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Career Tracks

New Residency Models Balance Training, Education and Patient Care

DEFINO, THERESA

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Career Tracks is Neurology Today's newest column. Look for future stories to focus on training and career and development issues, as well as advice from experts on how to transition and thrive in different areas of the field.

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If fourth-year neurology resident Steven B. Dawson, MD, could change anything about his program at the Mayo Clinic in Jacksonville, FL, it would be to reduce the hours he spends listening to lectures, so that he could have more time with patients. “I feel like we have a bit more classroom time than is optimal,” said Dr. Dawson, who spends on average five hours a week this way.

His team of four residents, aided by two attending physicians, care for an average of 20 patients a day, though the number can grow to 30. It's a volume of patients and level of supervision that he said is ideal preparation for life as a practicing neurologist.

So Dr. Dawson was more than a bit surprised when he read an article in the April 8 New England Journal of Medicine (NEJM) that described a year-long redesign of an internal medicine residency program that broke physicians into two teams, with one seeing only 3.5 patients per resident, part of “integrated teaching unit.”

The study, conducted by researchers at Brigham and Women's Hospital in Boston, concluded that the experimental team, which consisted of two attendings, two residents, and two interns “was associated with higher trainee satisfaction and increased time for educational activities.” The experimental team was compared with a control team of one resident, two interns and “multiple supervising attending physicians.” The experiment was carried at out at Faulkner Hospital, a community teaching hospital and affiliate of Brigham's.

“I don't support the model they are studying,” Dr. Dawson told Neurology Today. “I don't think reducing the exposure [to patients] increases safety in the long run. My larger concern is the sacrifice of long-term competence in independent practice after the completion of training.”

Regardless of one's personal opinion about the specific models in the NEJM paper or whether they provide lessons for neurology, many neurology residency programs are already in transition, with the lines separating training, education and patient care beginning to shift and blur.

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INCREASED SUPERVISION, REDUCED CALL

Jaffar Khan, MD, director of Emory University's neurology residency program, praised the experimental model for “being designed from the ground up with education in mind.”

“It wasn't designed around faculty careers or patient care,” Dr. Khan said.

The authors say they began the study as response to shortened work hours that have been imposed by the Accreditation Council for Graduate Medical Education (ACGME).

“In the model resulting from the implementation of ACGME standards, continuity between team members is diminished because of shorter, discontinuous schedules,” they wrote. The physicians in the experimental model admitted patients overnight every sixth night, “leaving by noon the next day.”

“Each of the two attending physicians served as the physician of record for approximately half the patients cared for by the team,” the authors wrote. “The two attending physicians supervised daily bedside rounds together with the multidisciplinary team for two scheduled hours more for each; at least one of these physicians remained available throughout the workday and met with the team to conduct additional teaching and to review progress at day's end.”

The groups each treated about 2,000 patients during the study year, and quality of care, and average length of stay were similar.

As Dr. Khan noted, the model in the paper was used in general medicine residency program, and would be difficult to replicate in neurology training programs for a number of reasons, with the comparatively small size of neurology programs the primary one.

“Internal medicine programs tend to be large, in contrast to neurology programs, and that is going to be the biggest challenge,” Dr. Khan said. Some may have as little as two residents per class, while others might have 10 or more.

Still, he said, “this is a model I believe neurology programs should move toward because it puts resident education first; this is the future of medical training.”

“Patient care has to be a priority for physicians and hospitals, with the primary responsibility of a residency program being training — not service — in order to assure future neurologists are fully prepared to practice provide the best possible patient care,” Dr. Khan added.

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CHANGES AT EMORY

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Dr. Khan said he saw “many challenges” to implementing a residency program like the one studied, the first one being how a system such as the integrated teaching unit would be supported financially.

Because the teams are capped at such a low number of patients, such a system would require more residents and faculty than are probably available in most neurology programs to treat the volume of patients, Dr. Khan said.

While not following the model studied in the paper, Emory's neurology residency program has itself been evolving in a three-phase plan. The first phase involved dividing its inpatient services into five groups focusing solely on inpatient consults, specialized stroke care, neurointensive care, epilepsy, and general neurology.

“We are currently in the second phase of integrating mid-level clinicians, such as nurse practitioners, into the inpatient services,” Dr. Khan said. The presence of these non-physician practitioners allows the residents to devote their attention to the evaluation of new patients and reserve more time for educational activities, he explained.

In the third phase, the program will develop inpatient non-teaching neuro-hospitalist services dedicated to the inpatient care of patients without the presence of residents. This will allow residents to shift their educational experiences to subspecialty care, which is more commonly found in the outpatient setting.

The changes and additional staff are necessary because of the increased patient load, he said.

“In many [residency] programs we are really a victim of our own success, in that were are seeing an increased number of patients and providing and increased number of services, yet the number of residents has not grown,” Dr. Khan said.

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MAYO: PATIENT-CENTERED, LEARNER-FOCUSED

David Capobianco, MD, the neurology residency program director at the Mayo Clinic in Jacksonville, said the NEJM paper is especially timely. “It is nice to see that an article concerning education and scholarship is being published,” said Dr. Capobianco. “It provides an opportunity for conversation and dialogue on an important topic.”

He agreed with the authors that some who try to improve residency programs have focused “too much on the duty hour standard, and not on the educational environment, which is the most fundamental aspect in providing high quality patient care and education.” In addition, he pointed out that patient satisfaction did not differ significantly between the integrated teaching unit and the general medical service.

The Mayo Jacksonville neurology program began in 2002 and provided an opportunity to “start from scratch,” Dr. Capobianco said. Based on feedback from Mayo Rochester residents and faculty at both locations, the Jacksonville program took as its mantra that it would be “patient centered and learner-focused,” he said.

Dr. Capobianco said: “The most important component is direct collaborative patient care, with a dedicated physician educator working with a resident at the point-of-care, at the bedside. That's where you learn medicine,” he said.

Regarding the NEJM article, Dr. Capobianco added that he would find it valuable to see the responses of the residents in the experimental group one year after the completion of their program. He wondered if their views would be changed and whether they would feel the program adequately prepared them for the “competent, confident practice” of internal medicine.

Having seven to eight patients allows residents to prioritize them in terms of their medical needs, he added, an essential real-world skill that might not be developed with a smaller patient load.

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ACCREDITATION COUNCIL TO MANDATE CHANGES

Changes are coming to all residency programs, including neurology. Later this summer, the ACGME will release revised requirements for residency programs, “keeping the promise to the community to revisit the 2003 Resident Duty Hour Standards after five years,” ACGME President Thomas J. Nasca wrote May 4 in an “open letter to the GME community.”

Once the standards are approved by the ACGME board, they will be released for a 45-day comment period. Specialty review groups will adapt the standards to each specialty. The changes are expected to be sweeping, and updating duty hours are mentioned almost as an afterthought in Nasca's letter. They are likely to be mandatory as of July 1, 2011.

“The draft standards written by the task force will address...expectations regarding: resident supervision, resident and faculty professionalism and fitness for duty, patient safety and quality improvement expectations, handover processes and inter-professional communications, as well as duty hours,” he wrote.

For more information, see http://bit.ly/dapNNm.

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References

McMahon GT, Katz JT, Loscalzo J, et al. Evaluation of a redesign initiative in an internal-medicine residency. N Engl J Med 2010;362:1304–1311.

©2010 American Academy of Neurology

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