Jeffrey H. Silber, MD, PhD
Director, Center for Outcomes Research
Nancy Abramson Wolfson Endowed Chair
Health Services Research
Children’s Hospital of Philadelphia
Professor of Pediatrics, Anesthesiology and Critical Care
Perelman School of Medicine, University of Pennsylvania
Professor of Health Care Management
Wharton School, University of Pennsylvania
MedicalResearch.com: What is the background for this study?
Response: This was a year-long randomized trial that involved 63 internal medicine residency programs from around the US. In 2015-2016, about half of the programs were randomized to follow the existing rules about resident duty hours that included restrictions on the lengths of shifts and the rest time required between shifts (the standard arm of the trial) and the other half of the programs didn’t have those shift length or rest period rules (the flexible arm of the trial). We measured what happened to the patients cared for in those programs (the safety study), and other studies examined how much sleep the residents received, and how alert they were at the end of shifts (the sleep study), and previously we published on the educational outcomes of the interns.
To measure the impact on patient outcomes when allowing program directors the ability to use a flexible shift length for their interns, we compared patient outcomes after the flexible regimen went into place to outcomes the year before in the same program. We did the same comparison for the standard arm. Then we compared the difference between these comparisons. Comparing before and after the implementation of the trial within the same program allowed us to be more confident that a particularly strong or weak program, or a program with especially sick or healthy patients, would not throw off the results of the study. The trial was designed to determine, with 95% confidence, if the flexible arm did not do more than 1% worse than the standard arm. If this were true for the flexible arm, we could say the flexible regimen was “non-inferior” to the standard regimen.
MedicalResearch.com Interview with: KathleenM. Finn MD, MPhil Christiana IyasereMD, MBA Division of General Internal Medicine
Department of Medicine
Massachusetts General Hospital, Boston
MedicalResearch.com: What is the background for this study?
Response: While the relationship between resident work hours and patient safety has been extensively studied, little research evaluates the role of attending supervision on patient safety. Beginning with the Bell Commission there have been increased calls for enhanced resident supervision due to patient safety concerns. At the same time, with the growth of the hospitalist movement more faculty physicians join daily resident work rounds under the assumption that increased supervision is better for patient safety and resident education. However, we know that supervision is a complex balancing act, so we wanted to study whether these assumptions were true. On the one hand patient safety is important, but on the other adult learning theory argues residents need to be challenged to work beyond their comfort level. Importantly, being pushed beyond your comfort level often requires appropriate space between teacher and learner. To investigate the role of attending supervision on patient safety and resident learning we studied the impact of two levels of physician supervision on an inpatient general medical team.
Twenty-two teaching faculty were randomized to either direct supervision of resident teams for patients previously known to the team vs usual care where they did not join rounds but rather discussed the patients later with the team. Faculty participated in both arms of the study, after completing the first arm they then crossed over to the other arm; each faculty member participated in the study for a total of 4 weeks.
Pamela S. Douglas, MD, MACC, FASE, FAHA
Ursula Geller Professor of Research in Cardiovascular Disease
Duke University School of Medicine
Durham, NC 27715
MedicalResearch.com: What is the background for this study? What are the main findings?
Response: For any profession to succeed, it needs to attract top talent. We surveyed internal medicine residents to find out what they valued most in their professional development, how they perceived cardiology as field and how these two areas are associated with their choosing a career in cardiology or another specialty.
We found that trainees were seeking careers that had stable hours, were family friendly and female friendly, while they perceived cardiology to have adverse work conditions, interfere with family life and to not be diverse. We were able to predict career choice with 89-97% accuracy from these responses; the predictors are mix of things that attract to cardiology and those that are deterrents.
For men, the attractors outnumber the deterrents, for women its just the opposite.
MedicalResearch.com Interview with:
Gustavo Saposnik, MD, MSc., FAHA, FRCPC
Director, Stroke Outcomes Research Center
Co-Director, Stroke Program – Research & Innovation
Associate Professor & Clinician Scientist
Departments of Medicine (Neurology) and
Health Policy, Management and Evaluation (HPME)
St. Michael’s Hospital University of Toronto
Medical Research: What is the background for this study? What are the main findings?
Dr. Saposnik: There is some controversy around worse outcomes at the beginning of academic year. Physicians recently graduated from medical schools begin their training and assume responsibilities for patient care in teaching hospitals, usually bearing the first-line duty for managing patients. Consequently, less experienced staff having new roles may influence access to care and contribute to adverse outcomes in patients managed at the beginning of academic year – the so-called “July Effect”. for example, increase of medication errors and in-hospital mortality in July has been reported from teaching hospitals.
In our large cohort study, comprising 10,319 stroke patients, 882 (8.5%) were admitted in July. Those patients were 28% less likely to receive thrombolysis (clot-buster treatment) (12% vs. 16%; odds ratio (OR), 0.72; 95% confidence interval (CI), 0.59-0.89) and 22% less likely to receive stroke unit care (62% vs. 68%; 0.78; 0.68-0.90). July admissions were not associated with either of higher death at 30 days (adjusted OR, 95% CI; 0.88, 0.74-1.03) or poor functional outcome (0.92, 0.74-1.14). Results remained consistent in the sensitivity analysis by including both July and August as part of the ‘July effect’.