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.

Causes of Death of Residents in ACGME-Accredited Programs 2000 Through 2014: Implications for the Learning Environment.

PURPOSE: To systematically study the number of U.S. resident deaths from all causes, including suicide. METHOD: The more than 9,900 programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) annually report the status of residents. The authors aggregated ACGME data on 381,614 residents in training during years 2000 through 2014. Names of residents reported as deceased were submitted to the National Death Index to learn causes of death. Person-year calculations were used to establish resident death rates and compare them with those in the general population. RESULTS: Between 2000 and 2014, 324 individuals (220 men, 104 women) died while in residency. The leading cause of death was neoplastic disease, followed by suicide, accidents, and other diseases. For male residents the leading cause was suicide, and for female residents, malignancies. Resident death rates were lower than in the age- and gender-matched general population. Temporal patterns showed higher rates of death early in residency. Deaths by suicide were higher early in training, and during the first and third quarters of the academic year. There was no upward or downward trend in resident deaths over the 15 years of this study. CONCLUSIONS: Neoplastic disease and suicide were the leading causes of death in residents. Data for death by suicide suggest added risk early in residency and during certain months of the academic year. Providing trainees with a supportive environment and with medical and mental health services is integral to reducing preventable deaths and fostering a healthy physician workforce.

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.

The ascent of Mt. Everest.

Earlier this Spring, I reread the account of the 1924 attempt of Mallory and Irvine to summit the highest mountain in the world, Mt. Everest. Apart from the recurring mystery of whether the English climbers actually achieved their goal before disappearing on the upper reaches of the mountain, what emerged for me were the many failed attempts (including two earlier ones of their own) before the summit was finally conquered by Sir Edmund Hillary and Tenzing Norgay in 1953. This put me in mind of the current efforts to once more try to implement the concept of interprofessional education and teamwork in the solution to our many problems in delivering quality health care to all our citizens. The recurring calls in every recent report on health care by the Institute of Medicine and other national groups for greater implementation of collaborative practice models and interprofessional education (IPE) have reawakened the hope that this time, at last, we might succeed. But looming over the horizon, like the storm clouds constantly shrouding the summit of Everest, are the oft-dashed hopes that resurfaced throughout the last century; such that the course of IPE and IPP (interprofessional practice) often has been described as one of successive cycles of "boom and bust."

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.

Enhancing the informal curriculum of a medical school: a case study in organizational culture change.

BACKGROUND: Calls for organizational culture change are audible in many health care discourses today, including those focused on medical education, patient safety, service quality, and translational research. In spite of many efforts, traditional "top-down" approaches to changing culture and relational patterns in organizations often disappoint. OBJECTIVE: In an effort to better align our informal curriculum with our formal competency-based curriculum, Indiana University School of Medicine (IUSM) initiated a school-wide culture change project using an alternative, participatory approach that built on the interests, strengths, and values of IUSM individuals and microsystems. APPROACH: Employing a strategy of "emergent design," we began by gathering and presenting stories of IUSM's culture at its best to foster mindfulness of positive relational patterns already present in the IUSM environment. We then tracked and supported new initiatives stimulated by dissemination of the stories. RESULTS: The vision of a new IUSM culture combined with the initial narrative intervention have prompted significant unanticipated shifts in ordinary activities and behavior, including a redesigned admissions process, new relational practices at faculty meetings, student-initiated publications, and modifications of major administrative projects such as department chair performance reviews and mission-based management. Students' satisfaction with their educational experience rose sharply from historical patterns, and reflective narratives describe significant changes in the work and learning environment. CONCLUSIONS: This case study of emergent change in a medical school's informal curriculum illustrates the efficacy of novel approaches to organizational development. Large-scale change can be promoted with an emergent, non-prescriptive strategy, an appreciative perspective, and focused and sustained attention to everyday relational patterns.