Residents' Ratings of Their Clinical Supervision and Their Self-Reported Medical Errors: Analysis of Data From 2009.

BACKGROUND: Medical errors and patient safety are major concerns for the medical and medical education communities. Improving clinical supervision for residents is important in avoiding errors, yet little is known about how residents perceive the adequacy of their supervision and how this relates to medical errors and other education outcomes, such as learning and satisfaction. METHODS: We analyzed data from a 2009 survey of residents in 4 large specialties regarding the adequacy and quality of supervision they receive as well as associations with self-reported data on medical errors and residents' perceptions of their learning environment. RESULTS: Residents' reports of working without adequate supervision were lower than data from a 1999 survey for all 4 specialties, and residents were least likely to rate "lack of supervision" as a problem. While few residents reported that they received inadequate supervision, problems with supervision were negatively correlated with sufficient time for clinical activities, overall ratings of the residency experience, and attending physicians as a source of learning. Problems with supervision were positively correlated with resident reports that they had made a significant medical error, had been belittled or humiliated, or had observed others falsifying medical records. CONCLUSIONS: Although working without supervision was not a pervasive problem in 2009, when it happened, it appeared to have negative consequences. The association between inadequate supervision and medical errors is of particular concern.

How Residents Say They Learn: A National, Multi-Specialty Survey of First- and Second-Year Residents.

Relatively little is known about how, from whom, and under what conditions residents say they most effectively learn. We examined the relationships between residents' self-reported ratings of 11 different sources of learning and a number of empirical variables, using a national, random sample of postgraduate year (PGY) 1 and PGY-2 residents in the 1998-1999 training year. Residents were surveyed by mail. Completed surveys were received from 64.2% of 5616 residents contacted. The most often reported sources of learning were other residents and attending physicians. Ratings varied by specialty, level of training, and US medical graduates (USMGs) versus international medical graduates (IMGs). Factor analysis identified 3 primary modes of learning: faculty-organized, peer-oriented, and self-directed. Residents in different specialties varied in their use of these 3 sources of learning. IMG residents reported significantly less learning from peers and more self-directed learning. Increased resident duty hours were associated with a decrease in faculty-organized and self-directed learning, and an increase in peer-oriented learning.

What do residents do when not working or sleeping? A multispecialty survey of 36 residency programs.

PURPOSE: To determine how residents spend their time when not working or sleeping, and to examine correlates of these outside activities. METHOD: In 2009, the authors surveyed 36 internal medicine, surgery, pediatrics, and obstetrics-gynecology programs. Residents answered questions about their recently completed first and second residency years, including, "During your past year of residency, outside of working hours, about how often did you…," followed by 10 listed activities and a four-point rating scale (1 = "less than once a week"; 4 = "almost daily"). RESULTS: The most frequent activity reported across all 634 respondents was using the Internet, followed by watching television and doing household tasks. The lowest reported activity was moonlighting, followed by seeing a movie. K-cluster analyses divided residents into three clusters: (1) "Friend Focused," reporting higher means for time with friends, Internet use, physical exercise, and watching television, (2) "Family Focused," reporting higher means for time with family, Internet use, household tasks, and watching television, and (3) "Low Activity," reporting the lowest ratings for all activities. Comparisons among these three clusters showed the Low Activity residents to have significantly higher scores on validated depression, anxiety, and sleepiness scales; higher stress; more reported work hours and sleep deprivation; and lower ratings for satisfaction, time with attendings, and learning. Scores for Friend-Focused and Family-Focused clusters were similar to each other. CONCLUSIONS: These data provide new information about the residency experience and suggest that activities outside of work and sleep hours correlate highly with residents' mood, learning, and satisfaction.

How residents view their clinical supervision: a reanalysis of classic national survey data.

BACKGROUND: Concerns over patient safety have made adequacy of clinical supervision an important component of care in teaching settings. Yet, few studies have examined residents' perceptions about the quality and adequacy of their supervision. We reanalyzed data from a survey conducted in 1999 to explore residents' perspectives on their supervision. METHODS: A national, multispecialty survey was distributed in 1999 to a 14.5% random sample of postgraduate year 2 (PGY-2) and PGY-3 residents. The response rate was 64.4%. Residents (n  =  3604) were queried about how often they had cared for patients "without adequate supervision" during their preceding year of training. RESULTS: Of responding residents, 21% (n  =  737) reported having seen patients without adequate supervision at least once a week, with 4.5% saying this occurred almost daily. Differences were found across specialties, with 45% of residents in ophthalmology, 46% in neurology, and 44% in neurosurgery stating that they had experienced inadequate supervision at least once a week throughout the year, compared with 1.5% of residents in pathology and 3% in dermatology. Inadequate supervision was found to be inversely correlated with residents' positive ratings of their learning, time with attendings, and overall residency experience (P < .001 for all), and positively correlated with negative features of training, including medical errors, sleep deprivation, stress, conflict with other medical personnel, falsifying patient records, and working while impaired (P < .001). CONCLUSIONS: In residents' self-report, inadequate clinical supervision correlates with other reported negative aspects of training. Collectively, this may detrimentally affect resident learning and patient safety.

Interprofessional conflict and medical errors: results of a national multi-specialty survey of hospital residents in the US.

Clear communication is considered the sine qua non of effective teamwork. Breakdowns in communication resulting from interprofessional conflict are believed to potentiate errors in the care of patients, although there is little supportive empirical evidence. In 1999, we surveyed a national, multi-specialty sample of 6,106 residents (64.2% response rate). Three questions inquired about "serious conflict" with another staff member. Residents were also asked whether they had made a "significant medical error" (SME) during their current year of training, and whether this resulted in an "adverse patient outcome" (APO). Just over 20% (n = 722) reported "serious conflict" with another staff member. Ten percent involved another resident, 8.3% supervisory faculty, and 8.9% nursing staff. Of the 2,813 residents reporting no conflict with other professional colleagues, 669, or 23.8%, recorded having made an SME, with 3.4% APOs. By contrast, the 523 residents who reported conflict with at least one other professional had 36.4% SMEs and 8.3% APOs. For the 187 reporting conflict with two or more other professionals, the SME rate was 51%, with 16% APOs. The empirical association between interprofessional conflict and medical errors is both alarming and intriguing, although the exact nature of this relationship cannot currently be determined from these data. Several theoretical constructs are advanced to assist our thinking about this complex issue.

Sleep deprivation and fatigue in residency training: results of a national survey of first- and second-year residents.

STUDY OBJECTIVES: To examine the relationship between residents' self-reported sleep hours, work hours, and other empirical correlates. DESIGN: Using the American Medical Association's Graduate Medical Education database, a national, random sample of PGY (postgraduate year) 1 and PGY2 residents in the 1998-1999 training year was surveyed by mail. MEASUREMENTS AND RESULTS: Residents completed a 5-page survey with 44 questions requiring 144 separate responses about their residency experience. Completed surveys were received from 3,604 of 5,616 residents contacted, a 64.2% response rate. Although work hours and sleep hours were significantly correlated (r = -.39), this relationship was less robust than is generally assumed. Total average sleep hours varied across specialties but also within specialties. Just over 20% of all residents reported sleeping an average of 5 hours or less per night, with 66% averaging 6 hours or less per night. Residents averaging 5 or fewer hours of sleep per night were more likely to report serious accidents or injuries, conflict with other professional staff, use of alcohol, use of medications to stay awake, noticeable weight change, working in an "impaired condition," and having made significant medical errors. CONCLUSIONS: Reduced sleep hours were significantly related to a number of work-related, learning, and personal health variables. Capping residents' work hours is unlikely to fully address the sleep deficits and resulting impairments reported by residents.

A national survey of residents' self-reported work hours: thinking beyond specialty.

PURPOSE: To secure data from residents regarding residency work hours and correlates. METHOD: A national, random sample of postgraduate year 1 (PGY1) and year 2 (PGY2) residents in the 1998-1999 training year was identified using the American Medical Association's Graduate Medical Education database. Residents completed a five-page survey with 44 questions and 144 separate data elements relating to their residency experience. RESULTS: Completed surveys were received from 3,604 of 5,616 (64.2%) residents contacted. PGY1 residents reported working an average of 83 hours a week versus 76.2 hours for PGY2 residents (p <.0001). Total work hours were significantly correlated with reported stress and hours of sleep per week. Residents averaging more than 80 work hours per week were more likely to be involved in a personal accident or injury, a serious conflict with other staff members, and making a significant medical error. Cluster analysis revealed four different types of residency experience: high intensity, moderate intensity, low intensity, and moonlighters, suggesting that residents may have some choice in selecting a residency experience suited to their particular personal and professional needs. CONCLUSION: Nearly half of PGY1 and one third of PGY2 residents reported working more than 80 hours per week. These extended hours are significantly correlated with a number of patient care and personal health variables. Given the variety of program and specialty requirements and demands, it seems unlikely that an arbitrary limit or a simple decrease in work hours will provide a satisfactory solution to many resident and patient care concerns.