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
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Orientation for Residents and Fellows Office of GME June 18, 2013 Jeanette Morrison, MD Associate Professor of Medicine Associate Dean for GME and DIO.
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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
– 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
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
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
• 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