Effect of Nonvisit Care on Resident Workload in a Family Medicine Residency

Background and Objectives: Primary care physicians can spend 24% of their ambulatory care work day on patient care duties outside the office visit (ie, nonvisit care [NVC]). Resident work hours must be performed within duty hour restrictions defined by the Accreditation Council for Graduate Medical Education, making it crucial for program directors to understand how much time residents spend on NVC tasks. Little information is available on resident work hours dedicated to NVC generated in the continuity clinic. We designed this study to look at an objective measure of the time family medicine residents spend on NVC. Methods: We collected and categorized from the electronic health record the NVC events completed by 22 family medicine residents in a rural residency training clinic over a 9-month period. With the use of an institutional time study performed in 2014, we identified the average amount of time required to complete a single event in each category of NVC. Results: Residents spent a mean of 13.6 hours per month completing NVC, which was equivalent to 127.3 minutes of NVC per 100 empaneled patients per month for each resident. Conclusions: This study quantified the amount of time residents spend on NVC, allowing program directors to plan curriculum so that residents can keep their work time within duty hour requirements.

iCOMPARE, what value does it add to resident duty-hour discussions?

Discussions regarding resident duty-hour restrictions have been ongoing and heated. One influential argument for restrictions has been patient safety. Two trials, FIRST and iCOMPARE, were performed to investigate this relationship with surgical and medicine training, respectively. As the authors are approaching this discussion from a medicine-based perspective, iCOMPARE will serve as the primary basis of our discussion. Results from the iCOMPARE trial comparing flexible (28-hour shifts allowed) to the original 2011 ACGME shift requirements (maximum 16 hours) were recently published in the New England Journal of Medicine. This non-inferiority trial used 30-day post-hospitalization mortality as its primary endpoint. Results met qualifications for non-inferiority, and ACGME policy was changed to allow for 28-hour shifts for medicine residents. iCOMPARE results were highly lauded and used as primary justification for extending resident duty hours. Despite this sweeping impact, few have critically evaluated what this study actually adds to the literature. Herein, we argue that serious questions regarding trial design are apparent. Most importantly, the non-inferiority margins chosen were large, and represent an ambiguous marker of resident performance. Additionally, we question the lack of both patient consenting and direct patient-reported or patient-centered outcomes within the hospital stay. As more discussion arises in the medical literature surrounding patient-reported outcomes and shared decision making, we argue that the results of iCOMPARE disregarded the patient perspective or meaningful patient outcomes in an attempt to maintain status quo. Lastly, we discuss how iCOMPARE missed the broader question of actual duty-hour restrictions, and some practical methods already in practice at some programs, which may more directly balance resident work hours with patient care and resident learning.

Epidemiologic and Outcome Analysis of Epistaxis in a Tertiary Care Center Emergency Department

Background The association between hypertension and recurrent epistaxis is controversial. The objective of this study is to examine the factors associated with recurrent epistaxis visits to the emergency department (ED) and establish an otolaryngology (ENT [ear, nose, and throat]) consult algorithm to optimize treatment and minimize unnecessary consultation. Methods A retrospective review of 100 patients presenting to the ED for epistaxis requiring ENT consult from 2013 to 2018 was conducted. Patient demographics, comorbidities, epistaxis etiology, blood pressure measurements during admission, and treatment methods were analyzed. Patient charts were reviewed for ED admissions, complications, and procedures. A consult algorithm was subsequently devised and retrospectively applied to our cohort. Results Patients who required more than one ED visit for epistaxis were more often males (77.8% vs 49.3%, P = .01), required posterior packing (51.9% vs 17 .8%, P < .001), and had more comorbid hypertension (66.7% vs 38.4%, P = .01) compared to patients who had 1 visit. Compared to patients presenting during summer and fall (May–October), patients presenting during winter and spring (November–April) were more often treated for anterior epistaxis with Surgicel®/Surgifoam® rather than posterior nasal packing (57.4% vs 37.0%, P = .04). Application of our consult algorithm decreased consultation by 78% and liberated 58.5 hours of ENT resident time. Conclusion Patients with recurrent epistaxis tended to be male and had more comorbid hypertension. Further prospective studies are warranted to ascertain the factors associated with recurrent epistaxis. Our consult algorithm for epistaxis helped reduce unnecessary ENT consultation and facilitated reallocation of valuable resident work hours.

Effects on resident work hours, sleep duration, and work experience in a randomized order safety trial evaluating resident-physician schedules (ROSTERS)

Study ObjectivesWe compared resident physician work hours and sleep in a multicenter clustered-randomized crossover clinical trial that randomized resident physicians to an Extended Duration Work Roster (EDWR) with extended-duration (≥24 hr) shifts or a Rapidly Cycling Work Roster (RCWR), in which scheduled shift lengths were limited to 16 or fewer consecutive hours.MethodsThree hundred two resident physicians were enrolled and completed 370 1 month pediatric intensive care unit rotations in six US academic medical centers. Sleep was objectively estimated with wrist-worn actigraphs. Work hours and subjective sleep data were collected via daily electronic diary.ResultsResident physicians worked fewer total hours per week during the RCWR compared with the EDWR (61.9 ± 4.8 versus 68.4 ± 7.4, respectively; p < 0.0001). During the RCWR, 73% of work hours occurred within shifts of ≤16 consecutive hours. In contrast, during the EDWR, 38% of work hours occurred on shifts of ≤16 consecutive hours. Resident physicians obtained significantly more sleep per week on the RCWR (52.9 ± 6.0 hr) compared with the EDWR (49.1 ± 5.8 hr, p < 0.0001). The percentage of 24 hr intervals with less than 4 hr of actigraphically measured sleep was 9% on the RCWR and 25% on the EDWR (p < 0.0001).ConclusionsRCWRs were effective in reducing weekly work hours and the occurrence of >16 consecutive hour shifts, and improving sleep duration of resident physicians. Although inclusion of the six operational healthcare sites increases the generalizability of these findings, there was heterogeneity in schedule implementation. Additional research is needed to optimize scheduling practices allowing for sufficient sleep prior to all work shifts.Clinical Trial: Multicenter Clinical Trial of Limiting Resident Work Hours on ICU Patient Safety (ROSTERS), https://clinicaltrials.gov/ct2/show/NCT02134847

Techniques: Utility of a 3D printed bladder model for teaching minimally invasive urethrovesical anastomosis

The urethrovesical anastomosis (UVA) is one of the most challenging steps during a minimally invasive radical prostatectomy. Not surprisingly, minimally invasive, in particular laparoscopic, prostatectomy is associated with a steep learning curve.1 With competency-based training on the horizon, as well as the recent reduction in resident work hours, surgical educators have shifted some training outside of the operating room into surgical skills labs. To reduce learning curves and improve resident education at our centre, we use a hands-on 3D printed bladder bench model to emulate the UVA task during a minimally invasive prostatectomy.