Resident duty hours: a survey of internal medicine program directors.

INTRODUCTION: In 2011, the Accreditation Council for Graduate Medical Education (ACGME) implemented new Common Program Requirements to regulate duty hours of resident physicians, with three goals: improved patient safety, quality of resident education and quality of life for trainees. We sought to assess Internal Medicine program director (IMPD) perceptions of the 2011 Common Program Requirements in July 2012, one year following implementation of the new standards. METHODS: A cross-sectional study of all IMPDs at ACGME-accredited programs in the United States (N = 381) was performed using a 32-question, self-administered survey. Contact information was identified for 323 IMPDs. Three individualized emails were sent to each director over a 6-week period, requesting participation in the survey. Outcomes measured included approval of duty hours regulations, as well as perceptions of changes in graduate medical education and patient care resulting from the revised ACGME standards. RESULTS: A total of 237 surveys were returned (73% response rate). More than half of the IMPDs (52%) reported "overall" approval of the 2011 duty hour regulations, with greater than 70% approval of all individual regulations except senior resident daily duty periods (49% approval) and 16-hour intern shifts (17% approval). Although a majority feel resident quality of life has improved (55%), most IMPDs believe that resident education (60%) is worse. A minority report that quality (8%) or safety (11%) of patient care has improved. CONCLUSION: One year after implementation of new ACGME duty hour requirements, IMPDs report overall approval of the standards, but strong disapproval of 16-hour shift limits for interns. Few program directors perceive that the duty hour restrictions have resulted in better care for patients or education of residents. Although resident quality of life seems improved, most IMPDs report that their own workload has increased. Based on these results, the intended benefits of duty hour regulations may not yet have been realized.

Fungal osteomyelitis and septic arthritis.

Management of fungal osteomyelitis and fungal septic arthritis is challenging, especially in the setting of immunodeficiency and conditions that require immunosuppression. Because fungal osteomyelitis and fungal septic arthritis are rare conditions, study of their pathophysiology and treatment has been limited. In the literature, evidence-based treatment is lacking and, historically, outcomes have been poor. The most common offending organisms are Candida and Aspergillus, which are widely distributed in humans and soil. However, some fungal pathogens, such as Histoplasma, Blastomyces, Coccidioides, Cryptococcus, and Sporothrix, have more focal areas of endemicity. Fungal bone and joint infections result from direct inoculation, contiguous infection spread, or hematogenous seeding of organisms. These infections may be difficult to diagnose and eradicate, especially in the setting of total joint arthroplasty. Although there is no clear consensus on treatment, guidelines are available for management of many of these pathogens.

Transmission of lymphocytic choriomeningitis virus by organ transplantation.

BACKGROUND: In December 2003 and April 2005, signs and symptoms suggestive of infection developed in two groups of recipients of solid-organ transplants. Each cluster was investigated because diagnostic evaluations were unrevealing, and in each a common donor was recognized. METHODS: We examined clinical specimens from the two donors and eight recipients, using viral culture, electron microscopy, serologic testing, molecular analysis, and histopathological examination with immunohistochemical staining to identify a cause. Epidemiologic investigations, including interviews, environmental assessments, and medical-record reviews, were performed to characterize clinical courses and to determine the cause of the illnesses. RESULTS: Laboratory testing revealed lymphocytic choriomeningitis virus (LCMV) in all the recipients, with a single, unique strain of LCMV identified in each cluster. In both investigations, LCMV could not be detected in the organ donor. In the 2005 cluster, the donor had had contact in her home with a pet hamster infected with an LCMV strain identical to that detected in the organ recipients; no source of LCMV infection was found in the 2003 cluster. The transplant recipients had abdominal pain, altered mental status, thrombocytopenia, elevated aminotransferase levels, coagulopathy, graft dysfunction, and either fever or leukocytosis within three weeks after transplantation. Diarrhea, peri-incisional rash, renal failure, and seizures were variably present. Seven of the eight recipients died, 9 to 76 days after transplantation. One recipient, who received ribavirin and reduced levels of immunosuppressive therapy, survived. CONCLUSIONS: We document two clusters of LCMV infection transmitted through organ transplantation.

Propionibacterium acnes colonization of the human shoulder.

BACKGROUND: Propionibacterium acnes (P. acnes) is frequently cultured in patients with wound infections after shoulder surgery. The purpose of this study was to characterize the colonization of various anatomic locations with P. acnes in order to explain this clinical observation. METHODS: Culture samples were collected from the skin overlying the shoulder, hip, and knee of 20 subjects (10 male, 10 female). Semi-quantitative cultures of P. acnes and Staphylococcus species were performed to define bacterial prevalence and burden at each site. The participants completed a questionnaire that assessed skin health, hygiene, and co-morbid medical conditions. Physical examination was performed to define local skin characteristics. RESULTS: Anterior and posterior acromial sites had a greater prevalence of P. acnes than the hip (anterior p=0.018; posterior p= 0.038) and knee (anterior p=0.0014; posterior p= 0.035) sites. The axilla had a greater prevalence of P. acnes than the knee (p=0.008). Males had a greater prevalence of P. acnes than females at the anterior (p=0.007) and posterior acromion sites (p=0.025). The burden of P. acnes at the anterior acromion (p=0.024), posterior acromion (p=0.035), and axilla (p=0.03) was greater than the mean burden at the hip. The burden of P. acnes at the anterior acromion (p=0.004), posterior acromion (p=0.007), and axilla (p=0.008) was greater than the mean burden at the knee. Males had a greater burden of P. acnes than females at the acromial sites (anterior p=0.0049; posterior p=0.0131). CONCLUSIONS: Propionibacterium acnes colonizes the shoulder at increased rates compared to the knee and hip, and men have a higher bacterial burden than females. These findings are consistent with clinical observations of postoperative shoulder infections. LEVEL OF EVIDENCE: Basic science study.

Is This Organ Donor Safe?: Donor-Derived Infections in Solid Organ Transplantation.

Infection is an inevitable complication of solid organ transplantation. Unrecognized infection may be transmitted from a donor and result in disseminated disease in the immunosuppressed host. Recent outbreaks of deceased donor-derived infections resulting in high rates of mortality and severe morbidity have emphasized the need to be cautious in using donors with possible meningoencephalitis. Screening of organ donors for potential transmissible infections is paramount to improving transplantation outcomes.

Is This Organ Donor Safe?: Donor-Derived Infections in Solid Organ Transplantation.

Infection is an inevitable complication of solid organ transplantation. Unrecognized infection may be transmitted from a donor and result in disseminated disease in the immunosuppressed host. Recent outbreaks of deceased donor-derived infections resulting in high rates of mortality and severe morbidity have emphasized the need to be cautious in using donors with possible meningoencephalitis. Screening of organ donors for potential transmissible infections is paramount to improving transplantation outcomes.

Infections complicating solid organ transplantation.

The requirements for immune suppression after solid organ transplantation increases the risk of infection with a myriad of organisms. There are many unique and evolving aspects of infection after solid organ transplantation. Advances in immunosuppressive therapy and improved protocols for infection prophylaxis have resulted in changes in the timing and clinical presentation of opportunistic infections. Vigilance in the diagnostic evaluation of suspected infection in the solid organ transplant recipient is essential. This article reviews the basic evaluation and treatment options for many of the infectious conditions peculiar to the immunosuppressed patient.

Difference in the incidence of Clostridium difficile among patients infected with human immunodeficiency virus admitted to a public hospital and a private hospital.

OBJECTIVE: To compare the occurrence of Clostridium difficile among inpatients infected with human immunodeficiency virus (HIV) in two different hospitals. DESIGN: Prospective, observational study. SETTING: Specialized HIV inpatient units. PATIENTS: HIV-infected inpatients at Cook County Hospital (CCH) and Rush Presbyterian St. Luke's Medical Center (RPSLMC). INTERVENTIONS: A clinical and epidemiologic assessment of patient risk factors for C. difficile was performed. C. difficile isolates found on stool, rectal, and environmental cultures were typed by pulsed-field gel electrophoresis. RESULTS: Twenty-seven percent of patients admitted to CCH versus 4% of patients admitted to RPSLMC had positive cultures for C. difficile (P = .001). At CCH, 14.7% of environmental cultures were positive versus 2.9% at RPSLMC (P = .002). Risk factors for C. difficile acquisition included hospitalization at CCH, more severe HIV, use of acyclovir and H2-blockers, and longer hospital stay. Patients admitted to CCH were taking more antibiotics, had longer hospital stays, and more frequently had a history of C. difficile infection. During the study, two strains (CD1A and CD4) extensively contaminated the CCH environment. However, only CD1A caused an outbreak. CONCLUSIONS: The C. difficile acquisition rate at CCH was sevenfold higher than that at RPSLMC, and CCH had a more contaminated environment. Differences in patient acquisition rates likely reflect a greater prevalence of traditional C. difficile risk factors and a concurrent outbreak at CCH. Although two strains heavily contaminated the environment at CCH, only one caused an outbreak, suggesting that factors other than the environment are important in initiating C. difficile outbreaks.

Epidemiology and outcome of Clostridium difficile infection and diarrhea in HIV infected inpatients.

Clostridium difficile causes diarrhea in HIV infected patients but reports of prevalence, risk factors, and outcome vary. We studied the impact of C. difficile in 161 HIV infected inpatients admitted to Cook County Hospital. Patients with C. difficile had more hospital admissions in the previous 6 months (p =.04), spent more days in the hospital in the previous 3 months (p =.02), more often had previously received H2 blockers or treatment for Pneumocystis carinii (p <.05), and had a more frequent history of herpesvirus (p =.03) or opportunistic infections (p =.04). C. difficile associated diarrhea (CDAD) was the etiology in 32% of all study patients with diarrhea. Patients with CDAD were hospitalized for longer periods (p =.02) and received more antibiotics (p =.002). C. difficile was frequently present in our HIV infected patients, especially those with advanced HIV disease, but appeared to have little impact on morbidity or mortality.

The impact of 2011 duty hours requirements on family medicine residents.

BACKGROUND AND OBJECTIVES: Our objective was to determine family medicine residents' perception of changes in education, patient care, and quality of life following implementation of the 2011 Accreditation Council of Graduate Medical Education (ACGME) Common Program Requirements. METHODS: Designated institutional officials at all 682 ACGME-accredited institutions were contacted and asked to distribute an anonymous, electronic survey to all residents at each sponsoring institution. The survey was administered to 2,956 family medicine residents at 61 institutions between December 2011 and February 2012. RESULTS: A large, demographically representative sample of residents (n=928) was identified as training in family medicine. Nearly half of residents (47.4%) reported disapproval of the duty hour requirements, with less than a quarter reporting approval (24.6%). Only quality of life for interns was identified as improved by a majority of respondents (63.3%). Meanwhile, quality of life for senior residents was generally reported as worse (53.0%). Likewise, a plurality of respondents stated that both quality of resident education (43.4%) and work schedules (47.9%) were negatively impacted, while more than half (56.5%) reported that preparation for more senior roles was worse. Aspects felt to be unchanged included amount of rest (45.4%) and hours worked by residents (52.8%). Although most respondents (52.0%) felt that safety of care was unchanged, more (77.9%) reported an increase in hand-offs and no increase in the availability of supervision (72.2%). Finally, the majority of residents (68.5%) agreed that there has been a shift of junior level responsibilities to more senior residents. CONCLUSIONS: It appears that family medicine residents generally disapprove of the 2011 ACGME duty hour regulations. They report negative consequences including a shift of intern responsibility to senior residents, as well as decreased preparedness for more senior roles. Further, patient safety, availability of supervision, and quality of education seem to be unimproved or worse.

Hospitalized Patients' Perceptions of Resident Fatigue, Duty Hours, and Continuity of Care.

BACKGROUND: Physicians' perceptions of duty hour regulations have been closely examined, yet patient opinions have been largely unstudied to date. OBJECTIVE: We studied patient perceptions of residency duty hours, fatigue, and continuity of care following implementation of the Accreditation Council for Graduate Medical Education 2011 Common Program Requirements. METHODS: A cross-sectional survey was administered between June and August 2013 to inpatients at a large academic medical center and an affiliated community hospital. Adult inpatients on teaching medical and surgical services were eligible for inclusion in the study. RESULTS: Survey response rate was 71.3% (513 of 720). Most respondents (57.1%, 293 of 513) believed residents should not be assigned to shifts longer than 12 hours, and nearly half (49.7%, 255 of 513) wanted to be notified if a resident caring for them had worked longer than 12 hours. Most patients (63.2%, 324 of 513) believed medical errors commonly occurred because of fatigue, and fewer (37.4%, 192 of 513; odds ratio, 0.56; P < .01) believed medical errors commonly occurred as a result of transfers of care. Given the choice between a familiar physician who "may be tired from a long shift" or a "fresh" physician who had received sign-out, more patients chose the fresh but unfamiliar physician (57.1% [293 of 513] versus 42.7% [219 of 513], P < .01). CONCLUSIONS: In a survey about physician attributes relevant to medical errors and patient safety, adult inpatients in a large and diverse sample reported greater concern about fatigue and working hours than about continuity of care.

The Current State of United States Spine Surgery Training: A Survey of Residency and Spine Fellowship Program Directors.

STUDY DESIGN: Program director survey. OBJECTIVES: To collect data on spine surgical experience during orthopedic and neurological surgery residency and assess the opinions of program directors (PDs) from orthopedic and neurological surgery residencies and spine surgery fellowships regarding current spine surgical training in the United States. SUMMARY OF BACKGROUND DATA: Current training for spine surgeons in the United States consists of a residency in either orthopedic or neurological surgery followed by an optional spine surgery fellowship. Program director survey data may assist in efforts to improve contemporary spine training. METHODS: An anonymous questionnaire was distributed to all PDs of orthopedic and neurological surgery residencies and spine fellowships in the United States (N = 382). A 5-point Likert scale was used to assess attitudinal questions. A 2-tailed independent-samples t test was used to compare responses to each question independently. RESULTS: A total of 147 PDs completed the survey. Orthopedic PDs most commonly indicated that their residents participate in 76 to 150 spine cases during residency, whereas neurological surgery PDs most often reported more than 450 spine cases during residency (p < .0001). Over 88% of orthopedic surgery program directors and 0% of neurological surgery PDs recommended that their trainees complete a fellowship if they wish to perform community spine surgery (p < .001). In contrast, 98.1% of orthopedic PDs and 86.4% of neurological surgery PDs recommended that their trainees complete a fellowship if they wish to perform spinal deformity surgery (p = .038). Most PDs agreed that surgical simulation and competency-based training could improve spine surgery training (76% and 72%, respectively). CONCLUSIONS: This study examined the opinions of orthopedic and neurological surgery residency and spine fellowship PDs regarding current spine surgery training in the United States. A large majority of PDs thought that both orthopedic and neurological surgical trainees should complete a fellowship if they plan to perform spinal deformity surgery. These results provide a background for further efforts to optimize contemporary spine surgical training.

Approval and perceived impact of duty hour regulations: survey of pediatric program directors.

OBJECTIVES: To determine pediatric program director (PD) approval and perception of changes to resident training and patient care resulting from 2011 Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements. METHODS: All US pediatric PDs (n = 181) were identified from the ACGME. Functional e-mail addresses were identified for 164 (90.6%). Three individualized e-mail requests were sent to each PD to complete an anonymous 32-question Web-based survey. RESULTS: A total of 151 responses were obtained (83.4%). Pediatrics PDs reported approval for nearly all of the 2011 ACGME duty hour regulations except for 16-hour intern shift limits (72.2% disapprove). Regarding the perceived impact of the new standards, many areas were reportedly unchanged, but most PDs reported negative effects on resident education (74.7%), preparation for senior roles (79.9%), resident ownership of patients (76.8%), and continuity of care (78.8%). There was a reported increase in PD workload (67.6%) and use of physician extenders (62.7%). Finally, only 48.3% of PDs reported that their residents are "always" compliant with 2011 requirements. CONCLUSIONS: Pediatric PDs think there have been numerous negative consequences of the 2011 Common Program Requirements. These include declines in resident education and preparation to take on more senior roles, as well as diminished resident accountability and continuity of care. Although they support individual aspects of duty hour regulation, almost three-quarters of pediatric PDs say there should be fewer regulations. The opinions expressed by PDs in this study should prompt research using quantitative metrics to assess the true impact of duty hour regulations.