Why Residencies Should Fly: Towards a Logical Approach to Duty Hour Reform.

Since 2011, aviation has revolutionized their approach to safety. The aviation industry has adopted a multi-faceted approach to improve safety through decreasing duty hour limits and implementing processes to mitigate fatigue-related errors as well as creating cultural shifts in responsibility for safety. These changes have been guided by data generated by quality-improvement methodology. In contrast, duty hour limits in graduate medical education have not yet seen dramatic data-driven reform. Key advancements in aviation fatigue mitigation and implications for residency education are explored in this article. Scientifically based processes to optimize duty hours, quality-improvement strategies to iteratively monitor and reform duty limits, systematic change focusing on a just culture, and financial disincentives and incentives as a catalyst for change are discussed.

Development and Validation of a Test for Competence in Evidence-Based Medicine.

BACKGROUND: Medical educators need valid, reliable, and efficient tools to assess evidence-based medicine (EBM) knowledge and skills. Available EBM assessment tools either do not assess skills or are laborious to grade. OBJECTIVE: To validate a multiple-choice-based EBM test-the Resident EBM Skills Evaluation Tool (RESET). DESIGN: Cross-sectional study. PARTICIPANTS: A total of 304 medicine residents from five training programs and 33 EBM experts comprised the validation cohort. MAIN MEASURES: Internal reliability, item difficulty, and item discrimination were assessed. Construct validity was assessed by comparing mean total scores of trainees to experts. Experts were also asked to rate importance of each test item to assess content validity. KEY RESULTS: Experts had higher total scores than trainees (35.6 vs. 29.4, P < 0.001) and also scored significantly higher than residents on 11/18 items. Cronbach's alpha was 0.6 (acceptable), and no items had a low item-total correlation. Item difficulty ranged from 7 to 86%. All items were deemed "important" by > 50% of experts. CONCLUSIONS: The proposed EBM assessment tool is a reliable and valid instrument to assess competence in EBM. It is easy to administer and grade and could be used to guide and assess interventions in EBM education.

A Curriculum to Teach Learners How to Develop and Present a Case Report.

Introduction: Residents are required by the Accreditation Council for Graduate Medical Education to complete a scholarly project during residency, but they may not have dedicated time or instruction to be able to successfully achieve this goal. Methods: In 2013 at Baystate Medical Center, we developed the Case Report Curriculum to guide internal medicine interns through the process of writing and presenting a case report. Core faculty and chief residents facilitate six sessions, which are scheduled throughout the year. Sessions combine large- and small-group discussion with facilitated independent work as well as postsession assignments and timely feedback from course facilitators. Topics include selecting a case report, crafting learning objectives, writing a discussion, authorship and creating a title, generating a poster, and presenting a poster. At the culmination of the conference series, interns present their completed case reports at an institutional academic day where judges critique and score their posters. Results: Over the past 4 years, 95%-100% of our interns have participated in the required curriculum and presented their posters. We found that the majority of interns go on to present additional scholarly works at regional and national meetings during their second and third postgraduate years. Due to the success of the curriculum, interns from additional programs within the institution now attend the conference series. Discussion: The Case Report Curriculum is a successful conference series that guides interns through the process of writing a case and can inspire additional scholarship during residency.

A case report curriculum to promote scholarship.

BACKGROUND: Engaging in scholarly activity during residency can facilitate the acquisition of important skills; however, residents may encounter barriers such as unclear expectations as to what constitutes scholarship, a paucity of dedicated time and a lack of mentorship. Residents may encounter barriers such as unclear expectations as to what constitutes scholarship OBJECTIVE: In July 2013, we developed a Case Report Curriculum (CRC) for first-year residents to guide them towards creating a high-quality case report and helping them to achieve the Accreditation Council for Graduate Medical Education scholarly activity requirement. METHODS: The CRC is composed of four 1-hour educational sessions (seminars and group work) at intervals of 4-6 weeks, with specific homework assignments. Sessions are divided into four topics: (1) importance of scholarship and selecting a case; (2) defining appropriate learning objectives; (3) writing a discussion; and (4) editing and submitting. The culmination of the CRC is a poster competition at our institutional Academic Week. RESULTS: In 2012/13, the year prior to CRC implementation, six of 18 (33%) first-year residents participated in scholarly activity. During the following 2 years, 20 of 20 (100%) of the 2013/14 first-year residents and 21 of 22 (95%) of the 2014/15 first-year residents participated in the CRC and presented a case report. Furthermore, 16 of 20 (80%) of the first-year residents who completed the CRC in 2013/14 voluntarily continued to work on scholarly projects, with a total of 44 projects published or presented regionally or nationally. DISCUSSION: The CRC represents a practical structured framework for promoting scholarship, which can be easily implemented in a residency programme.

Ambulatory Morning Report: A Case-Based Method of Teaching EBM Through Experiential Learning.

OBJECTIVES: Evidence-based medicine (EBM) skills are important to daily practice, but residents generally feel unskilled incorporating EBM into practice. The Kolb experiential learning theory, as applied to curricular planning, offers a unique methodology to help learners build an EBM skill set based on clinical experiences. We sought to blend the learner-centered, case-based merits of the morning report with an experientially based EBM curriculum. We describe and evaluate a patient-centered ambulatory morning report combining the User's Guides to the Medical Literature approach to EBM and experiential learning theory in the internal medicine department at Baystate Medical Center. METHODS: The Kolb experiential learning theory postulates that experience transforms knowledge; within that premise we designed a curriculum to build EBM skills incorporating residents' patient encounters. By developing structured clinical questions based on recent clinical problems, residents activate prior knowledge. Residents acquire new knowledge through selection and evaluation of an article that addresses the structured clinical questions. Residents then apply and use new knowledge in future patient encounters. RESULTS: To assess the curriculum, we designed an 18-question EBM test, which addressed applied knowledge and EBM skills based on the User's Guides approach. Of the 66 residents who could participate in the curriculum, 61 (92%) completed the test. There was a modest improvement in EBM knowledge, primarily during the first year of training. CONCLUSIONS: Our experiential curriculum teaches EBM skills essential to clinical practice. The curriculum differs from traditional EBM curricula in that ours blends experiential learning with an EBM skill set; learners use new knowledge in real time.

Residents-as-teachers: implementing a toolkit in morning report to redefine resident roles.

BACKGROUND: Morning report was initially created to meet service needs. PURPOSE: The objective was to improve morning report through a toolkit combining principles of learning theory with resident teaching. METHODS: The toolkit consists of three parts: a guideline describing expectations, a worksheet outlining teaching plans, and a feedback form facilitating post-presentation feedback. In 2009-2010, internal medicine residents met with a chief resident before their presentations to refine teaching plans. The chief resident then supported the presenter in achieving their objectives and provided post-presentation feedback. Residents were surveyed before and 6 months after the intervention. Mean scores were compared using an unpaired t test. RESULTS: Residents' ratings improved in the following domains: understanding expectations (3.10 vs. 4.02, p = .0003), presentation organization (3.50 vs. 4.25, p = .005), and creating and accomplishing learning objectives (3.31 vs. 4.00, p = .002). Residents commented positively on the improved presentations. CONCLUSIONS: This toolkit, based on educational principles, improved morning report presentations.

Postprandial hypotension.

Postprandial hypotension is both common in geriatric patients and an important but under-recognized cause of syncope. Other populations at risk include those with Parkinson disease and autonomic failure. The mechanism is not clearly understood, but appears to be secondary to a blunted sympathetic response to a meal. This review discusses the epidemiology, risk factors, and pathophysiology of postprandial hypotension in the elderly, as well as diagnosis and treatment strategies. Diagnosis can be made based on ambulatory blood pressure monitoring and patient symptoms. Lifestyle modifications such as increased water intake before eating or substituting 6 smaller meals daily for 3 larger meals may be effective treatment options. However, data from randomized, controlled trials are limited. Increased awareness of this disease may lead to improved quality of life, decreased falls and injuries, and the avoidance of unnecessary testing.