Digital Engagement Strategy and Health Care Worker Mental Health: A Randomized Clinical Trial.

Importance: The health care workforce continues to experience high rates of depression and anxiety. Finding ways to effectively support the mental health and well-being of health care workers is challenging. Objective: To test the effectiveness of remote, pushed digital assessments and engagement to improve depression and anxiety among health care workers compared with usual care. Design, Setting, and Participants: This was a 9-month randomized clinical trial with a 6-month intervention period. Participants were health care workers with self-reported daily access to a smartphone and at least 4 clinical hours per week. Participants were randomized to usual care or the intervention between January 2022 and March 2023. Data analyses were conducted between May and July 2023. Interventions: All participants completed baseline, 6-month, and 9-month mental health, well-being, and burnout assessments. The control group had open access to a web-based mental health platform. Participants in the intervention group received monthly text messaging about mental health, mental health assessments, and linkages to care. Main Outcomes and Measures: The primary outcomes were mean change in depression and anxiety scores at 6 months from baseline. Secondary outcomes include mean change in well-being, burnout, and self-reported workplace productivity. Results: In this study, 1275 participants were randomized (642 [50.4%] to the intervention group and 633 [49.6%] to control group). Participants had a mean (SD) age of 38.6 (10.9) years, 1063 participants (83.4%) were female, 320 (25.1%) self-identified as Black, and 793 (62.2%) self-identified as White. Across the groups, the mean difference in depression score was significantly different at 6 months (-0.96 [95% CI, -1.52 to -0.40]) and at 9 months (-1.14 [95% CI, -1.69 to -0.58]). The mean difference in anxiety score from baseline to 6 months was statistically significantly larger for those in the intervention group vs usual care (-0.71 [95% CI, -1.25 to -0.17]) and held true at 9 months (-1.06 [95% CI, -1.59 to -0.52]). Conclusions and Relevance: In a trial of health care workers, a proactive digital engagement strategy, including pushed text messaging, mobile mental health assessments, and connection to care, improved depression and anxiety over a 6-month period compared with simply making the same resources available for individuals to find and use. Trial Registration: ClinicalTrials.gov Identifier: NCT05028075.

Using poetry to elicit internal medicine residents' perspectives on wellness.

PURPOSE: To elicit internal medicine residents' perspectives on wellness through poetry writing, examining (1) response rates, (2) the tone/sentiment of their submissions and (3) the primary thematic content. STUDY DESIGN: In academic year 2019-2020, a random sample of 88 residents from four internal medicine residency programmes was invited to participate in a year-long study of wellness. In December 2019, an open-ended prompt asked residents to write a poem reflecting on their well-being. Responses were inductively coded using content analysis techniques. RESULTS: The response rate for the poetry prompt was 94%. The tone of the entries was most often neutral or contradictory (42%), followed by negative (33%) and positive (25%). There were three main themes: (1) Mindsets: most residents simply wanted to make it through their programme; (2) wellness influencers: the main wellness supporters were external to the programme such as vacationing and exercise; within hospitals, friendships with colleagues and boosted wellness and (3) scheduling/repetition: difficult schedules drained energy as did the monotony of administrative tasks. CONCLUSIONS: Poetry appears to be an innovative and effective vehicle to elicit residents' perspectives without compromising response rate. Poetry survey techniques allow medical trainees to provide powerful messaging to leadership. Most of what is known about trainee wellness is derived from quantitative surveys. This study showed medicine trainees' willingness to engage in poetry and add richness and personal detail to highlight key drivers of wellness. Such information provides context and brings attention in a compelling manner to an important topic.

An innovation tournament to improve medical residency.

Two large national studies of resident duty hours incidentally revealed surgical and medical resident dissatisfaction with residency training. Aiming for an inclusive and democratic approach to improve graduate medical education, we conducted a national innovation tournament--reaching out to the program directors of all 474 US internal medicine residency programs to invite them and their residents and associate program directors to participate. Participants could submit multiple ideas as individuals or teams in four domains: [1] resident well-being and personal and professional development; [2] resident education and clinical preparedness; [3] resident sleep and alertness; and [4] patient safety. Residents and program directors were reinvited to rate ideas, whether they had submitted ideas themselves or not. We used a schedule of lottery-based prizes to stimulate the submission and rating of ideas and encourage engagement. 164 residents and program directors from 51 different programs submitted 328 ideas. 153 residents and program directors from 48 different programs submitted 15,345 ratings of ideas. Winning ideas aimed to reduce residents' work burden or improve their mental health, sleep, eating, or relaxation or reflected technical fixes to the operations of residency, such as changing vacation schedules and the timing of pay. The results of this tournament provided actionable suggestions to improve residency training now being tested in our own residency programs. Innovation tournaments drive engagement and generate value by their opportunities for inclusion and by shifting problem solving to the end user.

Exploring Residents' Well-Being and Burnout via Qualitative Ecological Momentary Assessment.

PURPOSE: Most of what is known about resident burnout and wellness comes from cross-sectional snapshot surveys. The purpose of this study was to elicit qualitative perspectives on wellness from a cohort of internal residents over time using ecological momentary assessment. METHOD: Drawing on principles of ecological momentary assessment, 13 different open-ended survey prompts were delivered between October and March during the 2019-2020 academic year. Participants were 88 randomly selected internal medicine residents from 4 internal medicine training programs in the Northeast. RESULTS: The response rate was 95%. Three main themes regarding wellness were self, program/education environment, and medical/structural system. A fourth theme, the desire to provide quality patient care, cut across all other themes. The patient care theme repeatedly stressed residents' desire to spend more time with patients. The self theme primarily reflected messages about personal emotions and the need for work-life balance and wellness. The program/education environment theme reflected the value of learning, teamwork and community, and program culture. The medical/structural system theme showed that residents' experiences were shaped by the efficiency of their days and largely a product of their schedules and administrative support. Closing advice to future trainees was optimistic and reassuring. CONCLUSIONS: While findings support much of what has been learned via single-occasion survey snapshots, an ecological momentary assessment design allowed a deeper dive into contextual associations. The results affirm the primacy of patient care and also highlight the value of teamwork and culture. Peers and program leaders are heavily influential in setting the tone for the learning experience, whether for the day or with a more enduring message of respect and support. There is opportunity to maximize high- or higher-value learning experiences for residents and find solutions to reduce and reframe the perceived "low-value administrative work" that is part of care coordination.

Sleep and Alertness Among Interns in Intensive Care Compared to General Medicine Rotations: A Secondary Analysis of the iCOMPARE Trial.

BACKGROUND: Medical interns are at risk for sleep deprivation from long and often rotating work schedules. However, the effects of specific rotations on sleep are less clear. OBJECTIVE: To examine differences in sleep duration and alertness among internal medicine interns during inpatient intensive care unit (ICU) compared to general medicine (GM) rotations. METHODS: This secondary analysis compared interns during a GM or ICU rotation from a randomized trial (2015-2016) of 12 internal medicine residency programs assigned to different work hour limit policies (standard 16-hour shifts or no shift-length limits). The primary outcome was sleep duration/24-hour using continuous wrist actigraphy over a 13-day period. Secondary outcomes assessed each morning during the concomitant actigraphy period were sleepiness (Karolinska Sleepiness Scale [KSS]), alertness (number of Brief Psychomotor Vigilance Test [PVT-B] lapses), and self-report of excessive sleepiness over past 24 hours. Linear mixed-effect models with random program intercept determined associations between each outcome by rotation, controlling for age, sex, and work hour policy followed. RESULTS: Of 398 interns, 386 were included (n = 261 GM, n = 125 ICU). Average sleep duration was 7.00±0.08h and 6.84±0.10h, and number of PVT lapses were 5.5±0.5 and 5.7±0.7 for GM and ICU, respectively (all P > .05). KSS was 4.8±0.1 for both rotations. Compared to GM, ICU interns reported more days of excessive sleepiness from 12am-6am (2.6 vs 1.7, P < .001) and 6am-12pm (2.6 vs 1.9, P = .013) and had higher percent of days with sleep duration < 6 hours (27.6% vs 23.4%, P < .001). GM interns reported more days with no excessive sleepiness (5.3 vs 3.7, P < .001). CONCLUSIONS: Despite ICU interns reporting more excessive sleepiness in morning hours and more days of insufficient sleep (<6 hours), overall sleep duration and alertness did not significantly differ between rotations.

Dark Clouds With Silver Linings: Resident Anxieties About COVID-19 Coupled With Program Innovations and Increased Resident Well-Being.

BACKGROUND: The COVID-19 pandemic forced numerous unprecedented systemic changes within residency programs and hospital systems. OBJECTIVE: We explored how the COVID-19 pandemic, and associated changes in clinical and educational experiences, were related to internal medicine residents' well-being in the early months of the pandemic. METHODS: Across 4 internal medicine residency programs in the Northeast United States that have previously participated in the iCOMPARE study, all 394 residents were invited to participate in a study with open-ended survey prompts about well-being approximately every 2 weeks in academic year 2019-2020. In March and April 2020, survey prompts were refocused to COVID-19. Content analysis revealed themes in residents' open-ended responses to 4 prompts. RESULTS: One hundred and eighty-six residents expressed interest, and 88 were randomly selected (47%). There were 4 main themes: (1) in early days of the pandemic, internal medicine residents reported fear and anxiety about uncertainty and lack of personal protective equipment; (2) residents adapted and soon were able to reflect, rest, and pursue personal wellness; (3) communication from programs and health systems was inconsistent early in the pandemic but improved in clarity and frequency; (4) residents appreciated the changes programs had made, including shorter shifts, removal of pre-rounding, and telemedicine. CONCLUSIONS: COVID-19 introduced many challenges to internal medicine residency programs and to resident well-being. Programs made structural changes to clinical schedules, educational/conference options, and communication that boosted resident well-being. Many residents hoped these changes would continue regardless of the pandemic's course.

The Definition of Faculty Must Evolve: A Call to Action.

As academic medical centers and academic health centers continue to adapt to the changing landscape of medicine in the United States, the definition of what it means to be faculty must evolve as well. Both institutional economic priorities and the need to recalibrate educational programs to address current and future societal and patient needs have brought new complexity to faculty identity, faculty value, and the educational mission.The Council of Faculty and Academic Societies, 1 of 3 membership councils of the Association of American Medical Colleges (AAMC), established working groups in 2014 to provide a strong voice for academic faculty within the AAMC governance and leadership structures. The Faculty Identity and Value Working Group was charged with identifying the attributes and qualities of future academic medicine faculty in light of the transformational changes occurring at many medical schools and teaching hospitals. The working group developed a framework that could be applied throughout the United States by AAMC member schools to define and value teaching activities. This report adds to the work of others by offering a contemporary construct that is flexible and easily adaptable to enable fair and transparent implementation of an education value system; it is especially relevant for systems in which mergers and acquisitions lead to a large number of clinicians. An example of such an implementation at a large and growing academic medical center is provided.The ability to identify and quantify educational effort by faculty could be transformative by highlighting the fundamental importance of faculty to the development of the future medical workforce.

Assessment of Inpatient Time Allocation Among First-Year Internal Medicine Residents Using Time-Motion Observations.

Importance: The United States spends more than $12 billion annually on graduate medical education. Understanding how residents balance patient care and educational activities may provide insights into how the modern physician workforce is being trained. Objective: To describe how first-year internal medicine residents (interns) allocate time while working on general medicine inpatient services. Design, Setting, and Participants: Direct observational secondary analysis, including 6 US university-affiliated and community-based internal medicine programs in the mid-Atlantic region, of the Comparative Effectiveness of Models Optimizing Patient Safety and Resident Education (iCOMPARE) trial, a cluster-randomized trial comparing different duty-hour policies. A total of 194 weekday shifts were observed and time motion data were collected, sampled by daytime, nighttime, and call shifts in proportion to the distribution of shifts within each program from March 10 through May 31, 2016. Data were analyzed from June 1, 2016, through January 5, 2019. Main Outcomes and Measures: Mean time spent in direct and indirect patient care, education, rounds, handoffs, and miscellaneous activities within a 24-hour period and in each of four 6-hour periods (morning, afternoon, evening, and night). Time spent multitasking, simultaneously engaged in combinations of direct patient care, indirect patient care, or education, and in subcategories of indirect patient care were tracked. Results: A total of 80 interns (55% men; mean [SD] age, 28.7 [2.3] years) were observed across 194 shifts, totaling 2173 hours. A mean (SD) of 15.9 (0.7) hours of a 24-hour period (66%) was spent in indirect patient care, mostly interactions with the patient's medical record or documentation (mean [SD], 10.3 [0.7] hours; 43%). A mean (SD) of 3.0 (0.1) hours was spent in direct patient care (13%) and 1.8 (0.3) hours in education (7%). This pattern was consistent across the 4 periods of the day. Direct patient care and education frequently occurred when interns were performing indirect patient care. Multitasking with 2 or more indirect patient care activities occurred for a mean (SD) of 3.8 (0.4) hours (16%) of the day. Conclusions and Relevance: This study's findings suggest that within these US teaching programs, interns spend more time participating in indirect patient care than interacting with patients or in dedicated educational activities. These findings provide an essential baseline measure for future efforts designed to improve the workday structure and experience of internal medicine trainees, without making a judgment on the current allocation of time. Trial Registration: ClinicalTrials.gov identifier: NCT02274818.

Patient Safety Outcomes under Flexible and Standard Resident Duty-Hour Rules.

BACKGROUND: Concern persists that extended shifts in medical residency programs may adversely affect patient safety. METHODS: We conducted a cluster-randomized noninferiority trial in 63 internal-medicine residency programs during the 2015-2016 academic year. Programs underwent randomization to a group with standard duty hours, as adopted by the Accreditation Council for Graduate Medical Education (ACGME) in July 2011, or to a group with more flexible duty-hour rules that did not specify limits on shift length or mandatory time off between shifts. The primary outcome for each program was the change in unadjusted 30-day mortality from the pretrial year to the trial year, as ascertained from Medicare claims. We hypothesized that the change in 30-day mortality in the flexible programs would not be worse than the change in the standard programs (difference-in-difference analysis) by more than 1 percentage point (noninferiority margin). Secondary outcomes were changes in five other patient safety measures and risk-adjusted outcomes for all measures. RESULTS: The change in 30-day mortality (primary outcome) among the patients in the flexible programs (12.5% in the trial year vs. 12.6% in the pretrial year) was noninferior to that in the standard programs (12.2% in the trial year vs. 12.7% in the pretrial year). The test for noninferiority was significant (P = 0.03), with an estimate of the upper limit of the one-sided 95% confidence interval (0.93%) for a between-group difference in the change in mortality that was less than the prespecified noninferiority margin of 1 percentage point. Differences in changes between the flexible programs and the standard programs in the unadjusted rate of readmission at 7 days, patient safety indicators, and Medicare payments were also below 1 percentage point; the noninferiority criterion was not met for 30-day readmissions or prolonged length of hospital stay. Risk-adjusted measures generally showed similar findings. CONCLUSIONS: Allowing program directors flexibility in adjusting duty-hour schedules for trainees did not adversely affect 30-day mortality or several other measured outcomes of patient safety. (Funded by the National Heart, Lung, and Blood Institute and Accreditation Council for Graduate Medical Education; iCOMPARE ClinicalTrials.gov number, NCT02274818.).

Sleep and Alertness in a Duty-Hour Flexibility Trial in Internal Medicine.

BACKGROUND: A purpose of duty-hour regulations is to reduce sleep deprivation in medical trainees, but their effects on sleep, sleepiness, and alertness are largely unknown. METHODS: We randomly assigned 63 internal-medicine residency programs in the United States to follow either standard 2011 duty-hour policies or flexible policies that maintained an 80-hour workweek without limits on shift length or mandatory time off between shifts. Sleep duration and morning sleepiness and alertness were compared between the two groups by means of a noninferiority design, with outcome measures including sleep duration measured with actigraphy, the Karolinska Sleepiness Scale (with scores ranging from 1 [extremely alert] to 9 [extremely sleepy, fighting sleep]), and a brief computerized Psychomotor Vigilance Test (PVT-B), with long response times (lapses) indicating reduced alertness. RESULTS: Data were obtained over a period of 14 days for 205 interns at six flexible programs and 193 interns at six standard programs. The average sleep time per 24 hours was 6.85 hours (95% confidence interval [CI], 6.61 to 7.10) among those in flexible programs and 7.03 hours (95% CI, 6.78 to 7.27) among those in standard programs. Sleep duration in flexible programs was noninferior to that in standard programs (between-group difference, -0.17 hours per 24 hours; one-sided lower limit of the 95% confidence interval, -0.45 hours; noninferiority margin, -0.5 hours; P = 0.02 for noninferiority), as was the score on the Karolinska Sleepiness Scale (between-group difference, 0.12 points; one-sided upper limit of the 95% confidence interval, 0.31 points; noninferiority margin, 1 point; P<0.001). Noninferiority was not established for alertness according to the PVT-B (between-group difference, -0.3 lapses; one-sided upper limit of the 95% confidence interval, 1.6 lapses; noninferiority margin, 1 lapse; P = 0.10). CONCLUSIONS: This noninferiority trial showed no more chronic sleep loss or sleepiness across trial days among interns in flexible programs than among those in standard programs. Noninferiority of the flexible group for alertness was not established. (Funded by the National Heart, Lung, and Blood Institute and American Council for Graduate Medical Education; ClinicalTrials.gov number, NCT02274818.).

Providing Compassionate Off-Ramps for Medical Students Is a Moral Imperative.

It is highly unusual for learners to leave medical training in the United States even though some individuals' goals may change and others may not achieve expected competence. There are a number of possible reasons for this: (1) Students may feel that they have progressed too far into their careers and amassed too much debt to leave medical training; (2) students may be allowed to graduate despite marginal performance; and (3) students may have entered medical training with risk factors for poor performance that were not addressed. As stewards of the educational process, medical educators have an ethical obligation to students and the public to create off-ramps, or points along the educational continuum at which learners can reassess their goals and educators can assess competence, that allow students to leave medicine.Given the nationwide focus on physician health and wellness, the authors believe the creation of options to leave medical training without compromising one's self-esteem or incurring unmanageable debt (i.e., compassionate off-ramps) is a moral imperative. The practice of medicine should not be an exercise in survival; it should allow people to develop and thrive over the course of their careers. Offering students options to make use of the medical competencies they have accumulated in other attractive careers would enable medical educators to behave compassionately toward individual students and fulfill their societal obligation to graduate competent and committed physicians. To this end, the authors present six recommendations for consideration.

Development of the individualised Comparative Effectiveness of Models Optimizing Patient Safety and Resident Education (iCOMPARE) trial: a protocol summary of a national cluster-randomised trial of resident duty hour policies in internal medicine.

INTRODUCTION: Medical trainees' duty hours have received attention globally; restrictions in Europe, New Zealand and some Canadian provinces are much lower than the 80 hours per week enforced in USA. In USA, resident duty hours have been implemented without evidence simultaneously reflecting competing concerns about patient safety and physician education. The objective is to prospectively evaluate the implications of alternative resident duty hour rules for patient safety, trainee education and intern sleep and alertness. METHODS AND ANALYSIS: 63 US internal medicine training programmes were randomly assigned 1:1 to the 2011 Accreditation Council for Graduate Medical Education resident duty hour rules or to rules more flexible in intern shift length and number of hours off between shifts for academic year 2015-2016. The primary outcome is calculated for each programme as the difference in 30-day mortality rate among Medicare beneficiaries with any of several prespecified principal diagnoses in the intervention year minus 30-day mortality in the preintervention year among Medicare beneficiaries with any of several prespecified principal diagnoses. Additional safety outcomes include readmission rates, prolonged length of stay and costs. Measures derived from trainees' and faculty responses to surveys and from time-motion studies of interns compare the educational experiences of residents. Measures derived from wrist actigraphy, subjective ratings and psychomotor vigilance testing compare the sleep and alertness of interns. Differences between duty hour groups in outcomes will be assessed by intention-to-treat analyses. ETHICS AND DISSEMINATION: The University of Pennsylvania Institutional Review Board (IRB) approved the protocol and served as the IRB of record for 40 programmes that agreed to sign an Institutional Affiliation Agreement. Twenty-three programmes opted for a local review process. TRIAL REGISTRATION NUMBER: NCT02274818; Pre-results.

Leveraging the Continuum: A Novel Approach to Meeting Quality Improvement and Patient Safety Competency Requirements Across a Large Department of Medicine.

PROBLEM: Quality improvement (QI) and patient safety (PS) are now core competencies across the medical education continuum. A major challenge to developing and implementing these new curricular requirements is the lack of faculty expertise. APPROACH: In 2015, the authors developed a centralized, vertically integrated, competency-based approach to meet QI/PS educational requirements across the continuum of graduate medical education in the Department of Medicine, Perelman School of Medicine, University of Pennsylvania. By leveraging the QI/PS expertise of one individual, the authors identified and trained core QI/PS faculty members and sequentially deployed QI/PS activities that were tailored to the learner level and specialty. The curriculum includes PS event reporting, systems thinking and root causes analysis skills, adverse event disclosure, and a QI workshop series and project. OUTCOMES: PS event reporting, an indication of engagement in PS culture, increased by 186% among interns, 384% among postgraduate year 2 and 3 residents, and 613% among fellows between academic years (AYs) 2013-2014 and 2016-2017. In AY 2017-2018, 9 faculty members and 40 fellows from 9 fellowships participated in the QI workshop series, and 53 fellows from 7 fellowships participated in the adverse event disclosure simulation activity. All educational activities were rated highly. NEXT STEPS: The authors are expanding the adverse event disclosure activity to include residents and the remaining fellowship programs, identifying fellowships to pilot curricular efforts related to clinical quality metrics, developing introductory activities in basic QI/PS concepts for medical students, and evaluating the impact of efforts on participating faculty members.

Relationships Between the ACGME Resident and Faculty Surveys and Program Pass Rates on the ABIM Internal Medicine Certification Examination.

PURPOSE: The Accreditation Council for Graduate Medical Education (ACGME) has surveyed residents since 2003, and faculty since 2012. Surveys are designed to assess program functioning and specify areas for improvement. The purpose of this study was to assess the association of the ACGME's resident and faculty surveys with residency-program-specific performance on the American Board of Internal Medicine (ABIM) certification exam. METHOD: Data were available from residents and faculty in 375 U.S. ACGME-accredited internal medicine programs from the 2012-2013, 2013-2014, and 2014-2015 academic years. Analysis of variance and correlations were used to examine the relationship between noncompliance with ACGME program requirements as assessed by the resident and faculty surveys, and ABIM program pass rates. RESULTS: Noncompliance reported on the resident and faculty surveys was highest for programs not meeting the ACGME program requirement of an 80% pass rate on the ABIM certification examination. This relationship was significant for overall noncompliance, both within the resident (P < .001) and faculty (P < .05) surveys, for many areas within the two surveys (correlations ranged between -.07 and -.25, and P values ranged between .20 and < .001), and for the highest levels of noncompliance across areas of the resident (P < .001) and faculty (P < .04) surveys. CONCLUSIONS: ACGME resident and faculty surveys were significantly associated with ABIM program pass rates, supporting the importance of these surveys within the ACGME's Next Accreditation System.

Education Outcomes in a Duty-Hour Flexibility Trial in Internal Medicine.

BACKGROUND: Concern persists that inflexible duty-hour rules in medical residency programs may adversely affect the training of physicians. METHODS: We randomly assigned 63 internal medicine residency programs in the United States to be governed by standard duty-hour policies of the 2011 Accreditation Council for Graduate Medical Education (ACGME) or by more flexible policies that did not specify limits on shift length or mandatory time off between shifts. Measures of educational experience included observations of the activities of interns (first-year residents), surveys of trainees (both interns and residents) and faculty, and intern examination scores. RESULTS: There were no significant between-group differences in the mean percentages of time that interns spent in direct patient care and education nor in trainees' perceptions of an appropriate balance between clinical demands and education (primary outcome for trainee satisfaction with education; response rate, 91%) or in the assessments by program directors and faculty of whether trainees' workload exceeded their capacity (primary outcome for faculty satisfaction with education; response rate, 90%). Another survey of interns (response rate, 49%) revealed that those in flexible programs were more likely to report dissatisfaction with multiple aspects of training, including educational quality (odds ratio, 1.67; 95% confidence interval [CI], 1.02 to 2.73) and overall well-being (odds ratio, 2.47; 95% CI, 1.67 to 3.65). In contrast, directors of flexible programs were less likely to report dissatisfaction with multiple educational processes, including time for bedside teaching (response rate, 98%; odds ratio, 0.13; 95% CI, 0.03 to 0.49). Average scores (percent correct answers) on in-training examinations were 68.9% in flexible programs and 69.4% in standard programs; the difference did not meet the noninferiority margin of 2 percentage points (difference, -0.43; 95% CI, -2.38 to 1.52; P=0.06 for noninferiority). od Institute and the ACGME; iCOMPARE ClinicalTrials.gov number, NCT02274818 .). CONCLUSIONS: There was no significant difference in the proportion of time that medical interns spent on direct patient care and education between programs with standard duty-hour policies and programs with more flexible policies. Interns in flexible programs were less satisfied with their educational experience than were their peers in standard programs, but program directors were more satisfied. (Funded by the National Heart, Lung, and Blo

Toward a Utopian Model for Teaching and Nonteaching Services: Every Journey Begins With a First Step.

Nonteaching services are an imperfect step toward enabling inpatient teaching services to transition from an unregulated, natural state, driven solely by the exigencies of patient volume and throughput, to one that is more controlled and intends to achieve the proper balance between service and education. As career educators the authors prefer to view nonteaching services as critical components of an integrated system that enables the best possible patient care and learning, yet they acknowledge that, to meet the needs of patients and learners, teaching and nonteaching services alike must be truly complementary, collaborative, and integrated components of a single system.In this Invited Commentary the authors offer a "utopian" view of a teaching service in an institution that explicitly acknowledges its contract with society to transform health care delivery. In this setting, highly engaged teachers and learners are supported by a high-performing cast of an advanced practice provider, primary nurses, a social worker, a case manager, a clinical pharmacist, and an analyst. This group forms a Clinical Learning Unit (CLU) where the curriculum has evolved into an interdependent framework of basic, clinical, and systems science. CLUs train tomorrow's health care workforce through adaptive service learning made possible because the team has a manageable census, time for daily reflection, and inspiring relationships with trained teachers. CLUs cannot exist without complementary nonteaching services.Elsewhere in this issue Repp and colleagues outline seven design principles to improve nonteaching services. These are a good first step toward the utopian vision outlined by the authors.

Sleep and Alertness in Medical Interns and Residents: An Observational Study on the Role of Extended Shifts.

Study Objectives: Fatigue from sleep loss is a risk to physician and patient safety, but objective data on physician sleep and alertness on different duty hour schedules is scarce. This study objectively quantified differences in sleep duration and alertness between medical interns working extended overnight shifts and residents not or rarely working extended overnight shifts. Methods: Sleep-wake activity of 137 interns and 87 PGY-2/3 residents on 2-week Internal Medicine and Oncology rotations was assessed with wrist-actigraphy. Alertness was assessed daily with a brief Psychomotor Vigilance Test (PVT) and the Karolinska Sleepiness Scale. Results: Interns averaged 6.93 hours (95% confidence interval [CI] 6.84-7.03 hours) sleep per 24 hours across shifts, significantly less than residents not working overnight shifts (7.18 hours, 95% CI 7.06-7.30 hours, p = .007). Interns obtained on average 2.19 hours (95% CI 2.02-2.36 hours) sleep during on-call nights (17.5% obtained no sleep). Alertness was significantly lower on mornings after on-call nights compared to regular shifts (p < .001). Naps between 9 am and 6 pm on the first day post-call were frequent (90.8%) and averaged 2.84 hours (95% CI 2.69-3.00 hours), but interns still slept 1.66 hours less per 24 hours (95% CI 1.56-1.76 hours) compared to regular shift days (p < .001). Sleep inertia significantly affected alertness in the 60 minutes after waking on-call. Conclusions: Extended overnight shifts increase the likelihood of chronic sleep restriction in interns. Reduced levels of alertness after on-call nights need to be mitigated. A systematic comparison of sleep, alertness, and safety outcomes under current and past duty hour rules is encouraged.