1. Orientation for Residents and Fellows Office of GME June 18, 2013 Jeanette Morrison, MD Associate Professor of Medicine Associate Dean for GME and DIO Program Director, Department of Medicine Chicago Medical School Rosalind Franklin University of Medicine and Science

2. Objectives Become familiar with the role of the GME office and how we relate to various other groups –RRC, ACGME, CMS, FHCC, Departments of Medicine, Psychiatry Understand key policies pertinent to all residents and fellows Know where to go for help/resources Be aware of changing accreditation standards –CLER = Clinical Learning Environment Review Recognize the signs of fatigue in residency training –Basic understanding of the importance of sleep and the impact that sleep deprivation has on function, competence, mood, vitality, and overall health Context of Lifelong Physician Wellness and Self Care –Balancing personal and professional lives –Preventing and managing stress/burnout/impairment

3. GME Office http://www.rosalindfranklin.edu/cms/GMEOffice.aspx Manual of Policies & Procedures http://www.rosalindfranklin.edu/Portals/4/Documents/Clinical%20Affairs/hyperlinks%20and%20bookmarks%20GME%20Ma nual%20April%2020%202012%20-%20(1).pdf Key personnel –Jeanette Morrison, MD –Elsa Kurien, MA, MEd –Diane O’Gara Any issue related to: –RFUMS/CMS Policies and Procedures –Salaries, benefits, contracts –Learning environment

4. Important to know… RRC = Residency Review Committee ACGME = Accreditation Council for GME CMS/RFUMS FHCC

5. ACGME Competencies Patient Care = What you do Medical Knowledge = What you know Practice Based Learning = How you get better Interpersonal and Communication Skills = How you interact with others Professionalism = How you act Systems Based Practice = How you work with the system

6. Key policies Statement of commitment to GME Healthcare Industry Interactions in Education Promotion, Deficiency, Remediation, Misconduct, Probation, Dismissal, and Contracts Grievances Leave Moonlighting Impaired Physicians Clinical Learning Environment –Patient Safety, Quality Improvement, Supervision, Transitions of Care, Duty hours/Fatigue Management, Professionalism

7. Statement of Commitment May 17, 2013 Chicago Medical School is committed to supporting Graduate Medical Education (GME) programs of the highest caliber. The goal of these programs, consistent with the strategic goals of Chicago Medical School and Rosalind Franklin University of Medicine & Science, is the training of highly skilled, scholarly physicians whose practices will engender the highest ideals of compassion and professionalism.

8. Healthcare Industry Interactions in Education The following italicized words are selected excerpts from that policy: For purposes of this policy, health care industry means a commercial entity (or one of its representatives) that manufactures, sells, or otherwise provides medical devices, pharmaceuticals, medical equipment, research equipment, health services, or other similar products/services. Gifts to [a resident] from the health care industry are prohibited. A gift to [a resident] means any payment to [a resident] or provision to [a resident] of free or discounted items, medical samples for personal use, food, or travel when the [resident] is not providing, in return therefore, a service of similar or greater value. For example: pens, notepads, free textbooks, free meals, payment for attending a meeting, and samples are all considered gifts. [Residents] may not attend or participate in any purported professional continuing education program that is sponsored by the health care industry but that is not accredited [by the ACCME].

9. Promotion –Program director determines promotion using academic judgment –Resident must demonstrate proficiency in established competencies, appropriate progress, fulfill requirements –Non-promotion is determined by program director At least 4 month notification or as soon as circumstances allow Deficiency –Resident does not perform or progress as appropriate, failure to comply with policies Remediation of deficiency

10. Misconduct –Any act or acts of a resident that amounts to or attempts to amount to: Assault, violence, cheating, lying, abuse, etc. –when such act or acts relate to the residency program Obligation to report to Program Director Investigation Determination to be made by Program Director – No action, probation, non-renewal of contract, immediate dismissal

11. Complaints and grievances All complaints and grievances –Program Director –If complaint or grievance is against PD, submit to Associate Dean for GME EXCEPT decisions of PD to not promote, not renew residency contract, dismiss, or lengthen training –Dean of CMS

12. Leave Up to 30 days of annual leave per academic year –Proportionate to the amount of the academic year served in pay status –Must be used in the year it was accrued Sick leave policies vary by program/employer Consider specialty board policies regarding completion and eligibility

13. Moonlighting Must have written permission from program director Must have permanent Illinois license Time spent moonlighting counts toward duty hours Professional liability insurance does NOT cover moonlighting

14. Impaired physician An impaired physician is a resident or fellow, involved in training or research, licensed to practice medicine in the State of Illinois, who is unable to practice medicine with reasonable skill and safety to patients because of mental or physical illness or shortcoming. Notify Program Director immediately if you suspect behavior that may indicate impairment

15. Where to go for help Program Resources –Program Director, Faculty, Chief Resident GME Office Human Resources University Counseling Center

16. Accreditation Standards 2013: Next Accreditation System = NAS Continuous data reporting to ACGME, including: Annual resident survey Annual faculty survey Boards pass rate Scholarly activity CLER visit - clinical learning environment report –Patient Safety, Quality Improvement, Supervision, Transitions of Care, Duty hours/Fatigue Management, Professionalism

17. Coffee Break!

18. Objectives Become familiar with the role of the GME office and how we relate to various other groups –RRC, ACGME, CMS, FHCC, Departments of Medicine, Psychiatry Understand key policies pertinent to all residents and fellows Know where to go for help/resources Be aware of changing accreditation standards –CLER = Clinical Learning Environment Review Recognize the signs of fatigue in residency training –Basic understanding of the importance of sleep and the impact that sleep deprivation has on function, competence, mood, vitality, and overall health Context of Lifelong Physician Wellness and Self Care –Balancing personal and professional lives –Preventing and managing stress/burnout/impairment

19. Clinical Learning Environment Are residents engaged in institutional programs designed to enhance patient safety and quality of care? Is this the environment in which I want my doctor to be trained? 6 key areas Driven by continuous GME reform over past 30 years –Duty hours/sleepiness and fatigue/supervision

20. Sleepiness and Fatigue Issues in residency training –Recognizing sleepiness and fatigue –Consequences of sleepiness and fatigue Professional Personal –Interventions Personal Organizational Current ACGME Regulations –Outcomes of ACGME Regulations

21. Physician Wellness and Self Care Healthy Sleep Exercise Good Nutrition Develop and Maintain supportive relationships

22. Health Benefits of Sleep Cognition Learning Creativity Productivity Mood Vitality Growth, Cellular Repair Immune Function

23. Quantity of Sleep How long would you sleep if left to awaken spontaneously? How alert do you feel after different quantities of sleep? Mean = 8 hours with considerable variation 10 hours per night may be associated with higher mortality (Arch Gen Psychiatry 1979;36:103.)

24. Consequences of Sleep Deprivation - General Cognitive Functioning –Short term memory, attention, information processing Mental Status –Depression, Anxiety, Irritability, Anger, Hostility Accidents –MVAs, Major catastrophes Quality of Life Physiology - Impaired reaction time, judgment, vision Immune Function Vascular Inflammation and Dysfunction

25. Fatigue, alcohol, and performance impairment _________________ D Dawson, K Reid. Nature 1997. 388:235.

26. Measuring sleepiness Multiple Sleep Latency Test (MSLT) Maintenance of Wakefulness Test Stanford Sleepiness Scale Epworth Sleepiness Scale

27. Sleep Debt “Nature’s Loan Shark” Between 25 and 50 hours of “sleep debt” begins to result in impairment Feeling drowsy signifies the need for sleep! If ignored or resisted, sleep may happen when it is dangerous, inconvenient, or rude

28. “Drowsiness is RED ALERT” - William Dement, MD, PhD

29. Consequences of Sleepiness and Fatigue - Residents Professional –Quality of Patient Care, Patient Safety Personal –Safety, Satisfaction, Education, Relationships

30. Sleepiness and Fatigue - Residents Mood, Affect, Attitude, Empathy Performance –Psychomotor Testing –Simulated clinical scenarios Crises or novel situations Sustained concentration or vigilance –Actual Clinical Practice Personal safety

31. Mood, Affect, Attitude, Empathy Questionnaire and interviews of interns Sleep-deprived interns reported more sadness, less social affection, more difficulty thinking, depression, irritability, and recent memory deficits. _________________ Friedman, et al. NEJM 1971;285:201-203. Friedman et al. J. Med Educ 1973:48:436-441.

32. Mood, Affect, Attitude, Empathy Longitudinal study of 27 interns at four times during internship Anger, fatigue, dysphoria increased as the year progressed and were negatively correlated with amount of sleep in previous week. _______________ Ford CV, Wentz DK. Southern Medical Journal 1984;77:1435-1442.

33. Mood, Affect, Attitude, Empathy 149 residents (60 interns) from 5 Medical Centers and 6 specialties Focus groups and questionnaire (ESS) 64% stated that sleep loss and fatigue had “major impact on my personal life” 46% stated that sleep loss and fatigue had “major impact on my work” ______________ Papp KK, et al. Academic Medicine 2004;79:394-406.

34. Performance Anecdotes Artificial experimental situations Suturing, intubating mannequins, laparoscopy Board exam questions Reading ECGs Clinical Outcomes

35. Performance Tasks that require sustained vigilance and concentration are the most sensitive to fatigue and sleep loss ____________ Samkoff JS et al. Academic Medicine 1991;66:687.

36. Performance 11 Anesthesia residents at Stanford 3 separate conditions –Normal baseline work schedule –After 24 hour call –Following a period of extended sleep Subjective ability to determine their own level of sleepiness was inconsistent Ability to discriminate the onset of sleep was poor: did not know they had fallen asleep (by EEG criteria) 49% of episodes __________________ Howard SK et al. Academic Medicine 2002; 77:1019-1025.

37. Personal Safety Motor Vehicle Accidents National prospective cohort study –2737 Interns July 2002 - May 2003 –OR of MVA or near miss MVA after 24 hour shift compared to less than 24 hour shift was 2.3 (1.6 - 3.3) ________________ Barger et al. NEJM 2005

38. Personal Safety Needlestick Injury National prospective cohort study 2737 Interns July 2002- May 2003 498 percutaneous injuries Self reported lapses in concentration and fatigue were two most commonly reported contributing factors _________________________ Ayas et al. JAMA 2006

39. Sleepiness and Fatigue is not just an issue for residency… Healthy sleep is important for the rest of your life –Personal –Professional

40. Not just an issue for residency… National Sleep Foundation 2007 1000 women 22% reported sleepiness interferes with daily activities at least a few days per week 27% had driven drowsy at least once per month in the past year 29% reported a “good nights sleep” only a few nights per month or less

41. Solutions?

42. Preventive and Operational Countermeasures Pharmacologic Napping Planning and Monitoring –Self –Institutional –ACGME

43. Pharmacologic Consider Caffeine –Short term immediate benefits of 1 or 2 cups of coffee Addictive Side Effects Avoid Alcohol –Interferes with effective sleep

44. “I love a good nap. Sometimes it’s the only thing getting me out of bed in the morning.” -George Costanza

45. “Napping is by far the most important and effective tool for coping with sleep crises” “Naps can make you smarter, faster, and safer than you would be without them” “…people should be proud of the decision to take an emergency or preventive nap when driving a car or …people’s lives are at stake.” - William Dement, MD, PhD

46. 38 Medicine interns at U of Chicago from 2003- 2004 12 months, two weeks each of: “Nap schedule” –Coverage from midnight to 7am Standard Schedule –No additional coverage _______________ Arora V, et al. Annals of Internal Medicine 2006

47. More sleep on “Nap schedule” –2 hours, 20 minutes versus 3 hours Less Overall fatigue (as per SSS), p = 0.017 Concerns about discontinuity of care limited the use of coverage by the interns ______________________________________________________ Arora V, et al. Annals of Internal Medicine 2006

48. What defines a “nap” 5 minutes - 4 hours during the daytime “Emergency” nap –To cope with drowsiness “Preventive” nap –Prior to staying up all night

49. The longer the nap, the greater the benefit “Prophylactic naps” 45 minutes -----> 6 hours 60 minutes ----> 10 hours 60-120 minutes ------> 24 hours

50. Planning and Monitoring Self –How do you use your free time? –Good sleep habits/sleep hygiene Institutional –Facilitate balance between personal time for sleep and educational activities –Ensure quality of patient care –Limit changes in shift schedules ACGME/RRC –“Duty Hours”

51. Evolution of “duty hours” 1984 death of Libby Zion 18 year old college freshman Low grade fever, earache (erythromycin) Agitation, “jerking movements”, lucid with periods of confusion PMH: Depression Meds: Erythromycin, Phenelzine, Percodan Marijuana. Denied cocaine use T = 103 WBC = 18,000

52. Admit to Medicine –9 month intern with resident supervision –40 patients –Spoke with attending once “Viral syndrome with hysteria” 3:30 am - Meperidine for “shaking” 4:15 am - 4 point restraints (by phone) 4:30 am - Haloperidol (by phone) 6:30 am - T = 107 7:00 am - Cardiac Arrest and Death

53. Five stories about what happened to Libby Zion - and why Medical Malpractice “Broken medical system” that left overworked and unsupervised doctors in charge of her care Unpreventable death from unidentified cause Illicit cocaine use (which she concealed from her doctors) Actually, she “died twice,” first at the hospital, then as the victim of a vicious smear campaign _____________________ Barron H. Lerner, When Illness Goes Public: Celebrity Patients and How we Look at Illness, p. 201.

54. 80 hours? 17 recommendations for reform –1 for duty hour reform “80 hours” –10 hour day for five days, 1 in 4 call “Supervision in the hospital at all times by licensed physicians who are residency trained and board prepared or board certified.” “Improving the quality of patient care will come from supervision, not regulation of hours.” ___________________ Bertrand Bell. JAMA 2007.

55. ACGME duty hour rules Effective July 1, 2003 Maximum 80 hours per week On-call not to exceed Q 3 One full day off per week 24 hour “shift” with additional 6 hours 10-hour break

56. Results of ACGME Regulation Safety of patients Safety of residents Perceptions of Education Quality of patient care Compliance with regulations

57. Effect of Duty Hour Reform on Patient Outcomes Decreased attentional failures in the ICU Fewer serious medical errors in the ICU –Diagnostic errors, medication errors, no difference in adverse events _____________ Landrigan et al. NEJM 2004 Lockley et al. NEJM 2004

58. Decreased or no change in hospital mortality –Decreased mortality in “teaching intensive” VA hospitals for medical, not surgical patients –No difference in non-federal Medicare patients –Decreased mortality among high risk medical (not surgical) patients in community hospitals Decreased ICU utilization Increased rate of discharge to home or rehab There can be documentable, significant consequences of inadequate sign out ________________ Volpp et al. JAMA 2007 Shetty. Ann Int Med 2007 Horwitz et al. Ann Int Med 2007 Horwitz et al. Arch IM 2008

59. No consistent change in outcomes among high risk medical or surgical patients Total hours of work and sleep did not change, though less “burn out” Noncompliance with regulations was high in first year of implementation __________________ Volpp. JGIM 2009 Landrigan. Pediatrics 2008 Landrigan. JAMA 2006.

60. Copyright ©2008 American Academy of Pediatrics Landrigan, C. P. et al. Pediatrics 2008;122:250-258 FIGURE 1 Proportions of residents reporting MVCs, near-miss MVCs, occupational exposures, and medical errors, before (pre) and after (post) implementation of the ACGME duty hour standards

61. IOM recommendations December 2008 “…revisions to medical residents workloads and duty hours are necessary to better protect patients against fatigue-related errors and to enhance the learning environment for doctors in training.”

62. July 2011 Supervision –Clearly defined, progressive responsibility, levels of supervision Workload –Specialty specific, resident specific Transitions of care and communication between team members Duty Hours –80 hours/week –PGY1 not to exceed 16 hours –PGY2 and above 24 + 4 hours “Strategic napping” is strongly encouraged

63. Additional areas of reform - 2013 Education –Patient Safety, Quality Improvement Interprofessional Teams Evaluation and assessment –Competency-based, Milestones Accreditation Medicare Professionalism Technological/EMR

64. Take Home Points - SLEEP Daytime Drowsiness = Insufficient Sleep –Manage your Sleep Debt Drowsiness is Red Alert Be sensitive to your level of drowsiness There is no substitute for Sleep! Naps are important/underrated/healthy Healthy Sleep is an important aspect of wellness –Exercise, Nutrition, Relationships

65. Avoid driving between 2 am and 9 am Interaction between alcohol and sleep loss can be very dangerous There is no substitute for sleep!

66. Past, Present, and Future GME reform Patient Safety Quality of care Education Professional standards Competency Resident safety Resident satisfaction Faculty workload and satisfaction Cost Public scrutiny

67. Objectives Become familiar with the role of the GME office and how we relate to various other groups –RRC, ACGME, CMS, FHCC, Departments of Medicine, Psychiatry Understand key policies pertinent to all residents and fellows Know where to go for help/resources Be aware of changing accreditation standards –CLER = Clinical Learning Environment Review Recognize the signs of fatigue in residency training –Basic understanding of the importance of sleep and the impact that sleep deprivation has on function, competence, mood, vitality, and overall health Context of Lifelong Physician Wellness and Self Care –Balancing personal and professional lives –Preventing and managing stress/burnout/impairment