurred,
and when a resident performed an invasive procedure. Attendings desired
notification more often than residents wanted to contact them for transfers
from the ICU (p = .0009), transfers from an outside facility (p = .001),
patients’ receiving vasoactive medications for the first time (p = .02), or ini-
tiation of intravenous antibiotics. Clarification of expectations for consulta-
tions with supervisors in all programs would be beneficial.
In some situations, teaching physicians humiliate residents who provide
them with insufficient patient information or consider residents “weak,”
insecure, and lacking in knowledge, skill, and judgment if they ask for
help, thus suppressing needed discussion or calls for help even when resi-
dents know they are over their heads (Hoff et al., 2006; Kilminster and
Jolly, 2000; Shojania et al., 2006). Residents do not want to be seen as
unable to make their own judgments without support or to be viewed as
a nuisance by the attending, nor do they always want to admit to gaps in
their knowledge and skills or give up their autonomy (Farnan et al., 2008).
This avoidance of discussion with teachers undermines a critical role of
supervision—to help residents become aware of their cognitive biases and
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Improved
100
No change
90 Worsened
80
70
60
50
40
30
Key Clinical Faculty, %
20
10
0
Time Supervising Time Providing Ability to Mentoring Teaching Satisfaction With Career
Residents on Patient Care on Evaluate Relationships Satisfaction Personal-Professional Satisfaction
Inpatient Services Inpatient Services Residents With Residents Life Balance Overall
Figure 2. Views of 111 key clinical faculty on the effectfaculty on the effect of dutyfacultyregulations on satisfaction. 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.
NOTE: Sign test, p < .001 for all outcomes.
SOURCE: Reed et al., 2007. Copyright © 2007, American Medical Association. All rights reserved.
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4 RESIDENT DUTY HOURS
to develop effective ways for gathering and interpreting patient information
(Groopman, 2008). Furthermore, residents intimidated about asking ques-
tions or requesting help can present a risk to patient safety (e.g., by taking
undue time to reach decisions on courses of care).
To promote patient safety, medical teaching environments must sup-
port learners and the entire supervision and learning process. Teaching
physicians must be ready to coach, back up, and aid a resident in providing
quality patient care. It is the responsibility of house officers to call for help
when they are unsure about what to do, but it is an attending’s responsibil-
ity to foster conditions in which necessary consultations can take place. Su-
pervisory behavior should include demonstrating how to act constructively
upon recognizing a mistake. An effective teacher provides opportunity
and sufficient time for learners to reflect on their own experiences (Langer,
1990). Furthermore, an effective residency program develops, rewards, and
supports those physician supervisors who behave as appropriate role mod-
els for residents. 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 train-
ing, 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. The committee agrees that support for teaching time and recog-
nition of its importance in assessing professional development of faculty
should be encouraged. In conjunction with the evidence on error and pa-
tient safety in Chapter 6, the committee recommends the following:
Recommendation 4-1: To increase patient safety and enhance educa-
tion for residents, the ACGME should ensure that programs provide
adequate, direct, onsite supervision for residents. The ACGME should
require
• Residency Review Committees, in conjunction with teaching insti-
tutions and program directors, to establish measurable standards
of supervision for each level of doctor in training, as appropriate
to their specialty; and
• First-year residents not to be on duty without having immedi-
ate access to a residency program-approved supervisory physician
in-house.
There is no standard definition of whom or what level of “senior clini-
cian” qualifies to act as a supervisor to residents, although any patient’s
attending physician is ultimately responsible for the care received. The
committee recognized that this definition can depend on the specialty being
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IMPROVING THE RESIDENT LEARNING ENVIRONMENT
pursued, the task being performed or taught, the competency level of indi-
vidual residents, and the complexity of patient cases being cared for. While
an attending-level supervisor is the ideal for all residents to be taught and
guided under, for practical purposes and to avoid exacerbating the limited
supply of supervising staff, the committee concluded that a senior resident
(equivalent to a PGY-3) is an acceptable minimal level of experience to serve
a supervisory role to more junior residents (PGY-1 and PGY-2 residents).
For residents in their third year or higher of training, more senior clinicians
(i.e., attendings, faculty, fellows) should provide supervision. In many cases,
particularly in overseeing surgical procedures or dealing with highly com-
plex cases such as interventional angiographic and intracranial procedures,
an attending-level supervisor should always be required. Hospitalists and
other senior-level staff can also serve to provide in-hospital resident super-
vision when needed.
The committee suggests that in-house supervisors be readily available
to first-year residents, to help with any aspect of patient care duties, includ-
ing on nights and weekends. It is hoped that these supervisors are not so
overburdened with other clinical responsibilities such that their ability to
supervise is compromised. Furthermore, supervisors need not necessarily
be a member of the same team or service as the first year resident. It is ex-
pected, however, that they be a senior resident or higher level physician in
the same specialty training program as the first-year resident (i.e., internal
medicine first-years should have an internal resident senior with whom they
can consult, pediatrics with pediatrics, surgery with surgery, obstetrics-
gynecology with obstetrics-gynecology, etc.). The committee believes that
residency programs and specialties would benefit from creating their own
supervisory guidelines to ensure adequate supervision is provided for all
resident levels at all times.
The committee also stresses the importance of enhancing supervisory
leadership, by encouraging that supervisors at all levels (e.g., attendings
and PGY-3s and above) be pro-active in their role: making conscientious
efforts to contact their residents on a regular basis; providing feedback and
constructive instruction (regarding diagnoses, treatment plans, professional
behavior, or other attributes); and consistently helping residents identify
areas to improve patient safety and their own patient care. Communica-
tion should not be left solely to the discretion of residents to contact their
supervisors to address concerns or clarify questions they may have. Supervi-
sor-initiated contact, regardless of resident competency level, can serve to
catch problems with treatment plans or handle unexpected events sooner
than waiting for interns or residents to contact them, ultimately helping to
prevent patient harm. As previously mentioned, faculty and other supervi-
sors may need to be trained in this type of interaction to introduce it on a
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4 RESIDENT DUTY HOURS
the duty hour constraints limiting their schedules, these techniques provide
additional opportunities for residents to gain applicable clinical knowledge
without risk to patient safety. Simulation-based training enables trainees to
learn the necessary competencies (i.e., knowledge, skills, attitudes) (Salas
et al., 2005) and has been shown to improve performance in clinical skills,
such as procedural training (Lindquist et al., 2008; Medina et al., 2000;
Sica et al., 1999; Wong, 2004), and in nonclinical skills, including com-
munication, cooperation, leadership, and decision making (Medina et al.,
2000; Østergaard, 2004; Sica et al., 1999).
Simulation-based training is an effective training strategy when utilized
properly (Salas et al., 2008). Practice must be guided (through crafted
scenarios and timely, diagnostic feedback) to keep residents focused on
learning key competencies (Salas and Burke, 2002). 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. 120). Both medical students and physi-
cians have identified simulation-based training as a valuable tool for edu-
cational purposes (Bond and Spillane, 2002; Bond et al., 2001; Gordon,
2000; Gordon et al., 2001; Halamek et al., 2000). Several electronic tools
have also been shown to provide residents with learning opportunities in
the absence of available faculty, helping them to learn more efficiently on
their own (Cook et al., 2008).
Assessing effectiveness of specific simulation courses or methods is be-
yond the scope of this study. Numerous types and levels of simulation exist,
each for different intents, purposes, and costs. The committee encourages
examination and evaluation of the various simulation tools and methods
that might serve to support educational redesign solutions, innovational
training, and student evaluation.
Long-Block Design
In an effort to move away from service-oriented inpatient training
toward education-oriented training, an Educational Innovations Project
sponsored by ACGME was piloted by Warm and colleagues (2006) for
ambulatory care training in internal medicine. A continuous year-long am-
bulatory group practice, called a “long-block,” was created (beginning in a
resident’s 17th month of training) and separated from traditional inpatient
responsibilities. This long-block practice replaced sporadic ambulatory
training rotations previously completed over 3 years and was scheduled to
comply with duty hour limits. Results showed positive outcomes in multiple
areas including increased resident and patient satisfaction and improve-
ments in quality processes, outcome measures, and care continuity (Warm
et al., 2008). Residents reported more time for learning and increased
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IMPROVING THE RESIDENT LEARNING ENVIRONMENT
ability to focus in clinic with fewer interruptions in the long-block setting.
They also reported better patient relationships and increased ownership of
patient care (Warm et al., 2008).
Quality Improvement Techniques
Other redesign efforts, such as those based on teaching quality im-
provement (QI) techniques to residents, have also been effective. For ex-
ample, one internal medicine residency program sought to achieve one
of ACGME’s new six core competencies—practice-based learning and
improvement—which addresses “the need to teach and evaluate residents’
ability to apply quality improvement in their medical practice.” The faculty
of this program chose to teach this competency by modifying the curricu-
lum readings to focus on quality of care (which other programs have done),
but also by having residents reflect on their work with faculty and evaluate
their practice performances (Holmboe et al., 2005). The outcomes showed
that residents involved in this education intervention were more likely to
perform quality of care measures for their diabetic patients, which resulted
in more positive patient outcomes and improved resident satisfaction with
their education (Holmboe et al., 2005).
A more recent study also aimed to teach internal medicine residents
QI concepts and assessment techniques. Positive outcomes resulted after
redesigning ambulatory block rotations and introducing a new curriculum
specifically geared to achieve QI and assessment goals (Oyler et al., 2008).
The authors note that teaching these skills can be difficult with limited
staff availability or familiarity with the topics, but that using the American
Board of Internal Medicine’s practice improvement module for preventive
services was useful in overcoming these challenges. The new curriculum
improved resident confidence with assessing QI and learning how to apply
QI practices in their continuity clinics (Oyler et al., 2008).
The educational redesign approaches presented above each has its
strengths for teaching residents more effectively and efficiently. Additional
innovations exist (Wong, 2006) and more are encouraged. It will be impor-
tant 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. The
lack of published studies in most disciplines make assessments of educa-
tional outcomes difficult. There seems to be a general impression from
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0 RESIDENT DUTY HOURS
residents that their educational quality has remained relatively unchanged
since the implementation of duty hour restrictions, while supervisors and
faculty perceive that education has deteriorated in some instances. Look-
ing at quantitative measures of educational outcomes, different programs
and specialties have reported varying degrees of maintaining procedural
volume or resident test scores since the 2003 duty hour limits. However,
many of the more rigorous studies reported programs that managed either
to sustain or improve these outcomes. With demanding workloads and
less time in which to teach or learn, a new approach for graduate medical
education—befitting the evolving medical landscape of the 21st century—is
necessary.
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 ef-
fects 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 encour-
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