2008 chief resident development conference: caring for your residents roseanne c. berger, md senior...

2008 Chief Resident 2008 Chief Resident Development Conference:Development Conference:Caring for Your ResidentsCaring for Your Residents

Roseanne C. Berger, MDRoseanne C. Berger, MD

Senior Associate Dean for Graduate Medical Senior Associate Dean for Graduate Medical Education &Education &

ACGME Designated Institutional Official (DIO) for ACGME Designated Institutional Official (DIO) for UBUB

Goal: Effectively assist residents Goal: Effectively assist residents experiencing problems that impair experiencing problems that impair learning such as ….learning such as ….

FatigueFatigue

Academic DifficultyAcademic Difficulty

HarassmentHarassment

ImpairmentImpairment

Useful Background for Useful Background for Specific IssuesSpecific Issues

www.cphny.org 800-338-1833

Relative Risk by Specialty

0 0.5 1 1.5 2 2.5 3 3.5 4

Pathology

General Surgery

Pediatrics

Ophthalmology

Orthopedics

Internal Medicine

Neurology

Psychiatry

Radiology

Thoracic Surgery

OB/ Gyn

Otolaryngology

Family/ General Practice

Plastic surgery

Neurological Surgery

Emergency Medicine

Anesthesiology

www.cphny.org 800-338-1833

Sign and Symptom PatternsSign and Symptom Patterns

Change in baseline behaviorChange in baseline behavior

Deteriorating personal hygieneDeteriorating personal hygiene

Change in speech patternChange in speech pattern

Multiple physical complaintsMultiple physical complaints

Unfocused, confused, Unfocused, confused,

distracteddistracted

Mood swingsMood swings

Unprofessional demeanor or Unprofessional demeanor or

conductconduct

Anger/Abusive LanguageAnger/Abusive Language

Frequent lateness, absence or Frequent lateness, absence or

illnessillness

Isolation: avoidance of Isolation: avoidance of

associatesassociates

Inappropriate response to Inappropriate response to

patient needs or staff patient needs or staff

requests requests

Ignoring requests to catch Ignoring requests to catch

up on paperworkup on paperwork

Questionable ordersQuestionable orders

Uncooperative and defiant Uncooperative and defiant

approach to problems and/or approach to problems and/or

performance feedbackperformance feedback

Impairment/Substance AbuseImpairment/Substance Abuse

Signs & symptoms of impairmentSigns & symptoms of impairment Report to PD or GME – do not handle Report to PD or GME – do not handle

yourselfyourself Encourage individual to self-report to GME Encourage individual to self-report to GME

or CPHor CPH Individuals can return to residency Individuals can return to residency

programs and have done this quite programs and have done this quite successfullysuccessfully

Harrassment/DiscriminationHarrassment/Discrimination

Sexual or other forms Sexual or other forms If possible, tell harasser to stopIf possible, tell harasser to stop Discuss with PD, Chair, DIO, Office of Discuss with PD, Chair, DIO, Office of

Equity, Diversity, and Affirmative Action Equity, Diversity, and Affirmative Action 645-2266 645-2266

https://secure.newmedialearning.com/https://secure.newmedialearning.com/psh/ubuffalo/ psh/ubuffalo/

UB/GME ResourcesUB/GME Resources Susan Orrange, M.EdSusan Orrange, M.Ed. . [email protected]@buffalo.edu Roseanne Berger, M.D. Roseanne Berger, M.D. [email protected]@buffalo.edu Chief Resident ListservChief Resident Listserv Policies on Impairment, Harassment, and Academic Policies on Impairment, Harassment, and Academic

StatusStatus www.ACGME.orgwww.ACGME.org

Common Program RequirementsCommon Program Requirements RRC Requirements for your programRRC Requirements for your program

The Joint CommissionThe Joint Commission

http://www.jointcommission.org/http://www.jointcommission.org/

LIFE CurriculumLIFE Curriculum(Learning to Address Impairment and Fatigue to Enhance Patient (Learning to Address Impairment and Fatigue to Enhance Patient

Safety)Safety)

Self-directed learning modules in the Self-directed learning modules in the areas of:areas of: FatigueFatigue Disruptive PhysiciansDisruptive Physicians Stress & DepressionStress & Depression Substance AbuseSubstance Abuse BurnoutBurnout ImpairmentImpairment Negative FeedbackNegative Feedback

UB Human ResourcesUB Human Resources http://hr.buffalo.edu http://hr.buffalo.edu

Work/life balanceWork/life balance UB Employee discountsUB Employee discounts

• Fitness centers, theme parks & attractions, software, Fitness centers, theme parks & attractions, software, wireless phones, moving services, and morewireless phones, moving services, and more

Learning & DevelopmentLearning & Development Registration & Course CatalogRegistration & Course Catalog

• Short courses in Career and Personal Development, Short courses in Career and Personal Development, Software and Computer Productivity, Wellness & Software and Computer Productivity, Wellness & Worklife BalanceWorklife Balance

• Over 1,000 online, self-directed learning modules Over 1,000 online, self-directed learning modules (Skillsoft)(Skillsoft)

AssignmentAssignment

Read and Discuss the case scenarios and answer Read and Discuss the case scenarios and answer the following 4 questions. the following 4 questions.

1.1. What is your differential diagnosis?What is your differential diagnosis?2.2. How would you confirm or reject your How would you confirm or reject your

hypothesis? Give specific examples of hypothesis? Give specific examples of questions you would pose to the resident. questions you would pose to the resident.

3.3. How could you assist this resident?How could you assist this resident?4.4. How would you address the situation with the How would you address the situation with the

residency program director? residency program director?

AssignmentAssignment

1.1. What is the differential diagnosis for this What is the differential diagnosis for this struggling resident? struggling resident?

2.2. What is your treatment plan? What is your treatment plan? 3.3. How will you determine if it is effective? How will you determine if it is effective? 4.4. What areas of competence need What areas of competence need

improvement? improvement?

Case 1: Case 1:

Dr. X recently transferred into your program from a Dr. X recently transferred into your program from a different specialty. You learn that the resident different specialty. You learn that the resident was treated for substance abuse during a was treated for substance abuse during a stressful divorce. She is soft spoken, hard stressful divorce. She is soft spoken, hard working, and well liked but appears anxious working, and well liked but appears anxious when presenting cases and is not organized or when presenting cases and is not organized or focused. The faculty have openly shared their focused. The faculty have openly shared their concerns about her ability to “cut it” with other concerns about her ability to “cut it” with other residents and critique her judgment in front of residents and critique her judgment in front of others. others.

Case 1 continuedCase 1 continued

Evaluations do not include comments. Most Evaluations do not include comments. Most raters circled “3” on a 5-point scale under raters circled “3” on a 5-point scale under medical knowledge and patient care and 4 medical knowledge and patient care and 4 or 5 on professionalism and or 5 on professionalism and communication skills. The resident told communication skills. The resident told you the faculty have not directly spoken to you the faculty have not directly spoken to her about her performance. her about her performance.

Case 2: Case 2:

Dr. Y is never able to finish their work. Dr. Y is never able to finish their work. You know they’ve been coming in You know they’ve been coming in early and staying late to keep up. BFH early and staying late to keep up. BFH (Buffalo’s Finest Hospital) is cracking (Buffalo’s Finest Hospital) is cracking down on this behavior and even asked down on this behavior and even asked the residents to sign an attestation the residents to sign an attestation saying they would be subject to saying they would be subject to dismissal if they violated work hours. dismissal if they violated work hours.

Case 2 cont.Case 2 cont.

The resident has been nodding off during The resident has been nodding off during morning report. You’re concerned morning report. You’re concerned because the resident is about to start because the resident is about to start ‘night float’ and it will be important to finish ‘night float’ and it will be important to finish work in time for the day shift. work in time for the day shift.

Case 3:Case 3:

Dr. Z is performing well clinically but his Dr. Z is performing well clinically but his inservice exam scores are very low. The inservice exam scores are very low. The faculty have warned that he will not be faculty have warned that he will not be promoted to the next level of training if he promoted to the next level of training if he does not achieve a minimum standard on does not achieve a minimum standard on a repeat exam. He did particularly poorly a repeat exam. He did particularly poorly in the sections on GI and Renal disease, in the sections on GI and Renal disease, two areas that you have noticed are not two areas that you have noticed are not well covered by the faculty. well covered by the faculty.

Case 3 continuedCase 3 continued

Dr. Z had nearly perfect SAT’s and scored Dr. Z had nearly perfect SAT’s and scored 33 on the MCAT. His USMLE part I score 33 on the MCAT. His USMLE part I score was strong but USMLE II scores were was strong but USMLE II scores were marginal. marginal.

Formerly a slave to fashion, he is no Formerly a slave to fashion, he is no longer attentive to his appearance. He longer attentive to his appearance. He often wears scrubs at work and has taken often wears scrubs at work and has taken to wearing a ‘play-off’ beard when its still to wearing a ‘play-off’ beard when its still early in the season. early in the season.

Sleep Deprivation/FatigueSleep Deprivation/Fatigue

ACGME requirement for residents AND ACGME requirement for residents AND faculty to receive training in this areafaculty to receive training in this area

© American Academy of Sleep Medicine

American Academy of Sleep Medicine

Epworth Sleepiness Scale

Sleepiness in residents is equivalent to that found in patients with serious sleep disorders. Mustafa and Strohl, unpublished data. Papp, 2002



Across Tasks

Emergency Medicine: significant reductions in comprehensiveness of history & physical exam documentation in second-year residents Bertram 1988

Family Medicine: scores achieved on the ABFM practice in-training exam negatively correlated with pre-test sleep amounts Jacques et al 1990



• Surgery: 20% more errors and 14% more time required to perform simulated laparoscopy post-call (two studies) Taffinder et al, 1998; Grantcharov et al, 2001

• Internal Medicine: efficiency and accuracy of ECG interpretation impaired in sleep-deprived interns Lingenfelser et al, 1994

• Pediatrics: time required to place an intra-arterial line increased significantly in sleep-deprived Storer et al, 1989



0102030405060708090

100

< 4 hrs 5-6 hrs > 7 hrs

Hours of Sleep

Wor

k H

rs/w

k

0102030405060708090100

Percent

Work Hrs/wk

% ReportingSerious MedicalErrors

% ReportingSerious StaffConflicts

*Baldwin and Daugherty,1998-9 Survey of 3604 PGY1,2 Residents

Work Hours, Medical Errors, and Workplace Conflicts by Average Daily Hours of Sleep*



Sleep Loss and Fatigue: Safety Issues• 50% greater risk of blood-borne pathogen exposure

incidents (needlestick, laceration, etc) in residents between 10pm and 6am. Parks 2000

• 58% of emergency medicine residents reported near-crashes driving.-- 80% post night-shift-- Increased with number of night shifts/month

Steele et al 1999

•



Recognize The Warning Signs ofSleepiness

• Falling asleep in conferences or on rounds• Feeling restless and irritable with staff, colleagues,

family, and friends • Having to check your work repeatedly • Having difficulty focusing on the care of your

patients• Feeling like you really just don’t care



NappingPros: Naps temporarily improve alertness. Types: preventative (pre-call)

operational (on the job)Length:

short naps: no longer than 30 minutes to avoid the grogginess (“sleep inertia”) that occurs when you’re awakened from deep sleeplong naps: 2 hours (range 30 to 180 minutes)



Healthy Sleep Habits• Go to bed and get up at about the same time every day.• Develop a pre-sleep routine.• Use relaxation to help you fall asleep.• Protect your sleep time; enlist your family and friends! Use time off to sleep! • Get adequate (7 to 9 hours) sleep before anticipated sleep loss. Avoid starting out with a sleep deficit!



Healthy Sleep Habits• Sleeping environment:

– Cooler temperature– Dark (eye shades, room darkening shades)– Quiet (unplug phone, turn off pager, use ear

plugs, white noise machine)• Avoid going to bed hungry, but no heavy meals

within 3 hours of sleep. • Get regular exercise but avoid heavy exercise

within 3 hours of sleep.



How To Survive Night Float

• Protect your sleep.• Nap before work. • Consider “splitting” sleep into two 4 hour periods.• Have as much exposure to bright light as possible

when you need to be alert.• Avoid light exposure in the morning after night shift

(be cool and wear dark glasses driving home from work).



Drugs

• Melatonin: little data in residents• Hypnotics: may be helpful in specific situations (eg,

persistent insomnia)• AVOID: using stimulants (methylphenidate,

dextroamphetamine, modafinil) to stay awake• AVOID: using alcohol to help you fall asleep; it induces

sleep onset but disrupts sleep later on



Caffeine

• Strategic consumption is key• Effects within 15 – 30 minutes; half-life 3 to 7 hours• Use for temporary relief of sleepiness• Cons:

– disrupts subsequent sleep (more arousals)– tolerance may develop – diuretic effects

SUPERCHIEF!SUPERCHIEF!

2008 chief resident development conference: caring for your residents roseanne c. berger, md senior...

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