Resident wellness: institutional trends over 10 years since 2003.

BACKGROUND: The surveys in this study were carried out at the Graduate Medical Education Division at Oregon Health & Science University (OHSU). OHSU implemented two significant wellness initiatives: a wellness program in 2004, and a policy allowing 4 half-days off each academic year to pursue personal or family health care needs in 2010. This study provides a secondary data analysis of five cross-sectional surveys of career satisfaction of resident and fellow trainees. METHODS: All trainees were surveyed five times over a 10-year period using anonymous, cross-sectional web-based survey instruments. Surveys included questions about career satisfaction, perceived stress, sleep hours, burnout, and related factors. RESULTS: This represents 10 years of accumulated responses from over 2,200 residents with results showing continual improvement in their career satisfaction. Response rates ranged from 56% to 72%. During the study period, there was a significant positive change in overall resident career satisfaction, with little change in factors traditionally considered to be predictive of overall career satisfaction such as sleep hours or perceived stress level. In addition, our data support that availability of time for personal tasks could positively impact the overall training experience. CONCLUSION: We postulate that the improvements in satisfaction relate to two major institutional innovations designed to promote resident wellness.

Promoting resident wellness: evaluation of a time-off policy to increase residents' utilization of health care services.

PURPOSE: To evaluate awareness and utilization of a new institutional policy to grant residents time off to access personal and family health care. METHOD: In 2012, two years after policy implementation, an electronic survey was sent to all 546 residents and fellows at a tertiary care academic medical center in the United States. Residents were asked questions regarding awareness of the time-off policy, use of the policy, health care status, reasons for policy use, and barriers to use. RESULTS: A total of 490 (90%) residents responded. Eighty-nine percent of those surveyed were aware of the policy. Of those who were aware, 49.7% used the policy to access health care. Top reasons for policy use were for personal routine or preventive health care, dental care, and urgent health care needs. The most commonly reported barrier to policy use was concern about the impact the resident's absence would have on colleagues. CONCLUSIONS: Implementation of policies to prospectively schedule residents' time off during business hours to address health care needs is an important means to promote resident wellness. Such policies remove one commonly cited barrier to residents' access to health care. However, residents still reported concerns about impact on peers and patients as the main reason they were reluctant to take the time off to address their health care needs. More work is needed on both wellness policy implementation practices and on refining the systems that will allow seamless and guiltless transitions of care.

A comparison between physicians and demographically similar peers in accessing personal health care.

PURPOSE: Residents are a unique subpopulation of physicians, training in a complex work and educational environment that may create barriers to accessing preventive and illness-related health care. This study was designed to investigate residents' utilization of personal health care services and compare with those of demographically similar peers. METHOD: All 675 residents in a large, urban, tertiary care U.S. academic medical center were invited to participate in a confidential, Web-based, cross-sectional survey in January 2008. Survey responses to questions addressing personal health care were compared with those of a demographically similar group using the 2008 survey from the Behavioral Risk Factor Surveillance System (BRFSS). The final weights in BRFSS were used for a post hoc stratified adjustment in analysis. Logistic regression was employed to compare subgroups. RESULTS: Sixty-six percent of residents completed the survey. A significantly lower percentage of residents reported having a primary care provider (44%) or dentist (65%) or having routine health and dental care visits (39% and 53%, respectively) within the past year than those in the demographically similar group of 2008 BRFSS. In that group, 83% reported having a primary care provider, and 63% and 79% reported having routine primary and dental health care visits, respectively. CONCLUSIONS: The residents were significantly less likely than demographically similar peers to have a primary care provider or dentist or to participate in routine health maintenance. Further research into barriers preventing residents from accessing health care, and opportunities to address them, is needed.

Plug the leak: align public spending with public need.

We explore the history behind the current structure of graduate medical education funding and the problems with continuing along the current funding path. We then offer suggestions for change that could potentially manage this health care spill. Some of these changes include attracting more students into primary care, aligning federal graduate medical education spending with future workforce needs, and training physicians with skills they will require to practice in systems of the future.

A novel approach to increase residents' involvement in reporting adverse events.

PURPOSE: In the wake of the Patient Safety and Quality Improvement Act of 2005, national attention has increasingly focused on adverse-event reporting as a means of identifying systems changes to improve patient safety. However, physicians and residents have demonstrated meager involvement in this effort. METHOD: In 2008-2009, the authors measured participation in adverse-event reporting by 680 residents at Oregon Health & Science University before and after implementing a quality improvement initiative, which consisted of a financial incentive and multifaceted educational campaign. The primary measure of success was an increase in the average monthly adverse-event reports submitted by residents to greater than 5% of the institution's overall report submissions. RESULTS: The average number of adverse events reported by residents increased from 1.6% to 9.0% of the institution's overall event reports, representing a 5.6-fold increase during the initiative (P < .001). The relative percentage of resident-submitted reports defined as "near-misses" increased from 6% to 27% during the initiative (P < .001). CONCLUSIONS: The novel approach of integrating a retirement benefit and educational campaign to increase residents' involvement in adverse-event reporting was successful. In addition to increasing residents' contributions to adverse-event reporting to levels higher than any documented in the current literature, there was also a remarkable increase in the relative frequency of near-miss reporting by residents.

Fulminant, non-antibiotic associated Clostridium difficile colitis following Salmonella gastroenteritis.

In the last decade there has been increasing awareness of the virulence and changing epidemiology of Clostridium difficile (C. difficile). While the vast majority of clinical cases of C. difficile are associated with antimicrobial or nosocomial exposure, this syndrome has been well described in the absence of antibiotic use. We present an unusual case of fatal, non-antibiotic associated C. difficile colitis following Salmonella serotype Saintpaul gastroenteritis in a previously healthy young person. We review the typical risk factors for C. difficile colitis and fulminant disease. We also review the epidemiology of community-acquired C. difficile-associated disease (CA-CDAD) and highlight Salmonella infection as a potential risk factor for development of CA-CDAD.

Personal time off and residents' career satisfaction, attitudes and emotions.

OBJECTIVES: Doctors who are satisfied with their careers have less stress and burnout and are less likely to make medical errors and more likely to provide a higher quality of patient care. In response to reports that residents experienced barriers to taking time off, Oregon Health and Science University designed a survey to evaluate residents' awareness of their programmes' policies for time off, their ability to find time for personal needs, and associations of both with career satisfaction, emotions and training experience. METHODS: All 675 residents in a large, urban, tertiary care academic medical centre located in the USA were invited to participate in a confidential, web-based, cross-sectional survey in 2008; 66% completed the survey. The survey instrument consisted of a variety of items including yes/no, multiple choice, Likert scale and narrative response types. RESULTS: Only 41% of respondents were aware of their programmes' policies regarding time off. Residents who reported awareness of a policy were more able to find time to take care of personal needs (odds ratio=1.553, p=0.026). These respondents reported more positive experiences and emotions, fewer negative experiences and emotions, higher levels of career satisfaction and relatively less perceived stress than those who were unaware of a time-off policy. In addition, these respondents reported, on average, fewer work and more sleep hours. CONCLUSIONS: Our results highlight the importance of ensuring mechanisms for residents to find time to fulfil personal needs in order to enhance resident well-being and career satisfaction. Ensuring resident awareness of time-off policies is one way to do this. Our study demonstrates that ensuring residents are able to find time for personal needs has significant consequences with respect to resident perceptions of well-being and may be an effective strategy to promote career satisfaction and prevent burnout.

Education to return nonpracticing physicians to clinical activity: a case study in physician reentry.

INTRODUCTION: Physician shortages in the United States are estimated to reach as high as 85 000 by 2020. One strategy for addressing the shortage is to encourage physicians who left clinical practice to return to work, but few programs exist to prepare physicians to reenter practice. The Divisions of Continuing Medical Education and Graduate Medical Education (GME), Oregon Health & Science University, collaborated with clinical departments to establish a physician reentry program. METHODS: A case-study of education designed to return nonpracticing physicians to clinical activity was undertaken. RESULTS: Fourteen candidates were accepted into the program. Accepted candidates were appointed special fellows at the university and provided with restricted institutional license and liability coverage. Based on retraining assessment and planned scope of practice, applicants and program directors designed individualized curricula. As trainees demonstrated clinical proficiency, their level of independence increased in a condensed version of the residency training model. Of the 14 accepted candidates, 13 successfully completed the program and are actively engaged in clinical practice. One trainee did not successfully complete the program. DISCUSSION: This reentry program reintroduced clinically inactive physicians into supervised direct patient care. Use of the GME model allowed acceptance of special fellows and provided institutional malpractice coverage for them.

Institute of medicine committee report on resident duty hours: a view from a trench.

BACKGROUND: In late 2008, the Institute of Medicine (IOM) published a report recommending more restrictive limits on resident work hours to promote patient safety. Reaction from the graduate medical education community has focused on concerns about a lack of evidence supporting the IOM's recommendations. We highlight 3 concerns with the report: 1) a disproportionate attention to resident fatigue when changes in other areas may have a larger impact on patient safety. Data supporting a causal link between resident fatigue and medical errors that harm patients are not robust. Two areas where data support a stronger impact on patient safety include resident supervision and transitions of care; 2) a "one size fits all" model when specialty-specific recommendations may be more appropriate. For example, 16 hours on task is not at all similar for residents in different specialties (ie, surgery and primary care); and 3) the absence of a process to evaluate the impact of current or potential duty hour requirements on outcomes. Because these potential impacts have not been sufficiently researched, it is premature to support additional changes at this time. RECOMMENDATIONS: TO MOVE FORWARD IN A COMPREHENSIVE MANNER, WE RECOMMEND THE FOLLOWING: 1) support more research to evaluate the effects of duty hours in conjunction with other interrelated factors on patient safety, 2) encourage individual Accreditation Council for Graduate Medical Education (ACGME) Review committees to develop specialty specific duty hour limitations, and 3) develop partnerships between the IOM, ACGME, and the institutions directly involved with medical education to study how to maximize patient safety while maintaining quality educational outcomes.