Orientation for Residents and Fellows Office of GMEJune 18, 2013

Jeanette Morrison, MDAssociate Professor of MedicineAssociate 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 & Procedureshttp://www.rosalindfranklin.edu/Portals/4/Documents/Clinical%20Affairs/hyperlinks%20and%20bookmarks%20GME%20Manual%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…

• RRC = Residency Review Committee

• ACGME = Accreditation Council for GME

• CMS/RFUMS• FHCC

ACGME Competencies

• 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 = NASContinuous data reporting to ACGME, including:Annual resident surveyAnnual faculty surveyBoards pass rateScholarly activityCLER 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

• Healthy Sleep• Exercise• Good Nutrition• Develop and Maintain supportive relationships

Health Benefits of Sleep

• 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

• 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• 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…

• 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

AddictiveSide 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 2003-2004

• 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

• 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 freshmanLow grade fever, earache (erythromycin)Agitation, “jerking movements”, lucid with periods of confusion

PMH: DepressionMeds: Erythromycin, Phenelzine, PercodanMarijuana. Denied cocaine useT = 103WBC = 18,000

• Admit to Medicine– 9 month intern with resident supervision– 40 patients– Spoke with attending once

• “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

•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

• 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 2004Lockley 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 2007Shetty. Ann Int Med 2007Horwitz et al. Ann Int Med 2007Horwitz 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 2009Landrigan. Pediatrics 2008Landrigan. JAMA 2006.

Copyright ©2008 American Academy of Pediatrics

Landrigan, C. P. et al. Pediatrics 2008;122:250-258

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

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

• Accreditation• Medicare• Professionalism• Technological/EMR

Take Home Points - SLEEP

• Daytime Drowsiness = Insufficient Sleep– Manage your Sleep Debt

• 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

• 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