Orientation for Residents and Fellows
Office of GME
June 18, 2013
Jeanette Morrison, MD
Associate Professor of Medicine
Associate Dean for GME and DIO
Program Director, Department of Medicine
Chicago Medical School
Rosalind Franklin University of Medicine and Science
Objectives
• Become familiar with the role of the GME office and how
we relate to various other groups
– RRC, ACGME, CMS, FHCC, Departments of Medicine,
Psychiatry
• Understand key policies pertinent to all residents and
fellows
• Know where to go for help/resources
• Be aware of changing accreditation standards
– CLER = Clinical Learning Environment Review
• Recognize the signs of fatigue in residency training
– Basic understanding of the importance of sleep and the impact that
sleep deprivation has on function, competence, mood, vitality, and
overall health
• Context of Lifelong Physician Wellness and Self Care
– Balancing personal and professional lives
– Preventing and managing stress/burnout/impairment
GME Office
• http://www.rosalindfranklin.edu/cms/GMEOffice.aspx
• Manual of Policies & Procedures
http://www.rosalindfranklin.edu/Portals/4/Documents/Clinical%20Affairs/hyperlinks%20and%20bookmarks%20GME%20Ma
nual%20April%2020%202012%20-%20(1).pdf
• Key personnel
– Jeanette Morrison, MD
– Elsa Kurien, MA, MEd
– Diane O’Gara
• Any issue related to:
– RFUMS/CMS Policies and Procedures
– Salaries, benefits, contracts
– Learning environment
Important to know…
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RRC = Residency Review Committee
ACGME = Accreditation Council for GME
CMS/RFUMS
FHCC
ACGME Competencies
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Patient Care = What you do
Medical Knowledge = What you know
Practice Based Learning = How you get better
Interpersonal and Communication Skills = How you
interact with others
• Professionalism = How you act
• Systems Based Practice = How you work with the
system
Key policies
• Statement of commitment to GME
• Healthcare Industry Interactions in Education
• Promotion, Deficiency, Remediation, Misconduct,
Probation, Dismissal, and Contracts
• Grievances
• Leave
• Moonlighting
• Impaired Physicians
• Clinical Learning Environment
– Patient Safety, Quality Improvement, Supervision,
Transitions of Care, Duty hours/Fatigue Management,
Professionalism
Statement of Commitment
May 17, 2013
• Chicago Medical School is committed to supporting Graduate
Medical Education (GME) programs of the highest caliber. The
goal of these programs, consistent with the strategic goals of
Chicago Medical School and Rosalind Franklin University of
Medicine & Science, is the training of highly skilled, scholarly
physicians whose practices will engender the highest ideals of
compassion and professionalism.
Healthcare Industry
Interactions in Education
•
The following italicized words are selected excerpts from that policy:
• For purposes of this policy, health care industry means a commercial
entity (or one of its representatives) that manufactures, sells, or
otherwise provides medical devices, pharmaceuticals, medical
equipment, research equipment, health services, or other similar
products/services. Gifts to [a resident] from the health care industry are
prohibited. A gift to [a resident] means any payment to [a resident] or
provision to [a resident] of free or discounted items, medical samples
for personal use, food, or travel when the [resident] is not providing, in
return therefore, a service of similar or greater value. For example:
pens, notepads, free textbooks, free meals, payment for attending a
meeting, and samples are all considered gifts. [Residents] may not
attend or participate in any purported professional continuing education
program that is sponsored by the health care industry but that is not
accredited [by the ACCME].
• Promotion
– Program director determines promotion using academic
judgment
– Resident must demonstrate proficiency in established
competencies, appropriate progress, fulfill requirements
– Non-promotion is determined by program director
• At least 4 month notification or as soon as circumstances allow
• Deficiency
– Resident does not perform or progress as appropriate,
failure to comply with policies
• Remediation of deficiency
• Misconduct
– Any act or acts of a resident that amounts to or attempts
to amount to:
• Assault, violence, cheating, lying, abuse, etc.
– when such act or acts relate to the residency program
• Obligation to report to Program Director
• Investigation
• Determination to be made by Program Director
– No action, probation, non-renewal of contract,
immediate dismissal
Complaints and grievances
• All complaints and grievances
– Program Director
– If complaint or grievance is against PD, submit
to Associate Dean for GME
• EXCEPT decisions of PD to not promote,
not renew residency contract, dismiss, or
lengthen training
– Dean of CMS
Leave
• Up to 30 days of annual leave per academic year
– Proportionate to the amount of the academic year
served in pay status
– Must be used in the year it was accrued
• Sick leave policies vary by program/employer
• Consider specialty board policies regarding
completion and eligibility
Moonlighting
• Must have written permission from program
director
• Must have permanent Illinois license
• Time spent moonlighting counts toward
duty hours
• Professional liability insurance does NOT
cover moonlighting
Impaired physician
• An impaired physician is a resident or fellow,
involved in training or research, licensed to
practice medicine in the State of Illinois, who is
unable to practice medicine with reasonable skill
and safety to patients because of mental or
physical illness or shortcoming.
• Notify Program Director immediately if you
suspect behavior that may indicate impairment
Where to go for help
• Program Resources
– Program Director, Faculty, Chief Resident
• GME Office
• Human Resources
• University Counseling Center
Accreditation Standards
2013: Next Accreditation System = NAS
Continuous data reporting to ACGME, including:
Annual resident survey
Annual faculty survey
Boards pass rate
Scholarly activity
CLER visit - clinical learning environment report
– Patient Safety, Quality Improvement, Supervision,
Transitions of Care, Duty hours/Fatigue Management,
Professionalism
Coffee Break!
Objectives
• Become familiar with the role of the GME office and how
we relate to various other groups
– RRC, ACGME, CMS, FHCC, Departments of Medicine,
Psychiatry
• Understand key policies pertinent to all residents and
fellows
• Know where to go for help/resources
• Be aware of changing accreditation standards
– CLER = Clinical Learning Environment Review
• Recognize the signs of fatigue in residency training
– Basic understanding of the importance of sleep and the impact that
sleep deprivation has on function, competence, mood, vitality, and
overall health
• Context of Lifelong Physician Wellness and Self Care
– Balancing personal and professional lives
– Preventing and managing stress/burnout/impairment
Clinical Learning Environment
• Are residents engaged in institutional programs
designed to enhance patient safety and quality of
care?
• Is this the environment in which I want my doctor
to be trained?
• 6 key areas
• Driven by continuous GME reform over past 30
years
– Duty hours/sleepiness and fatigue/supervision
Sleepiness and Fatigue
• Issues in residency training
– Recognizing sleepiness and fatigue
– Consequences of sleepiness and fatigue
• Professional
• Personal
– Interventions
• Personal
• Organizational
• Current ACGME Regulations
– Outcomes of ACGME Regulations
Physician Wellness and Self Care
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Healthy Sleep
Exercise
Good Nutrition
Develop and Maintain supportive
relationships
Health Benefits of Sleep
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Cognition
Learning
Creativity
Productivity
Mood
Vitality
Growth, Cellular Repair
Immune Function
Quantity of Sleep
How long would you sleep if left to
awaken spontaneously?
How alert do you feel after different
quantities of sleep?
Mean = 8 hours with considerable variation
<4 or >10 hours per night may be
associated with higher mortality (Arch
Gen Psychiatry 1979;36:103.)
Consequences of Sleep
Deprivation - General
• Cognitive Functioning
– Short term memory, attention, information processing
• Mental Status
– Depression, Anxiety, Irritability, Anger, Hostility
• Accidents
– MVAs, Major catastrophes
• Quality of Life
• Physiology
- Impaired reaction time, judgment, vision
• Immune Function
• Vascular Inflammation and Dysfunction
Fatigue, alcohol, and performance
impairment
_________________
D Dawson, K Reid. Nature 1997. 388:235.
Measuring sleepiness
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Multiple Sleep Latency Test (MSLT)
Maintenance of Wakefulness Test
Stanford Sleepiness Scale
Epworth Sleepiness Scale
Sleep Debt
• “Nature’s Loan Shark”
• Between 25 and 50 hours of “sleep debt”
begins to result in impairment
• Feeling drowsy signifies the need for sleep!
• If ignored or resisted, sleep may happen
when it is dangerous, inconvenient, or rude
“Drowsiness is RED ALERT”
- William Dement, MD, PhD
Consequences of Sleepiness and
Fatigue - Residents
• Professional
– Quality of Patient Care, Patient Safety
• Personal
– Safety, Satisfaction, Education, Relationships
Sleepiness and Fatigue Residents
• Mood, Affect, Attitude, Empathy
• Performance
– Psychomotor Testing
– Simulated clinical scenarios
• Crises or novel situations
• Sustained concentration or vigilance
– Actual Clinical Practice
• Personal safety
Mood, Affect, Attitude, Empathy
• Questionnaire and interviews of interns
• Sleep-deprived interns reported more
sadness, less social affection, more
difficulty thinking, depression, irritability,
and recent memory deficits.
_________________
Friedman, et al. NEJM 1971;285:201-203.
Friedman et al. J. Med Educ 1973:48:436-441.
Mood, Affect, Attitude, Empathy
• Longitudinal study of 27 interns at four times
during internship
• Anger, fatigue, dysphoria increased as the year
progressed and were negatively correlated with
amount of sleep in previous week.
_______________
Ford CV, Wentz DK. Southern Medical Journal 1984;77:1435-1442.
Mood, Affect, Attitude, Empathy
• 149 residents (60 interns) from 5 Medical Centers
and 6 specialties
• Focus groups and questionnaire (ESS)
• 64% stated that sleep loss and fatigue had
“major impact on my personal life”
• 46% stated that sleep loss and fatigue had “major
impact on my work”
______________
Papp KK, et al. Academic Medicine 2004;79:394-406.
Performance
Anecdotes
Artificial experimental situations
• Suturing, intubating mannequins,
laparoscopy
• Board exam questions
• Reading ECGs
Clinical Outcomes
Performance
Tasks that require sustained vigilance and
concentration are the most sensitive to
fatigue and sleep loss
____________
Samkoff JS et al. Academic Medicine 1991;66:687.
Performance
• 11 Anesthesia residents at Stanford
• 3 separate conditions
– Normal baseline work schedule
– After 24 hour call
– Following a period of extended sleep
• Subjective ability to determine their own level of
sleepiness was inconsistent
• Ability to discriminate the onset of sleep was poor: did not
know they had fallen asleep (by EEG criteria) 49% of
episodes
__________________
Howard SK et al. Academic Medicine 2002; 77:1019-1025.
Personal Safety
• Motor Vehicle Accidents
• National prospective cohort study
– 2737 Interns July 2002 - May 2003
– OR of MVA or near miss MVA after 24
hour shift compared to less than 24 hour
shift was 2.3 (1.6 - 3.3)
________________
Barger et al. NEJM 2005
Personal Safety
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Needlestick Injury
National prospective cohort study
2737 Interns
July 2002- May 2003
498 percutaneous injuries
Self reported lapses in concentration and fatigue
were two most commonly reported contributing
factors
_________________________
Ayas et al. JAMA 2006
Sleepiness and Fatigue is not just
an issue for residency…
• Healthy sleep is important for the rest of
your life
– Personal
– Professional
Not just an issue for residency…
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National Sleep Foundation
2007
1000 women
22% reported sleepiness interferes with daily
activities at least a few days per week
• 27% had driven drowsy at least once per month in
the past year
• 29% reported a “good nights sleep” only a few
nights per month or less
Solutions?
Preventive and Operational
Countermeasures
• Pharmacologic
• Napping
• Planning and Monitoring
–Self
–Institutional
–ACGME
Pharmacologic
• Consider Caffeine
– Short term immediate benefits of 1 or 2 cups of
coffee
Addictive
Side Effects
• Avoid Alcohol
– Interferes with effective sleep
“I love a good nap. Sometimes it’s the
only thing getting me out of bed in the
morning.”
-George Costanza
• “Napping is by far the most important and effective tool
for coping with sleep crises”
• “Naps can make you smarter, faster, and safer than you
would be without them”
• “…people should be proud of the decision to take an
emergency or preventive nap when driving a car or
…people’s lives are at stake.”
- William Dement, MD, PhD
• 38 Medicine interns at U of Chicago from 20032004
• 12 months, two weeks each of:
• “Nap schedule”
– Coverage from midnight to 7am
• Standard Schedule
– No additional coverage
_______________
Arora V, et al. Annals of Internal Medicine 2006
• More sleep on “Nap schedule”
– 2 hours, 20 minutes versus 3 hours
• Less Overall fatigue (as per SSS), p = 0.017
• Concerns about discontinuity of care limited the
use of coverage by the interns
______________________________________________________
Arora V, et al. Annals of Internal Medicine 2006
What defines a “nap”
• 5 minutes - 4 hours during the daytime
• “Emergency” nap
– To cope with drowsiness
• “Preventive” nap
– Prior to staying up all night
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The longer the nap, the greater the benefit
“Prophylactic naps”
45 minutes -----> 6 hours
60 minutes ----> 10 hours
60-120 minutes ------> 24 hours
Planning and Monitoring
• Self
– How do you use your free time?
– Good sleep habits/sleep hygiene
• Institutional
– Facilitate balance between personal time for sleep and
educational activities
– Ensure quality of patient care
– Limit changes in shift schedules
• ACGME/RRC
– “Duty Hours”
Evolution of “duty hours”
• 1984 death of Libby Zion
18 year old college freshman
Low grade fever, earache (erythromycin)
Agitation, “jerking movements”, lucid with periods of
confusion
PMH: Depression
Meds: Erythromycin, Phenelzine, Percodan
Marijuana. Denied cocaine use
T = 103
WBC = 18,000
• Admit to Medicine
– 9 month intern with resident supervision
– 40 patients
– Spoke with attending once
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“Viral syndrome with hysteria”
3:30 am - Meperidine for “shaking”
4:15 am - 4 point restraints (by phone)
4:30 am - Haloperidol (by phone)
6:30 am - T = 107
7:00 am - Cardiac Arrest and Death
Five stories about what happened
to Libby Zion - and why
• Medical Malpractice
• “Broken medical system” that left overworked and
unsupervised doctors in charge of her care
• Unpreventable death from unidentified cause
• Illicit cocaine use (which she concealed from her
doctors)
• Actually, she “died twice,” first at the hospital,
then as the victim of a vicious smear campaign
_____________________
Barron H. Lerner, When Illness Goes Public: Celebrity Patients and How we Look at Illness, p. 201.
80 hours?
• 17 recommendations for reform
– 1 for duty hour reform
• “80 hours”
– 10 hour day for five days, 1 in 4 call
• “Supervision in the hospital at all times by
licensed physicians who are residency trained and
board prepared or board certified.”
• “Improving the quality of patient care will come
from supervision, not regulation of hours.”
___________________
Bertrand Bell. JAMA 2007.
ACGME duty hour rules
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Effective July 1, 2003
Maximum 80 hours per week
On-call not to exceed Q 3
One full day off per week
24 hour “shift” with additional 6
hours
• 10-hour break
Results of ACGME Regulation
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Safety of patients
Safety of residents
Perceptions of Education
Quality of patient care
Compliance with regulations
Effect of Duty Hour Reform on
Patient Outcomes
• Decreased attentional failures in the ICU
• Fewer serious medical errors in the ICU
– Diagnostic errors, medication errors, no
difference in adverse events
_____________
Landrigan et al. NEJM 2004
Lockley et al. NEJM 2004
• Decreased or no change in hospital mortality
– Decreased mortality in “teaching intensive” VA
hospitals for medical, not surgical patients
– No difference in non-federal Medicare patients
– Decreased mortality among high risk medical (not
surgical) patients in community hospitals
• Decreased ICU utilization
• Increased rate of discharge to home or rehab
• There can be documentable, significant
consequences of inadequate sign out
________________
Volpp et al. JAMA 2007
Shetty. Ann Int Med 2007
Horwitz et al. Ann Int Med 2007
Horwitz et al. Arch IM 2008
• No consistent change in outcomes among high
risk medical or surgical patients
• Total hours of work and sleep did not change,
though less “burn out”
• Noncompliance with regulations was high in first
year of implementation
__________________
Volpp. JGIM 2009
Landrigan. Pediatrics 2008
Landrigan. JAMA 2006.
FIGURE 1 Proportions of residents reporting MVCs, near-miss MVCs, occupational
exposures, and medical errors, before (pre) and after (post) implementation of the
ACGME duty hour standards
Landrigan, C. P. et al. Pediatrics 2008;122:250-258
Copyright ©2008 American Academy of Pediatrics
IOM recommendations
December 2008
“…revisions to medical residents workloads
and duty hours are necessary to better
protect patients against fatigue-related
errors and to enhance the learning
environment for doctors in training.”
July 2011
• Supervision
– Clearly defined, progressive responsibility, levels of
supervision
• Workload
– Specialty specific, resident specific
• Transitions of care and communication between
team members
• Duty Hours
– 80 hours/week
– PGY1 not to exceed 16 hours
– PGY2 and above 24 + 4 hours
• “Strategic napping” is strongly encouraged
Additional areas of reform - 2013
• Education
– Patient Safety, Quality Improvement
• Interprofessional Teams
• Evaluation and assessment
– Competency-based, Milestones
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Accreditation
Medicare
Professionalism
Technological/EMR
Take Home Points - SLEEP
• Daytime Drowsiness = Insufficient Sleep
– Manage your Sleep Debt
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Drowsiness is Red Alert
Be sensitive to your level of drowsiness
There is no substitute for Sleep!
Naps are important/underrated/healthy
Healthy Sleep is an important aspect of wellness
– Exercise, Nutrition, Relationships
• Avoid driving between 2 am and 9 am
• Interaction between alcohol and sleep loss
can be very dangerous
• There is no substitute for sleep!
Past, Present, and Future GME
reform
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Patient Safety
Quality of care
Education
Professional standards
Competency
Resident safety
Resident satisfaction
Faculty workload and satisfaction
Cost
Public scrutiny
Objectives
• Become familiar with the role of the GME office and how
we relate to various other groups
– RRC, ACGME, CMS, FHCC, Departments of Medicine,
Psychiatry
• Understand key policies pertinent to all residents and
fellows
• Know where to go for help/resources
• Be aware of changing accreditation standards
– CLER = Clinical Learning Environment Review
• Recognize the signs of fatigue in residency training
– Basic understanding of the importance of sleep and the impact that
sleep deprivation has on function, competence, mood, vitality, and
overall health
• Context of Lifelong Physician Wellness and Self Care
– Balancing personal and professional lives
– Preventing and managing stress/burnout/impairment