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When the latest resident duty-hour changes kicked in last July, they caused barely a ripple here. The new requirements were put into effect, tested and adjusted months before they had to be – and all of it done by the residents themselves.
“All I did was give them the new rules and tell them what was required,” says Javier Gonzalez del Rey, MD, MEd, director of the Residency Training Program. “The residents ran it. They completely changed the schedules. And now, even in the middle of our busiest season, the schedules are working.”
Being open to change — such as giving residents a greater role in determining their own futures — has been the formula for our residency program’s success. It is part forward-thinking leadership, part the demands of a new generation of trainees.
“Our residents want to be included, to be interactive, to be questioned and to ask questions,” says Sue Poynter, MD, the residency program’s associate director.
Nearly a decade ago, residency leaders created a residency council to address issues and solve problems that arise during training. The group now totals more than 40 residents, with representation from each program year. They have a formal business structure, meet monthly and publish minutes on a resident-run website. Program directors and other leadership serve only as ad hoc advisors to the group.
“Fifty percent of the changes for the better in our program have come out of that group,” says Gonzalez del Rey. “The residents have taken ownership to bring the residency to the next level.”
Residency council is just one of the many changes that Gonzalez del Rey and his team have embraced in his 12 years as program director. The result is one of the nation’s most sought-after training programs. This year, a record 1,400 students applied for 39 slots.
Like many of the doctors who staff our residency training program, Dr. Poynter is a product of it as well. She came here 14 years ago as a resident in pediatrics, served as chief resident, then did a fellowship in critical care medicine. She continues to work as an attending physician in critical care and is completing a master’s degree in medical education.
Of the many changes the program has faced, Poynter thinks the regulation of resident work hours has been most challenging.
“It’s required us to become much more streamlined to give our residents better training experiences – and to maximize the hours they are here,” she says.
In 2003, the Accreditation Council for Graduate Medical Education (ACGME) mandated an 80-hour work week for residents and limited shifts to 30 hours. In July 2011, the ACGME further reduced shifts to 24 plus 4, where residents work a 24-hour shift with 4 hours allotted to transitioning care to incoming doctors. The 2011 change also mandates that first-year residents work only 16 hours at a time.
Although a far cry from the stamina-defying shifts required during her residency, Poynter sees these changes as positive.
“It reflects a very different mindset. The old thinking was that ‘first years’ are naïve to the system, so let’s give them as much as possible,” she says. “The new rules do more to ease first-year students into the responsibilities of patient care.”
But there may be a point when enough is enough. Talk of further hours restrictions in the future finds Gonzalez del Rey less enthusiastic.
“In medicine, you need to see a lot of patients to know about one disease,” he says. “I am concerned that if we keep moving in the direction of these restricted hours, we may end up with the problem of enough knowledge but not enough experience.”
Another big change in resident training has been adapting to generational differences.
With four generations working in the same environment, there are inevitable clashes between the learning styles and experiences of the traditionalists, the baby boomers, and generations X and Y.
“These younger doctors have grown up with electronic media and teaching devices,” Poynter says. “They are demanding stimulating ways of learning and more involvement. They are much less tolerant of the old-fashioned PowerPoint lecture where you maybe get to ask a question at the end. That’s not how they learn.”
So lengthy classroom lectures have given way to hands-on learning, involvement in discussions and simulation exercises – all methods that create better-prepared doctors, Gonzalez del Rey believes.
“The best way to learn medicine is by seeing and doing. Unless you practice, knowledge doesn’t stay in your head,” he says. “Teaching needs to change behavior so that it is incorporated automatically in your daily practices.”
One final change in the training landscape, says Gonzalez del Rey, is that residents must be prepared for patients who come armed with information and willing to challenge what their doctor tells them.
“I think medicine is safer when patients challenge us. But how do you prepare a recent medical school graduate who comes with a background that concentrates on knowledge, and then the first day of residency needs to know how to manage conflict and difference of opinion?”
Gonzalez del Rey believes that residents who train at Cincinnati Children’s have an advantage because of our family-centered rounds and what he calls a “melting pot” culture that attracts trainees and faculty from all over the world.
“When you bring together people with different views, there is no one way to do things,” he says. “We are used to agreeing, disagreeing, discussing and moving forward.”
Dr. Javier Gonzalez del Ray, MD, MEd.
Research shows that communication failures during patient handoffs — when clinicians turn over patient care to a new shift — contribute to as many as two thirds of the serious adverse safety events happening in hospitals nationwide.
Yet new work-hour restrictions for resident physicians are resulting in more shift changes and more patient handoffs than ever.
“All resident physicians, at every hospital across the country, participate in handoffs. But until now, there has been very little formal training for residents on how to communicate in a handoff. Actual practice varies from hospital to hospital and even from department to department,” says Jennifer O’Toole, MD, associate program director for the Internal Medicine/ Pediatrics Residency Training Program at Cincinnati Children’s.
Now, the Accreditation Council for Graduate Medical Education (ACGME) requires residency programs to have structured handoff programs. As these changes occur, residents here will play an important role in setting best practices.
Cincinnati Children’s is one of 10 pediatric centers nationwide participating in the $3 million I-PASS study, which seeks to implement and evaluate a structured handoff process designed to reduce medical errors and improve resident workflow. The program, coordinated by Children’s Hospital Boston and funded by the US Department of Health and Human Services, began launching in 2011. All residents at Cincinnati Children’s were using the I-PASS handoff process by April 2012.
The I-PASS curriculum includes a three hour workshop on team communication training and learning a verbal mnemonic to use during handoffs. Residents also will receive six months of faculty feedback during actual handoffs, as well as other “just-in-time” refresher training activities.
The curriculum serves the needs of adult learners; including learning style assessments, simulations, and online learning. In addition, Lauren Solan, MD, a fellow in Hospital Medicine, has been working with the EPIC team to reformat printed handoff documents to correspond with the I-PASS process.
A small-scale pilot study of this process, completed in 2010 at Children’s Hospital Boston, reported decreased medical error rates, reduced time spent working on computer records, and increased contact time between physicians and patients. Once residents adopt the I-PASS method, O’Toole predicts the concept will spread throughout hospitalist services, nursing teams and other care teams, eventually becoming a unified language for medical communication.
“Gone are the days when residents stayed in the hospital for two days straight,” O’Toole says. “Frequent handoffs are a fact of life for today’s residents. It’s crucial that they are handled well.”
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