Educating Clerkship Students in the Era of Resident Duty Hour Restrictions
2011; Elsevier BV; Volume: 124; Issue: 7 Linguagem: Inglês
10.1016/j.amjmed.2011.03.019
ISSN1555-7162
AutoresL. James Nixon, Meenakshy Aiyer, Steven J. Durning, Chris Gouveia, Jennifer R. Kogan, Valerie J. Lang, Olle ten Cate, Karen E. Hauer,
Tópico(s)Emergency and Acute Care Studies
ResumoIn 2003, the Accreditation Council for Graduate Medical Education defined for the first time an upper limit on the number of hours that residents can work. This initial reduction in work hours was made with the goal of improving patient safety, resident education, and resident well-being.1Steinbrook R. The debate over residents' work hours.N Engl J Med. 2002; 347: 1296-1302Crossref PubMed Scopus (157) Google Scholar Now, 8 years later, further duty hour restrictions are slated to take effect July 1, 2011. These new reductions are largely a response to growing public concern about the effects of sleep deprivation on residents.2Ulmer C.W.D. Johns M.eds Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. National Academies Press, Washington, DC2008Google Scholar Educators and residents alike have mixed opinions about the effects of prior and future duty hour restrictions on resident education.3Drolet B.C. Spalluto L.B. Fischer S.A. Residents' perspectives on ACGME regulation of supervision and duty hours—a national survey.N Engl J Med. 2010; 363: e34Crossref PubMed Scopus (83) Google Scholar The potential effects of resident duty hour restrictions on medical student education have received less attention.Perspectives Viewpoints•Changes to graduate medical education have the potential to affect medical students' experiences and learning during their clerkships.•This paper provides an overview of the current knowledge of the effects of duty hour restrictions (DHR) on medical student education to guide educators in planning for consequences of further resident DHR.•In light of the greater time pressure during rounds, models for improving teaching efficiency and effectiveness should be adopted.•It may be time to consider whether students would be better served by a new structure of undergraduate training that is less dependent on residents, and could include innovative strategies such as simulation or longitudinal integrated clerkships. •Changes to graduate medical education have the potential to affect medical students' experiences and learning during their clerkships.•This paper provides an overview of the current knowledge of the effects of duty hour restrictions (DHR) on medical student education to guide educators in planning for consequences of further resident DHR.•In light of the greater time pressure during rounds, models for improving teaching efficiency and effectiveness should be adopted.•It may be time to consider whether students would be better served by a new structure of undergraduate training that is less dependent on residents, and could include innovative strategies such as simulation or longitudinal integrated clerkships. Changes to graduate medical education have the potential to affect medical students' experiences and learning during their clerkships. With further duty hour restrictions imminent, now is the ideal time to learn from past duty hour restrictions and predict the likely effects of further resident duty hour restrictions on medical students. A forward-looking approach to the new duty hours regulations allows medical educators to anticipate, and potentially prevent, negative effects while providing an opportunity to capitalize on potential benefits. This article provides an overview of the current knowledge of the effects of duty hour restrictions on medical student education to guide educators in planning for consequences of further resident duty hour restrictions. A literature review was conducted using the MeSH subheadings “internship and residency” and “students, medical.” These reviews were then combined with separate key word searches using the terms “duty hours” and “work hours.” For articles deemed relevant to this topic, a related article search was conducted in PubMed and included articles' references were reviewed for relevance. The authors of this article include clerkship directors and medical educators, and many have published previously on this topic. This article was reviewed and endorsed by the Clerkship Directors in Internal Medicine Council in January 2011. A narrative review of the literature demonstrates that most of the concerns regarding resident duty hour restrictions and medical student education address 4 key areas. These areas include teaching, discontinuity, team structure, and educational climate. Teaching concerns relate to residents' role as educator and rounds and the role of the attending. Discontinuity concerns relate to shift work and handoffs. For each area, we have summarized the current literature and interpreted the effects of these changes on medical student education. We also include best practices for teaching students in the context of these changes. A significant percentage of medical student teaching is provided by residents.4Boex J.R. Leahy P.J. Understanding residents' work: moving beyond counting hours to assessing educational value.Acad Med. 2003; 78: 939-944Crossref PubMed Scopus (69) Google Scholar, 5O'Sullivan P.S. Weinberg E. Boll A. Nelson T.R. Students educational activities during clerkship.Acad Med. 1997; 72: 308-313Crossref PubMed Scopus (18) Google Scholar, 62010 Medical School Graduation QuestionnaireFinal All Schools Report. Association of American Medical Colleges, 2010.https://www.aamc.org/download/140716/data/2010_gq_all_schools.pdfGoogle Scholar, 7Nixon L.J. Benson B.J. Rogers T. et al.Effects of Accreditation Council for Graduate Medical Education work restrictions on medical student experience.J Gen Intern Med. 2007; 22: 937-941Crossref PubMed Scopus (14) Google Scholar As duty hour restrictions limit time to provide patient care, advance their own education, and teach students, residents may sacrifice teaching in an effort to address their other responsibilities. The majority of residents,8Zahn C.M. Dunlow S.G. Alvero R. et al.Too little time to teach? Medical student education and the resident work-hour restriction.Mil Med. 2007; 172: 1053-1057PubMed Google Scholar, 9Lin G.A. Beck D.C. Garbutt J.M. Residents' perceptions of the effects of work hour limitations at a large teaching hospital.Acad Med. 2006; 81: 63-67Crossref PubMed Scopus (41) Google Scholar faculty,10Reed D.A. Impact of duty hour regulations on medical students' education: views of key clinical faculty.J Gen Intern Med. 2008; 23: 1084-1089Crossref PubMed Scopus (22) Google Scholar and clerkship directors11Kogan J.R. The impact of resident duty hours reform on the internal medicine core clerkship: results from the clerkship directors in internal medicine.Acad Med. 2006; 81: 1038-1044Crossref PubMed Scopus (35) Google Scholar perceived that the effects of the 2003 duty hour restrictions would leave residents with less time for teaching and possibly more negative attitudes toward teaching. Studies of students' perceptions of the teaching provided by their residents after 2003 resident duty hour restrictions tell a different story. They found either no difference or an increase in residents' direct teaching of students7Nixon L.J. Benson B.J. Rogers T. et al.Effects of Accreditation Council for Graduate Medical Education work restrictions on medical student experience.J Gen Intern Med. 2007; 22: 937-941Crossref PubMed Scopus (14) Google Scholar, 12Kogan J.R. Bellini L.M. Shea J.A. The impact of resident duty hour reform on a medicine core clerkship.Acad Med. 2004; 79: S58-S61Crossref PubMed Scopus (17) Google Scholar and in resident availability for and interest in teaching post-duty hour restrictions.13Jagsi R. Shapiro J. Weinstein D.F. Perceived impact of resident work hour limitations on medical student clerkships: a survey study.Acad Med. 2005; 80: 752-757Crossref PubMed Scopus (22) Google Scholar What about the quality of that teaching? Some studies have shown no effect or a positive effect on the quality of resident teaching,7Nixon L.J. Benson B.J. Rogers T. et al.Effects of Accreditation Council for Graduate Medical Education work restrictions on medical student experience.J Gen Intern Med. 2007; 22: 937-941Crossref PubMed Scopus (14) Google Scholar, 13Jagsi R. Shapiro J. Weinstein D.F. Perceived impact of resident work hour limitations on medical student clerkships: a survey study.Acad Med. 2005; 80: 752-757Crossref PubMed Scopus (22) Google Scholar, 14Arora V.M. Effect of student duty hours policy on teaching and satisfaction of 3rd year medical students.Am J Med. 2006; 119: 1089-1095Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar whereas others found greater student dissatisfaction with teaching at the bedside,15Brasher A.E. Medical students' perceptions of resident teaching: have duty hours regulations had an impact?.Ann Surg. 2005; 242: 548-553PubMed Google Scholar the quality of feedback, and the overall teaching quality and accessibility.16White C.B. Multidimensional effects of the 80-hour work week at the University of Michigan Medical School.Acad Med. 2006; 81: 57-62Crossref PubMed Scopus (34) Google Scholar Studies showing more negative effects of duty hour restrictions on student education tended to be single institution reports from surgically oriented clerkships.15Brasher A.E. Medical students' perceptions of resident teaching: have duty hours regulations had an impact?.Ann Surg. 2005; 242: 548-553PubMed Google Scholar, 16White C.B. Multidimensional effects of the 80-hour work week at the University of Michigan Medical School.Acad Med. 2006; 81: 57-62Crossref PubMed Scopus (34) Google Scholar In teaching hospitals, attending rounds are a core activity whereby students learn the practice of medicine and are the primary means for information exchange in the provision of patient care. Learners on the clinical wards value faculty who are available and interested in teaching.17Sutkin G. Waner E. Harris I. Schiffer R. What makes a good clinical teacher in medicine? A review of the literature.Acad Med. 2008; 83: 452-466Crossref PubMed Scopus (256) Google Scholar, 18Ullian J.A. Bland C.J. Simpson D.E. An alternative approach to defining the role of the clinical teacher.Acad Med. 1994; 69: 832-838Crossref PubMed Scopus (85) Google Scholar Faculty, especially if heavily involved with student teaching, tend to believe that duty hour restrictions will threaten their attending role.10Reed D.A. Impact of duty hour regulations on medical students' education: views of key clinical faculty.J Gen Intern Med. 2008; 23: 1084-1089Crossref PubMed Scopus (22) Google Scholar, 11Kogan J.R. The impact of resident duty hours reform on the internal medicine core clerkship: results from the clerkship directors in internal medicine.Acad Med. 2006; 81: 1038-1044Crossref PubMed Scopus (35) Google Scholar, 19Harrison R. Allen E. Teaching internal medicine residents in the new era: inpatient attending with duty hour regulations.J Gen Intern Med. 2006; 21: 447-452Crossref PubMed Scopus (29) Google Scholar Concerns include less time available for teaching during rounds, less bedside teaching,11Kogan J.R. The impact of resident duty hours reform on the internal medicine core clerkship: results from the clerkship directors in internal medicine.Acad Med. 2006; 81: 1038-1044Crossref PubMed Scopus (35) Google Scholar and an overall decline in the medical student educational experience post-duty hour restrictions.10Reed D.A. Impact of duty hour regulations on medical students' education: views of key clinical faculty.J Gen Intern Med. 2008; 23: 1084-1089Crossref PubMed Scopus (22) Google Scholar Another concern is that duty hour restrictions may alter attending rounds' discussions to render them less educationally valuable for students. Internal medicine attending and resident physicians in a focus group study thought that rounds post-duty hour restrictions emphasized the clinical and managerial aspects of rounding (focused on making clinical decisions) at the expense of teaching.19Harrison R. Allen E. Teaching internal medicine residents in the new era: inpatient attending with duty hour regulations.J Gen Intern Med. 2006; 21: 447-452Crossref PubMed Scopus (29) Google Scholar Specifically, attendings were concerned that compressed time and emphasis on rounding efficiency had the potential to limit medical student opportunities to give traditional long patient presentations and learn from attendings at the bedside. Attendings did acknowledge that the increased focus of rounds on clinical care promoted opportunities to observe how learners process information in real time.19Harrison R. Allen E. Teaching internal medicine residents in the new era: inpatient attending with duty hour regulations.J Gen Intern Med. 2006; 21: 447-452Crossref PubMed Scopus (29) Google Scholar This perception of less time for teaching is supported by a study that found 29% of rounding time was spent on educational activities in internal medicine pre-duty hour restrictions,20Elliot D.L. Hickam D.H. Attending rounds on in-patient units: differences between medical and non-medical services.Med Educ. 1993; 27: 503-508Crossref PubMed Scopus (27) Google Scholar whereas a separate study performed post-duty hour restrictions found that 9% of time during internal medicine rounds was spent on educational activities.21Priest J.R. Bereknyei S. Hooper K. Braddock C.H. Relationships of the location and content of rounds to specialty, institution, patient-census, and team size.PLoS One. 2010; 5: e11246Crossref PubMed Scopus (21) Google Scholar Attendings' predominantly negative views of duty hour restrictions contrast with the majority of studies evaluating student perspectives. Students generally perceived little impact of duty hour restrictions on attending availability or quality of teaching.7Nixon L.J. Benson B.J. Rogers T. et al.Effects of Accreditation Council for Graduate Medical Education work restrictions on medical student experience.J Gen Intern Med. 2007; 22: 937-941Crossref PubMed Scopus (14) Google Scholar, 12Kogan J.R. Bellini L.M. Shea J.A. The impact of resident duty hour reform on a medicine core clerkship.Acad Med. 2004; 79: S58-S61Crossref PubMed Scopus (17) Google Scholar, 13Jagsi R. Shapiro J. Weinstein D.F. Perceived impact of resident work hour limitations on medical student clerkships: a survey study.Acad Med. 2005; 80: 752-757Crossref PubMed Scopus (22) Google Scholar, 16White C.B. Multidimensional effects of the 80-hour work week at the University of Michigan Medical School.Acad Med. 2006; 81: 57-62Crossref PubMed Scopus (34) Google Scholar Specifically, students' ratings of attendings' interest, skill, and availability, as well as the quality and quantity of their feedback, did not significantly change.13Jagsi R. Shapiro J. Weinstein D.F. Perceived impact of resident work hour limitations on medical student clerkships: a survey study.Acad Med. 2005; 80: 752-757Crossref PubMed Scopus (22) Google Scholar Similarly, duty hour restrictions did not translate into decreased teaching by attendings or decline in teaching quality or feedback provided in the medicine or surgery clerkships.7Nixon L.J. Benson B.J. Rogers T. et al.Effects of Accreditation Council for Graduate Medical Education work restrictions on medical student experience.J Gen Intern Med. 2007; 22: 937-941Crossref PubMed Scopus (14) Google Scholar In addition, there was no change in the proportion of time medicine clerkship students spent on attending rounds or the ratings of their educational value pre- to post-duty hour restrictions.12Kogan J.R. Bellini L.M. Shea J.A. The impact of resident duty hour reform on a medicine core clerkship.Acad Med. 2004; 79: S58-S61Crossref PubMed Scopus (17) Google Scholar Notable exceptions to these general trends include a decline in availability of faculty post-duty hour restrictions for surgical services at one institution16White C.B. Multidimensional effects of the 80-hour work week at the University of Michigan Medical School.Acad Med. 2006; 81: 57-62Crossref PubMed Scopus (34) Google Scholar and a decline in pediatrics teaching at another.7Nixon L.J. Benson B.J. Rogers T. et al.Effects of Accreditation Council for Graduate Medical Education work restrictions on medical student experience.J Gen Intern Med. 2007; 22: 937-941Crossref PubMed Scopus (14) Google Scholar It is difficult to reconcile resident and attending perceptions with student perceptions of duty hour restrictions. We were unable to locate any side-by-side comparison studies exploring these differences. It is possible that resident and attending effort or other structural changes have protected students from these effects. Alternatively, different perspectives may stem from methodological difficulties in measuring differences, particularly without randomized controlled trials. Medical educators have expressed concern that increases in shift work will decrease student continuity with their team and patients. This discontinuity could erode students' sense of ownership for their patients, thereby impairing their professional development.11Kogan J.R. The impact of resident duty hours reform on the internal medicine core clerkship: results from the clerkship directors in internal medicine.Acad Med. 2006; 81: 1038-1044Crossref PubMed Scopus (35) Google Scholar, 22Schwartz A. Pappas C. Bashook P.G. et al.Conceptual frameworks in the study of duty hours changes in graduate medical education: a review.Acad Med. 2011; 86: 18-29Crossref PubMed Scopus (13) Google Scholar Similarly, excessive shift work could erode a learner's work ethic and sense of responsibility to patients.23Woodrow S.I. Segouin C. Armbruster J. et al.Duty hours reforms in the United States, France, and Canada: is it time to refocus our attention on education?.Acad Med. 2006; 81: 1045-1051Crossref PubMed Scopus (46) Google Scholar The actual impact of duty hour restrictions on student continuity with patients has been mixed. Key clinical faculty have worried that student ability to follow a patient throughout a hospitalization has worsened post-duty hour restrictions,10Reed D.A. Impact of duty hour regulations on medical students' education: views of key clinical faculty.J Gen Intern Med. 2008; 23: 1084-1089Crossref PubMed Scopus (22) Google Scholar whereas clerkship directors think that student ability to follow patients is unchanged.11Kogan J.R. The impact of resident duty hours reform on the internal medicine core clerkship: results from the clerkship directors in internal medicine.Acad Med. 2006; 81: 1038-1044Crossref PubMed Scopus (35) Google Scholar From the student perspective, despite reporting fewer hours worked at one institution, they noted no change in the quality of their relationships with patients pre- to post-duty hour restrictions.7Nixon L.J. Benson B.J. Rogers T. et al.Effects of Accreditation Council for Graduate Medical Education work restrictions on medical student experience.J Gen Intern Med. 2007; 22: 937-941Crossref PubMed Scopus (14) Google Scholar This finding may be partially explained by the lack of major structural change to the core medical student activities. The students worked fewer hours, but no changes were made to overnight call (absent pre- and post-duty hour restrictions) and no new experiences such as night float or day float were added. This observation may be transferable to other clerkships given the infrequency with which medicine clerkships have required overnight call both before and after duty hour restrictions.11Kogan J.R. The impact of resident duty hours reform on the internal medicine core clerkship: results from the clerkship directors in internal medicine.Acad Med. 2006; 81: 1038-1044Crossref PubMed Scopus (35) Google Scholar Most likely, required overnight call for medical students will continue to decline as residents do less overnight call. Whether students will start to have a role on night float or other teams outside of the traditional team remains unknown. The impact of overnight call on student learning is unclear, and students seem ambivalent about its value.24Corriere M. Denton D. Overnight call: a survey of medical student experiences, attitudes and skills.http://www.im.org/Meetings/Past/2010/AIMW10/Presentations/Documents/2010%20CDIM%20National%20Meeting/PSIII_Corriere.pdfGoogle Scholar In response to duty hour restrictions, many residency programs have implemented night float, day float, and other shift work models that can increase patient handoffs.25Reed D.A. Fletcher K.E. Arora V.M. Systematic review: association of shift length, protected sleep time, and night float with patient care, residents' health and education.Ann Intern Med. 2010; 153: 829-842Crossref PubMed Scopus (111) Google Scholar Concurrent with these changes, handoffs have been estimated to increase by 11% to 40%.26Vidyarthi A.R. Arora V. Schnipper J.L. Wall S.D. Wachter R.M. Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out.J Hosp Med. 2006; 1: 257-266Crossref PubMed Scopus (222) Google Scholar, 27Horwitz L.I. Krumholz H.M. Green M.L. Huot S.J. Transfers of patient care between staff on internal medicine wards.Arch Intern Med. 2006; 166: 1173-1177Crossref PubMed Scopus (226) Google Scholar Although transfers of care are becoming more prevalent, only 8% of medical schools have any curricula about handoffs.28Solet D.J. Norvell J.M. Rutan G.H. Frankel R.M. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs.Acad Med. 2005; 80: 1094-1099Crossref PubMed Scopus (381) Google Scholar Although the impact of night float on patient care, resident health, and resident education has been examined,25Reed D.A. Fletcher K.E. Arora V.M. Systematic review: association of shift length, protected sleep time, and night float with patient care, residents' health and education.Ann Intern Med. 2010; 153: 829-842Crossref PubMed Scopus (111) Google Scholar the implications for medical student learning and the overall clerkship experience are not clear. One study showed that “fresh” patients (ie, patients from the office or emergency department who have not been given a diagnosis to explain their clinical presentation) comprised just more than one half of student admissions and that the number of “fresh” patients a student admitted positively correlated with their score on the National Board of Medical Examiners' subject examination.29Lang V.J. Mooney C.J. O'Connor A.B. Bordley D.R. Lurie S.J. Association between handoff patients and subject exam performance in medicine clerkship students.J Gen Intern Med. 2009; 24 (Epub 2009 Jul 5): 1018-1022Crossref PubMed Scopus (11) Google Scholar Whether students will assume roles on night float or teams outside of the traditional team also is unknown, but the effects on their exposure to “fresh patients” will need to be considered. As residents have fewer hours in which to perform their work and attending physicians have increasing responsibility, hospital leaders have attempted to alter work load on the teaching services through addition of faculty-only teams, non-physician practitioners, or day float/night float residents.30Weinstein D.F. Duty hours for resident physicians—tough choices for teaching hospitals.N Engl J Med. 2002; 347: 1275-1278Crossref PubMed Scopus (99) Google Scholar, 31Gordon C.R. Axelrad A. Alexander J.B. Dellinger R.P. Ross S.E. Care of critically ill surgical patients using the 80-hour Accreditation Council of Graduate Medical Education work-week guidelines: a survey of current strategies.Am Surg. 2006; 72: 497-499PubMed Google Scholar These structural and workforce changes can affect medical student education by freeing up resident and attending time for teaching.32Cawley J.F. Hooker R.S. The effects of resident work hour restrictions on physician assistant hospital utilization.J Phys Asst Educ. 2006; 17: 41-43Google Scholar, 33Cooper R.A. New directions for nurse practitioners and physician assistants in the era of physician shortages.Acad Med. 2007; 82: 827-828Crossref PubMed Scopus (82) Google Scholar In fact, some of the programs observed positive or no effects of duty hour restrictions on student education when they used non-physician practitioners to offset the work of the teaching teams.12Kogan J.R. Bellini L.M. Shea J.A. The impact of resident duty hour reform on a medicine core clerkship.Acad Med. 2004; 79: S58-S61Crossref PubMed Scopus (17) Google Scholar, 16White C.B. Multidimensional effects of the 80-hour work week at the University of Michigan Medical School.Acad Med. 2006; 81: 57-62Crossref PubMed Scopus (34) Google Scholar Structural changes also may alter students' clinical responsibilities. In one example, duty hour restrictions shifted activities of minimal educational value to medical students on medicine and surgery clerkships.16White C.B. Multidimensional effects of the 80-hour work week at the University of Michigan Medical School.Acad Med. 2006; 81: 57-62Crossref PubMed Scopus (34) Google Scholar Students subsequently perceived less time available for independent study and learning. The addition of 24-hour hospitalist coverage for a pediatrics service at the same hospital, however, ameliorated this perceived influx of “scutwork.”16White C.B. Multidimensional effects of the 80-hour work week at the University of Michigan Medical School.Acad Med. 2006; 81: 57-62Crossref PubMed Scopus (34) Google Scholar Little has been written specifically addressing the educational climate for students, but studies have found no significant difference in the time spent on or the quality of student learning activities pre- to post-duty hour restrictions. The current duty hour restrictions specifically apply to residents, not students. However, a survey of deans of the Liaison Committee on Medical Education-accredited US medical schools found that most schools have a written policy restricting student duty hours.34Friedman E. Karani R. Fallar R. Regulation of medical student work hours: a national survey of deans.Acad Med. 2011; 86: 30-33Crossref PubMed Scopus (16) Google Scholar There was not consensus across schools on what those regulations should entail, and only one half of respondents supported the Accreditation Council for Graduate Medical Education duty hour regulations for students. Although deans thought that restriction of student hours enhances student well-being, most believed its impact on patient care, student evaluation, direct time with patients, and the student-resident team relationship would be neutral. As discussions proceed regarding the impact of resident duty hour restrictions on medical student education, consideration will need to be given to student duty hour regulations, particularly if regulations and policies differ. It is unclear whether these changes in student duty hours have resulted in an improvement in student quality of life, but residents with similar changes have thought that duty hour restrictions helped them live a more balanced life.9Lin G.A. Beck D.C. Garbutt J.M. Residents' perceptions of the effects of work hour limitations at a large teaching hospital.Acad Med. 2006; 81: 63-67Crossref PubMed Scopus (41) Google Scholar In light of the greater time pressure during rounds, models for improving teaching efficiency and effectiveness should be adopted (Table). Concise, targeted teaching is expected in the ambulatory setting, and these same skills will need to be adapted to the inpatient teaching arena. Potentially successful models include the microskills model35Neher J.O. Gordon K.C. Meyer B. Stephens N. A five-step “microskills” model of clinical teaching.Clin Teach. 1992; 5: 419-424Google Scholar and Summarize, Narrow, Analyze, Probe, Plan, Select (SNAPPS),36Wolpaw T.M. Wolpaw D.R. Papp K.K. SNAPPS: a learner-centered model for outpatient education.Acad Med. 2003; 78: 893-898Crossref PubMed Scopus (170) Google Scholar which emphasize concise and directed patient case presentations. Teaching learners to reflect on their performance and share their learning goals will allow attendings to make the most of teachable moments. Because attending rounds post-duty hour restrictions have a greater focus on clinical decision-making, attendings should capitalize on this opportunity to observe learners process information and teach skills in patient assessment and medical decision-making.TableManaging Duty Hour Restrictions for the Benefit of Student EducationKey AreasBest PracticesTeachingDevelop attendings' skills during rounds:Concise, targeted teaching, such as microskills model35Neher J.O. Gordon K.C. Meyer B. Stephens N. A five-step “microskills” model of clinical teaching.Clin Teach. 1992; 5: 419-424Google ScholarObserve learners process information in real time and provide feedbackTeach in relation to real-time patient assessment and medical decision-makingDevelop attendings' skills for outside of rounds or separate teaching attending:In-depth bedside teaching of physical examination and communication skillsReview and critique comprehensive presentations and associated medical decision-makingDevelop students' skills:Direct patient case presentations during rounds, such as SNAPPS36Wolpaw T.M. Wolpaw D.R. Papp K.K. SNAPPS: a learner-centered model for outpatient education.Acad Med. 2003; 78: 893-898Crossref PubMed Scopus (170) Google ScholarReflect on performance and sharing learning goalsDevelop residents' skills:Incorporate students into a clinical teamBest practices for teachingInclude developmentally appropriate experiences for learnersInclude competencies and milestones to mark learner progressDiscontinuityMaximize opportunities to evaluate “fresh” patients or simulate “fresh” patients:Night float or other rotations where more new patients are admitted“Blind” evaluations of patients before reviewing night-float's admit-noteLive or computer-based simulationsTeach students best practices for giving and receiving hand-offsImprove instruction in patient safety and quality improvement as it relates to hand-offsTeam structureUse hospitalist services and non-physician practitioner to redistribute workload and maximize educational value of ward experienceClearly define the roles and responsibilities of all team membersConsider new structures for training that are less dependent on residentsEducational climateClearly define student work hours Open table in a new tab High demands for rapid delivery of patient care necessitate shifting some educational activities out of work rounds into dedicated teaching venues. For instance, comprehensive student oral presentations may occur as a part of the clerkship teaching structure and separate from the teams. Attendings may choose to dedicate individual time later in the day to provide students bedside teaching of physical examination and communication skills or focus on presentations and medical decision-making. Models that rely on the attending physician for offloading resident work will likely require a separate teaching physician to fulfill these student teaching roles. Faculty development should address effective methods of teaching in this environment. Residents should be taught best practices for teaching and incorporating students into a clinical team post-duty hour restrictions. Shift work and handoffs are here to stay, so maximizing learning in this environment is essential. Students should have opportunities to evaluate fresh patients; student rotations on night float teams or other teams that routinely admit new patients may facilitate student “first contact” with patients. Interventions to improve the “freshness” of handoff patients could include having students perform evaluations of patients before reviewing the night float team's admissions note or patient chart. Computer-based simulations are another option for learning the approach to an undifferentiated patient. Students need to learn strategies for both giving and receiving handoffs; students also should be given the opportunity to understand how they relate to the broader issues of patient safety and quality improvement. A health care system's response to duty hour restrictions should include a proactive and prospective approach. Those programs that had more positive response to prior duty hour restrictions anticipated the coming change and designed systems to maximize education in a new environment. Systems can maximize learning for students by the addition of hospitalist services and non-physician practitioners that can help redistribute workload to maximize its educational value. Direct costs are associated with the addition of these services, but also there is evidence that such changes can be cost neutral.37Lundberg S. Balingit P. Wali S. Cope D. Cost-effectiveness of a hospitalist service in a public teaching hospital.Acad Med. 2010; 85: 1312-1315Crossref PubMed Scopus (6) Google Scholar New care delivery models will require clear delineation of the roles and responsibilities of all team members, including medical students. Lack of role delineation and assumption of too much responsibility by non-physician practitioners have been cited as potential challenges of using non-physician practitioners in residency training.38Mathur M. Rampersad A. Howard K. Goldman G.M. Physician assistants as physician extenders in the pediatric intensive care unit setting—a 5-year experience.Pediatr Crit Care Med. 2005; 6: 14-19Crossref PubMed Scopus (43) Google Scholar It is important to define the student role in patient care, outline resident teaching responsibilities, and articulate the relationships between the medical students and non-physician practitioners within the health care team to ensure a positive learning climate and educational outcomes. Student participation on multidisciplinary teams including non-physician practitioners creates the opportunity to highlight interprofessional education and enhance medical student education post-duty hour restrictions. Individual schools should define clearly the duty hour limitations for students on clinical clerkships. There should be consideration for a national consensus defining these work hours across Liaison Committee on Medical Education-accredited schools. Our observations and recommendations should be taken with many caveats. We recognize duty hour restrictions are not the only changes in the current dynamic clinical environment with the potential to affect student education. Also, most of the published studies on which we are basing our recommendations were observational and single institution, representing only a few specialties; most outcomes were attitudes, perceptions, and satisfaction versus more robust outcomes such as performance. There is ongoing pressure from the evolving clinical and educational environment on our traditional Flexnerian apprenticeship model for training medical students on their inpatient clerkships. Adaptation of this traditional model may no longer be sufficient to train students to practice medicine in the 21st century. It may be time to consider whether students would be better served by a new structure of undergraduate training that is less dependent on residents. This structure may require increased use of simulation with subtle modification of the current structure or a more significant shift to models such as longitudinal integrated clerkships.39Norris T.E. Schaad D.C. DeWitt D. et al.Longitudinal integrated clerkships for medical students: an innovation adopted by medical schools in Australia, Canada, South Africa, and the United States.Acad Med. 2009; 84: 902-907Crossref PubMed Scopus (187) Google Scholar Regardless, the ideal model should include developmentally appropriate experiences for learners and competencies and milestones to mark learner progress to ensure that, despite the potential for fewer hours spent in the hospital, our learners are still achieving the same outcome.40Carracio C. Benson B.J. Nixon L.J. Derstine P. From the educational bench to the clinical bedside: translating the Dreyfus developmental model to the learning of clinical skills.Acad Med. 2008; 83: 761-767Crossref PubMed Scopus (197) Google Scholar
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