Influence of medical trainee sleep pattern (chronotype) on burn-out and satisfaction with work schedules: a multicentre observational study.

BACKGROUND: Medical trainees' work schedule is designed to cover duties without consideration of differences in circadian rhythms during a 24-hour period (chronotype). OBJECTIVE: To explore chronotype variation among medical trainees and understand its association with burn-out and schedule satisfaction. METHODS: In a multicentre observational study, we conducted two surveys between 1 October 2018 and 1 April 2019. Trainees from nine centres across the USA participated. We measured burn-out using Maslach Burnout Inventory (MBI), and trainee chronotype using the Morningness-Eveningness Questionnaire (MEQ). RESULTS: 324 (32%) out of 1012 responded to our survey. Participants were 51% female and had a mean age of 30.8 years. Most participants had an intermediate MEQ type (65%). A large proportion of participants had burn-out on at least one of three tested MBI scales (62%); 5% of participants had burn-out on all three MBI scales. More participants with evening MEQ type had burn-out (66%) compared with morning MEQ type (55%), however, the results were not statically significant (p=0.294). Overall satisfaction with work shifts was 6.5 (95% CI 6.3 to 6.7), with higher satisfaction with day shift 7.7 (95% CI 7.5 to 7.9) and lowest satisfaction with overnight 24-hour call 3.5 (95% CI 3.2 to 3.9). Satisfaction was lower in trainees with burn-out 6.0 (95% CI 5.7 to 6.4), (p<0.001). In the follow-up survey, burn-out was present in at least one scale in 64% compared with 60% of respondents in the initial survey. CONCLUSION: Burn-out is prevalent among medical trainees. Improving alignment between trainee preferences may improve performance, reduce human errors and burn-out.

Application of the Multi-Facet Rasch Model to Evaluate the Chief Resident Selection Survey: A Two-Year Study.

Introduction The Chief Resident (CR) selection process is described by many residency programs as a collective effort from the residency program leadership, key faculty members, and resident peers. Unfortunately, the literature does not show any established guidelines, methods, or psychometric sound instruments to aid this process. The purpose of this study was to evaluate the properties of the newly developed CRs selection survey across two years using the Multi-Facet Rasch Model (MFRM). Methods This study used the MFRM to analyze two-year data from the newly developed CRs selection survey. After the first implementation of the tool in 2015, this instrument had its second-round evaluation process for the CRs selection in 2016. We applied a three-facet Rasch model (candidates, questions, and raters). We used Facets v. 3.66 and SAS 9.4 (SAS Institute Inc., Cary, NC) for data analysis. Results In 2015, 40 out of100 residents completed the survey to select three of the four candidates for the 2017-2018 CRs positions. The mean rating for each candidate showed that Candidate 1 received the highest rating of 5.56 while Candidates 2 and 4 received the exact same ratings. The majority of survey items performed very well based on the results from the MFRM while leaving room for improvement for a few items. In 2016, 55 out of 100 residents completed the revised survey to select three of the six candidates for the 2018-2019 CR positions. The mean rating showed that Candidate 3 received the highest mean rating of 5.81 while Candidate 2 received the lowest mean rating of 5.12. The item reliability was improved from 0.70 to 0.88 based on the results from the revised survey. The results were used to help inform decisions regarding the selection of chief residents. Conclusions The CR selection process requires a fair and collective effort from program leadership, relevant faculty members, and input from the resident group. Our study demonstrated that the survey tool we developed is appropriate to select CR candidates and MFRM is a promising technique in survey development and the evaluation of survey items.

When a Family Seeks to Exclude Residents From Their Child's Care.

A primary goal of our medical education system is to produce physicians qualified to promote health, prevent and treat disease, and relieve suffering. Although some aspects of the practice of medicine can be learned in classrooms, from textbooks, or with simulators, other aspects can only be learned through the direct provision of patient care. Residency programs therefore offer essential educational experiences that support residents' acquisition of knowledge, skills, and professional judgment through the assumption of progressive responsibility under an appropriate level of supervision. Yet, ethical questions can arise when medical education is integrated with patient care. How should we balance the educational needs of residents and the social benefits of medical education against obligations to patients and families? In this article, we present the case of a child whose family requests that residents not be allowed to perform any procedures on their child and then ask experts (a pediatric residency program director, a pediatrics resident, and an ethicist) to comment.

Rates of ICU Transfers After a Scheduled Night-Shift Interprofessional Huddle.

OBJECTIVES: To evaluate a scheduled interprofessional huddle among pediatric residents, nursing staff, and cardiologists on the number of high-risk transfers to the ICU. METHODS: A daily, night-shift huddle intervention was initiated between the in-house pediatric residents and nursing staff covering the cardiology ward patients with the at-home attending cardiologist. Retrospective cohort chart review identified high-risk transfers from the inpatient floor to the ICU over a 24-month period (eg, inotropic support, intubation, and/or respiratory support within 1 hour of ICU transfer). Satisfaction with the intervention and the impact of the intervention on team-based communication and resident education was collected using a retrospective pre-post survey. RESULTS: Ninety-three patients were identified as unscheduled transfers from the ward team to the ICU. Overall, 21 preintervention transfers were considered high risk, whereas only 8 patients were considered high risk after the intervention (P=.004). During the night shift, high risk transfers decreased from 8 of 17 (47%) to 3 of 21 patients (14%) (P=.03). Interprofessional communication improved with 12 of 14 nurses and 24 of 25 residents reporting effective communication after the intervention (P<.0001) compared with only 1 nurse and 15 residents reporting a positive experience before the intervention. Overall, all 3 provider groups stated an improved experience covering a high-risk cardiology patient population. CONCLUSIONS: Implementation of an interprofessional huddle may contribute to decreasing high-risk transfers to the ICU. Initiating a daily huddle was well received and allowed for open lines of communication across all provider groups.

Impact of a guideline on management of children hospitalized with community-acquired pneumonia.

OBJECTIVES: We sought to describe the impact a clinical practice guideline (CPG) had on antibiotic management of children hospitalized with community-acquired pneumonia (CAP). PATIENTS AND METHODS: We conducted a retrospective study of discharged patients from a children's hospital with an ICD-9-CM code for pneumonia (480-486). Eligible patients were admitted from July 8, 2007, through July 9, 2009, 12 months before and after the CAP CPG was introduced. Three-stage least squares regression analyses were performed to examine hypothesized simultaneous relationships, including the impact of our institution\x{2019}s antimicrobial stewardship program (ASP). RESULTS: The final analysis included 1033 patients: 530 (51%) before the CPG (pre-CPG) and 503 (49%) after the CPG (post-CPG). Pre-CPG, ceftriaxone (72%) was the most commonly prescribed antibiotic, followed by ampicillin (13%). Post-CPG, the most common antibiotic was ampicillin (63%). The effect of the CPG was associated with a 34% increase in ampicillin use (P < .001). Discharge antibiotics also changed post-CPG, showing a significant increase in amoxicillin use (P < .001) and a significant decrease in cefdinir and amoxicillin/clavulanate (P < .001), with the combined effect of the CPG and ASP leading to 12% (P < 0.001) and 16% (P < .001) reduction, respectively. Overall, treatment failure was infrequent (1.5% vs 1%). CONCLUSIONS: A CPG and ASP led to the increase in use of ampicillin for children hospitalized with CAP. In addition, less broad-spectrum discharge antibiotics were used. Patient adverse outcomes were low, indicating that ampicillin is appropriate first-line therapy for otherwise healthy children admitted with uncomplicated CAP.