We are thrilled to announce the JGME/Royal College Top 3 Papers, each of which are innovative, stimulating and thought-provoking, and will be highlighted at a special session at this year’s ICRE conference in Calgary, Alta. The winner of the JGME/Royal College Top 3 Paper session will be announced at the Residency Education Awards dinner on the Saturday night, and will be able to publish his/her paper in the JGME.
Abstract: The impact of varying levels of implementation fidelity on resident perceptions of an assessment innovation
Author: Shelley P. Ross; co-authors: Michel Donoff, Paul Humphries, Terra Manca and Shirley Schipper.
Background/Objective: Medical education researchers regularly develop excellent, evidence-based innovations. Often, these innovations are implemented, yet fail. In our program, we witnessed varying levels of success with an assessment innovation. In this study we explored the reasons for varying levels of success with an innovation that was solidly grounded in evidence and theory.
Method: A multiple methods design was used. Using a grounded theory approach, we conducted focus groups with Family Medicine residents. Thirty-two 1st and 2nd year residents across 5 different teaching sites responded to a set of semi-structured questions. An “implementation fidelity” (the degree to which the innovation in action resembles the innovation in theory) inventory was also conducted, with data collected through quantitative analysis of use of the innovation at individual teaching sites.
Results: Many residents who participated in our focus groups perceived substantial problems with the assessment innovation, which stem predominantly from 1) technical issues with the web-based portfolio, and 2) varying levels of preceptor involvement. In some instances, where preceptors sounded highly involved, residents voiced satisfaction with the innovation. Value was seen for learning and for guided self-assessment in sites where implementation fidelity was highest. Sites where champions of the innovation could be identified showed highest implementation fidelity and highest degree of resident perception of learning benefits from the innovation. Frustration with technical clumsiness of the web-based interface was seen for all sites.
Conclusion: The results demonstrate the need for active preceptor involvement in any medical education innovation in order for the innovation to be effective. Learner-driven innovations will falter when preceptors do not take an active role in effective practice of innovations. Implementation fidelity was a constant factor in the success of the innovation.
Abstract: Case review and supervision on the clinical teaching unit: Time to be more explicit
Author: Mark Goldszmidt, co-authors: Georges Bordage, Tim Dornan, Lisa Faden, Lorelei Lingard and Jeroen van Merrienboer.
Purpose: On internal medicine clinical teaching units (CTUs), admission case reviews play an important role in both teaching and patient care. Prior studies have explored teaching strategies for case reviews, but none have considered how attending physicians shape their supervisory role to optimize teaching and patient care simultaneously. The purpose of this study was to explore how attendings approach admission case reviews and the supervision of residents in order to respond to the challenges of shifting team membership and patient complexity.
Methods: A constructivist grounded theory approach was used to iteratively collect and analyze the data. Data was collected through 4 focus groups and 18 individual interviews with 24 attendings at two academic hospitals.
Results: Analysis revealed that attendings have strategies for balancing teaching and patient care, but these vary widely from one attending to the next and are largely hidden from the rest of the team. Often strategies required a supervisory role that is omniscient and ever-present, an unrealistic expectation in the complex environment of CTUs. Attendings indicated that they rarely articulate their expectations about team roles during and following review, thus increasing the chances of residents not following up on patient care issues. Few attendings had strategies for supporting the team to formally document changes in thinking arising from review. Acknowledging the problem of follow-up, attendings described needing to keep personal notes in order to keep track of their patients; the content of these were rarely shared with the team.
Conclusions: This study is a first step in initiating a dialogue and a research agenda regarding how attendings can optimize teaching and patient care. Given the wide variation in assumptions associated with individual attendings’ strategies for conducting admission case reviews and documentation, attendings may want to consider making these more explicit for their teams.
Abstract: Resident sleep associated with overnight duty periods of 12, 16 and 24 hours duration
Author: Roisin Osborne; co-authors: Christopher S. Parshuram and the ICU Resident Study Group.
Introduction: Acute and chronic sleep deprivation are associated with fatigue and reduced performance and have provided rationale to modify resident schedules. We evaluated sleep in trainees working in 3 Canadian ICUs during trials of 3 resident overnight schedules; conventional 24 hour, 16 hour, and sequential 12 hour overnight duty.
Methods: Consenting ICU residents wore wrist-Actigraphs. Data were reviewed for completeness and sleep was estimated. Days were classified as on-call, post-call, weekday or weekend (no duty). Sleep duration (minutes), presented as median (interquartile range), was compared using ANOVA.
Results: The 25 trainees had a median(IQR) of 6(5-8) complete 24-hour periods of actigraph data (total 185). Sleep in the 24 hours preceding the end of duty was greatest in sequential 12-h night schedule 409(358-447), vs. 16-h night 145(112-239) and conventional 24-hour 118(38-215) schedules (p=0.001). Sleep from 8pm-8am was similar: 12-h night 126(62-174); 16-h night 85(40-100) and conventional 24 hour 84(17-185) (p=0.50). Midway through the 3 or 4 day sequence of 12-h nights trainees were sleeping for 410(359-447) minutes per day. Sleep duration was 664(542-853) minutes post-call, 450(400-521) minutes on weekdays, and 485(391-548) minutes on weekends free of duty.
Interpretation: Canadian trainees in ICU are acutely, but not chronically sleep deprived, and routinely obtain a median of 1-2 hours of sleep when working overnight. However, over the 24 hours ending at morning handover, trainees working sequential nights obtained the most sleep. The median duration of post-call recovery sleep (11 hours) and routine sleep (>7hours) suggests that Canadian ICU trainees are not chronically sleep deprived.