The Accreditation Council for Graduate Medical Education, the body that accredits all residencies and institutions that provide residency training has identified six competencies for residents to achieve regardless of their specialty. All programs must implement a plan to teach, and even more importantly assess these competencies beginning July 1, 2002. http://www.acgme.org/Outcome/
Duke's plan includes making you aware of these competencies beginning at orientation. The competencies listed below may be found at this web address: http://www.acgme.org/outcome/comp/compFull.asp
I. Patient Care
Residents must be able to provide patient care that is compassionate, appropriate and effective for the treatment of health problems and the promotion of health. Residents are expected to Communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and their families Gather essential and accurate information about their patients Make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up to date scientific evidence and clinical judgment Develop and carry out management plans Counsel and educate patients and their families Use information technology to support patient care decisions and patient education Perform competently all medical and invasive procedures considered essential for the area of practice Provide health care services aimed at preventing health problems or maintaining health Work with health care professionals, including those from other disciplines to provide patient focused care
II. Medical Knowledge
Residents must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social behavioral) sciences and the application of this knowledge to patient care. Residents are expected to:
· Demonstrate investigatory & analytic thinking approach to clinical situations
· Know and apply the basic and clinically supportive sciences, which are appropriate to their discipline
III. Practice Based Learning and Improvement
Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence and improve their patient care practices. Residents are expected to
· Analyze practice experience and perform practice based improvement activities using a systematic methodology
· Locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems
· Obtain and use information about their own population of patients and the larger population from which their patients are drawn
· Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness
· Use information technology to manage information, access on-line medical information, and support their own education
· Facilitate the learning of students and other health care professionals
IV. Interpersonal and Communication Skills
Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients’ families and professional associates. Residents are expected to:
· Create and sustain a therapeutic and ethically sound relationship with patients
· Use effective listening skills and elicit and provide information using effective nonverbal, explanatory, questioning and writing skills
· Work effectively with others as a member or leader of a health care team or other professional group
V. Professionalism
Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles and sensitivity to a diverse patient population. Residents are expected to:
· Demonstrate self interest; accountability to patients, society and the profession; and a commitment to excellence and on -going professional development
· Demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent and business practices
· Demonstrate sensitivity and responsiveness to patients’ culture, age gender and disabilities
VI. Systems Based Practice
Residents must demonstrate an awareness of, and responsiveness to, the larger context and system of health care, and the ability to effectively call on system resources to provide care that is of optimal value. Residents are expected to:
· Understand how their patient care and other professional practices affect other health care professionals, the health care organization, and the larger society and how these elements of the system affect their own practice
Know how types of medical practice and delivery systems differ from one another including methods of controlling health care costs and allocating resources
· Practice cost-effective health care and resource utilization that does not compromise quality of care
· Advocate for quality patient care and assist patients in dealing with system complexities
Know how to partner with health care managers and health care providers to assess, coordinate, and improve health care and know how these activities can affect system performance
This project will involve activities developed by your individual department or program, institutional program as well as those specifically developed and/or sponsored by GME.
· All incoming residents and graduating residents will complete a self-assessment rating their confidence with each of these areas.
· All incoming residents will be required to attend the GME orientation, which will incorporate several of these topics
· All incoming residents will be required to complete several Internet modules including a posttest and an evaluation. This will include HIPPA and safety training, pain management, interaction with the pharmaceutical products and cultural competency.
You will be required to demonstrate competency in these elements as part of successfully completing your training at Duke and before any certificate of completion will be awarded.
To fulfill these requirements you must:
· Satisfactorily complete the training and evaluation in these areas provided and required by your program and as mandated by your own specialty Residency Review Committee
· Complete a self assessment at entry to and when completing your Duke program
· Attend pertinent sessions at the Duke Institutional Orientation
· Complete all required Educational experiences including “post tests” (i.e. Internet, CD-ROM) http://gmemodules.mc.duke.edu/
For questions contact Kathryn Andolsek MD MPH
The Office of Graduate Medical Education requires proof of *ACLS and BLS certification. House Staff must be certified when they arrive at Duke and must re-certify every two years. Upon completion of the re-certification courses, the House Staff trainee must provide a copy of the life support cards to the GME Office.
· *Pediatrics may take PALS in place of ACLS
· Medicine/Pediatrics and Emergency Medicine must be certified in ACLS, BLS and PALS
Revised: July 1999
Duke Hospital will provide adequate departmental call room space for House Staff who are required to do in-house call.
Developed: Prior to 1989
It is the policy of Duke University Medical Center, (regardless of other less restrictive policies), all graduate medical trainees within the Duke University Medical Center residency training system, sponsored by the Accreditation Council for Graduate Medical Education, receive equal compensation according to graduate medical education training level. Any exceptions must be approved by the Institutional Committee for Graduate Medical Education and confirmed by the Executive Committee of the Medical Staff.
Developed: July 8, 1998
ICGME Approval: August 12, 1998
ECMS Approval: September 21, 1998
Corrective Action and Hearing Procedures
The new Corrective Action Policy was approved by ECMS on August 20, 2007. Click here for the updated policy
In compliance with the federal Drug-Free Workplace Act of 1988, Duke University is committed to maintaining a healthy, drug-free work environment. The unlawful manufacture, distribution, dispensation, possession, or use of a controlled substance, as defined by the Act is prohibited in the workplace.
In addition to abiding by this requirement, employees are also required by the Act to notify the University of any Criminal Drug Statute Conviction for a occurring in the workplace no later than five days after the conviction. Upon notification by the employee, the University must report the conviction to the federal government within ten days.
Effective July 1, 1995, all Duke University Health System job openings require the selected applicant to submit to a substance abuse screening test as a condition of employment. This policy also applies for initial graduate medical education appointments at the Hospital. All resident physicians must undergo substance abuse testing as a condition of the appointment process. Any applicant who refuses to submit to screening or whose drug screen results in a confirmed positive result will have his or her offer of appointment rescinded. The clinical departments shall provide this information to all GME applicants at the time of the candidates’ initial application. All other administrative offices in the School of Medicine receiving inquiries will also inform applicants of this requirement.
Drug dependency is an illness and a major health problem. Drug abuse is also a potential safety and security problem for the University. Employees needing help are encouraged to use the Personal Assistance Service. Other resources are available at the University and in the local community. Conscientious efforts to seek help with a substance abuse problem will not jeopardize an employee's job and will be kept strictly confidential.
Also, House Staff must agree to a criminal background check. Based upon a clean report, House Staff will be eligible to begin their training.
Developed: January 1, 1995
Background
Providing graduate medical trainees (trainees) with a sound academic and clinical education must be carefully planned and balanced with concerns for patient safety and trainee well being. Each program must ensure that the learning objectives of the program are not compromised by excessive reliance on trainees to fulfill service obligations. Didactic and clinical education must have priority in the allotment of trainees’ time and energies. Duty hour assignments must recognize that faculty and trainees collectively have responsibility for the safety and welfare of patients and adherence to this policy. The institution is committed to the promotion of an educational environment, support of the physical and emotional well-being of its graduate medical trainees, and the facilitation of high quality patient care.
Policy
ACGME institutional and program requirements take precedence over all other policy statements and apply to all institutions at which trainees rotate.
Duty Hours
1. Duty hours are defined as all clinical and academic activities related to the graduate medical education program, ie, patient care (both inpatient and outpatient), administrative duties related to patient care, the provision for transfer of patient care, time spent in-house during call activities, and scheduled academic activities such as conferences. Duty hours do not include reading and preparation time spent away from the duty site.
2. Duty hours must be limited to 80 hours per week, averaged over a four-week period, inclusive of all in-house call activities.
3. Trainees must be provided with 1 day in 7 free from all educational and clinical responsibilities, averaged over a 4-week period, inclusive of call. One day is defined as one continuous 24-hour period free from all clinical, educational, and administrative activities.
4. Adequate time for rest and personal activities must be provided. This should consist of a 10-hour time period provided between all daily duty periods and after in-house call.
On-Call Activities
The objective of on-call activities is to provide residents with continuity of patient care experiences throughout a 24-hour period. In-house call is defined as those duty hours beyond the normal workday when trainees are required to be immediately available in the assigned institution.
1. In-house call must occur no more frequently than every third night, averaged over a four-week period.
2. Continuous on-site duty, including in-house call, must not exceed 24 consecutive hours. Trainees may remain on duty for up to 6 additional hours to participate in didactic activities, transfer care of patients, conduct outpatient clinics and maintain continuity of medical and surgical care (unless further limited by the relevant Program Requirements).
3. No new patients may be accepted after 24 continuous hours on duty. A new patient is defined as any patient for whom the trainee has not previously provided care (unless otherwise defined in the relevant Program Requirements).
4. At-home call (pager call) is defined as call taken from outside the assigned institution.
1. The frequency of at-home call is not subject to the every third night limitation. However, at-home call must not be so frequent as to preclude rest and reasonable personal time for each trainee. Trainees taking at-home call must be provided with 1 day in 7 completely free from all educational and clinical responsibilities, averaged over a 4-week period.
2. When trainees are called into the hospital from home, the hours trainees spend in-house are counted toward the 80-hour limit.
3. The program director and the faculty must monitor the demands of at-home call in their programs and make scheduling adjustments as necessary to mitigate excessive service demands and/or fatigue.
Moonlighting
1. Because graduate medical education is a full-time endeavor, the program director must ensure that moonlighting does not interfere with the ability of the trainee to achieve the goals and objectives of the educational program.
2. The program director must comply with the sponsoring institution's written policies and procedures regarding moonlighting, in compliance with the ACGME Institutional Requirements III. D.1.k.
3. Moonlighting that occurs within the graduate medical education program and/or the sponsoring institution or the non-hospital sponsor's primary clinical site(s), ie, internal moonlighting (Temporary Special Medical Activity), must be counted toward the 80-hour weekly limit on duty hours.
4. Requests for Temporary special Medical Activity will include documentation of duty hours.
Oversight
1. Each program must have written policies and procedures consistent with the Institutional and Program Requirements for resident duty hours and the working environment. These policies must be distributed to the trainees and the faculty. Monitoring of duty hours is required with frequency sufficient to ensure an appropriate balance between education and service.
2. Back-up support systems must be provided when patient care responsibilities are unusually difficult or prolonged, or if unexpected circumstances create trainee fatigue sufficient to jeopardize patient care.
3. Surveillance of duty hours will be the continuing responsibility of the Trainee Section of the Institutional Committee for Graduate Medical Education (ICGME) who will report to the full ICGME at least biannually.
4. Violations of the duty hour standards may result in institutional sanctions, such as withdrawal of program sponsorship or Corrective Actions for Associate Members of the Medical Staff.
Duty Hours Exception
An RRC may grant exceptions for up to 10 % of the 80-hour limit, to individual programs based on a sound educational rationale. However, prior permission of the ICGME is required.
Process:
1. Exceptions to the above standards for reasons of sound educational rationale may be submitted to the trainee section of the ICGME for consideration. The trainee section will then present the proposal along with their recommendations to the full ICGME for approval/denial. If approved, the exception request will then be forwarded on to the appropriate Residency Review Committee (RRC). Exceptions approved by ICGME will not be effective until direct notification to the Designated Institutional Official (DIO) from the RRC that it was accepted.
2. All duty hour concerns by trainees will be directed to the trainee section of the ICGME for consideration, investigation, and action. The trainee section of the ICGME will then present the concerns and proposed action to the full ICGME for approval/denial.
Developed: Sept/Oct, 2000
Revised: February 20, 2003
ICGME Approval: April 9, 2003
ECMS Approval: April 21, 2003
Trainees are responsible for checking their Duke e-mail account regularly as some important GME information will only be sent electronically. The Duke e-mail account should NOT be forwarded to a non-Duke account.
The qualifications for membership to the Associate Medical Staff (Graduate Medical Trainee) eligibility are as follows:
This policy applies to all graduate medical trainees whether United States or International Medical School graduates. An Agreement of Appointment will not be valid without satisfying this requirement.
A trainee may begin his or her clinical work when he or she has met the above Graduate Medical Education Requirements.
All GME trainees will receive written evaluations regarding medical and personal development by their program director and/or faculty at least twice per year. (It is recommended we request feedback is given more frequently, as part of routine patient care and after rotations.) These evaluations will be discussed with the trainee, signed by both the trainee and Program Training Director, and placed in the trainee's file.
All GME trainees will evaluate their training programs at least annually, anonymously if possible. These evaluations will be copied to the GME Office.
ECMS Approval: February 19, 2001
The Accreditation Council on Graduate Medical Education requires all training programs to “…educate faculty and residents …to recognize the signs of fatigue…and adopt and apply policies to prevent and counteract the potential negative effects.” Examples of such policies include, specialty -specific duty hour requirements such as maximum of 80 duty hours per week, in -house call no more frequently than one in three nights, a minimum of one 24- hour period off each week, a minimum of 10 hours free between consecutive duty periods, and duty periods of no more than 24 hours with up to an additional 6 hours for continuity or education. Every ACGME-accredited residency program in the United States must adhere to these regulations, although there are some differences among the specialties Emergency Medicine has stricter hours; some specialties allow “averaging” over 4 weeks and a few RCs allow requests for exceptions.
The American Medical Association Council on Ethical and Judicial Affairs considers physicians attending to their own health and wellness, as well as the health of their colleagues, an ethical imperative.
Duke’s own institutional duty hours policy (adopted in 2001) predated but anticipated that of the ACGME. All Duke ACGME and ICGME programs must be in full compliance. Only one Duke program (Neurosurgery) currently has pursued the internal process necessary to seek a duty hours exception from their RC to allow up to 86 hours per week).
Compliance with duty hours is monitored. Residents are urged to report any concern regarding duty hours, fatigue and other issues to the GME hotline 681-2999. Initially these efforts translated into major reductions in percentages of residents reporting they worked > 80 hours weekly and between 80-90 hours. Unfortunately recently there has been some “slippage” especially among the most junior residents.
Parallel to the focus on “duty hours” are efforts to increase the awareness of fatigue’s impact on trainee well- being, learning, and patient safety. These include dissemination of:
Restricting duty hours alone does not preclude fatigue. Of particular concern, is that the very strategies that training programs may adopt in a good faith effort to adhere to the 80-hour workweek may result in unintended adverse consequences. Programs may feel their work is “done” if they demonstrate compliance with duty hours standards, even though 80 hours is twice the work week duration of the average employed American. Programs may miss identifying persistent fatigue. Although perhaps better rested, resident stress may increase if residents are concerned about losing significant learning opportunities, procedural experience, and interaction with colleagues. Residents may feel trapped by competing demands between work hours and professionalism. They may feel support is lacking from senior residents and faculty who may have an inadequate understanding of this mandate and perhaps are resentful of restrictions on duty hours.
CAUSES OF FATIGUE
Fatigue, or “excessive daytime sleepiness”, may be due to a variety of factors. These may exist singly or in combination and include:
Too little sleep
This may be the most common reason for sleepiness among medical trainees, occurring when residents get less sleep than optimal. Although there is individual variation, most adults require an average of 8.2 hours of sleep each night. Residents may not have developed “good sleep habits” in high school, college and medical school for adequate sleep even on their nights “off”.
Fragmented Sleep
Alternatively, the duration of sleep may be optimal but the sleep itself is fragmented. Insufficient time may be spent in the “deeper, restorative” stages of sleep. Though “in bed”, trainees may be interrupted by frequent phone calls, pages, the need to follow up on patients, or to supervise more junior trainees. Residents may also be interrupted by residents who share the same call space. Even the “anxiety” of call or anticipation of sleep interruption can impair sleep. Call from home, though not counted in the duty hours, may still put residents at risk due to sleep disruption with frequent phone calls or the drive back and forth to the hospital.
Circadian Rhythm Disruption
Residency training may disrupt natural circadian rhythm. This problem may be exacerbated as programs implement solutions, such as “night floats” to adhere to duty hour requirements. Night float systems and shifts may put residents on duty during periods in which there are predictable mismatches between circadian and endogenous rhythms of asleep and awake. Energy lows, for example, characteristically occur around 3-7 am and 3-5 PM. Residents may be more prone to errors during these times. It is extremely difficult to adapt to “shift work”, regardless of how it is scheduled or its duration. Over 90% of individuals never adapt and may be at risk for sub-optimal performance. Working more nights in a row, rather than acclimatizing someone to night work, almost always only makes someone more tired.
Other Conditions Masquerading as Fatigue
Residents may also display symptoms of “fatigue” or attribute symptoms to fatigue when the etiology is in fact anxiety, depression, stress, thyroid disease, other medical conditions, medication side effects, burnout, or career dissatisfaction.
Primary Sleep Disorders
Finally, residents may have a primary, undiagnosed sleep disorder such as obstructive sleep apnea, narcolepsy, restless leg syndrome or insomnia.
SIGNS AND SYMPTOMS OF SLEEP DEPRIVATION
Disruption in sleep leads to a sleep debt. Performance can be impaired with two hours less sleep than “normal” per night. Significant sleep debt may occur if sleep is sub-optimal over as few as 2-3 nights. Adverse health consequences may occur if sleep debt is allowed to accumulate. Sleep debt requires several consecutive full nights sleep for adequate recovery, depending upon the number of days during which the sleep debt was accumulated as well as the individual’s susceptibility and ability to “recover”. Though it is difficult to quantify what is “sufficient”, the individual should feel “rested” after their recovery sleep.
Psychomotor function after 24 hours without sleep is equivalent to a blood alcohol content of 0.08%, a level recognized legally as inebriation. As is true with alcohol, one cannot depend on the individuals to perceive their own degree of impairment. Studies confirm residents, as true of other individuals, can’t adequately evaluate their own degree of sleepiness. Furthermore, the ability to recognize “sleepiness” declines the sleepier someone is.
Characteristic symptoms of sleepiness may be unrecognized. These include:
One of the first skills lost is the ability to do something quickly. If you slow down at a task, you may be able to compensate. But if the task requires a quick response, errors are more likely. Time pressure + fatigue is a major risk.
Of particular significance for residents, perhaps, is sleep inertia, the confusion and dysfunction that occurs upon awakening from deep sleep during deep NREM sleep, sleep in the middle of the night, or following a period of sleep deprivation. This may occur after as brief an interval as 30 minutes of sleep. This disorientation may include a period of amnesia for the period of awakening. The impairment from sleep inertia may be greater than that from sleep loss. Opinions in the sleep medicine field differ on the significance of sleep inertia.
Residents may be vulnerable to error when awakened during the night. Increased metabolic activity, such as exercise may minimize effects. Although the research evidence is inconsistent and people react with a great deal of individual variability, be aware this phenomenon may occur and may color judgment and responses for the first 10 minutes (and up to 2 hours) following arousal.
ADVERSE EFFECTS OF SLEEP DEPRIVATION
Sleep deprivation results in adverse physiologic changes such as hypoxemia, insulin resistance, increased sympathetic activity, a blunted arousal response, immunologic changes, , increased appetite, weight gain and diminished motor coordination. It impairs cognitive processes resulting in diminished attention, vigilance, decision-making, and memory. It increases tolerance for risk and decreases motivation for learning. Other professions, such as aviation and the military have previously recognized the potential impact of both acute and chronic sleep loss on job performance. Belenky, a psychiatrist who has studied sleep for the Army notes, “…If you’re sleep deprived, you’re not going to make good decisions.” The same observation seems valid in other professions. Fatigue has been linked to errors resulting in serious accidents (Exxon Valdez Bhopal, Chernobyl, and Three Mile Island). It is estimated to be responsible for 15-20 percent of transportation accidents, more than attributed to drugs and alcohol combined.
Governmental and Associations Recognition of Fatigue
The Institute of Medicine highlights the importance of medical errors as a major cause of mortality and morbidity. Fatigue probably contributes to at least some of these errors.
JCAHO considers fatigue so important that it had health care worker fatigue in its draft 2007 Patient Safety Goals. It narrowly missed begin included in the final set this year.
Other western countries have substantially decreased the resident workweek and will potentially decrease hours even further. Denmark currently mandates a 37½-hourwork week compared to the Australian duty hour limit of 72 hours. The UK will adopt a 48-hour workweek for its residents.
Sleep Debt: Could you have one and not know it?
Most people don’t accurately assess how sleepy they are. You may be chronically tired and not know it. The easiest way to determine if you have a sleep debit is to imagine what time you would wake up spontaneously if you were allowed to sleep in on a morning without an alarm clock, child, pet, etc awakening. Would you sleep “past” your usual wake up time on days you’re working? If you sleep two or more hours extra on your days off compared to work days, you’re carrying some “sleep debt” and your body is trying to “recover” lost sleep.
The Literature on Sleep, Fatigue and Residents
Recent articles (2006-2007) are referenced at the end of this paper.
Sleepiness
There is a considerable body of literature on fatigue and graduate medical education trainees. A multicenter survey of residents in a variety of specialties suggests that residents have Epworth Sleepiness Scale values comparable to patients with diagnosed sleep disorders such as sleep apnea and narcolepsy. This scale assesses an individual’s tendency for dozing) You can measure yourself on this scale at http://www.drugdigest.org/DD/HRA/Sleepiness/1,21887,,00.html
Attention Impaired
Sustained attention and vigilance tasks were impaired equally when residents were exposed to a heavy call schedule versus light call schedule with a blood alcohol level of 0.04 – 0.05 g%.
Yet another survey of internal medicine housestaff found that 64% were chronically sleep deprived; many admitted to dozing while writing notes (69%), reviewing medication lists (61%), interpreting labs (51%), and writing orders (46%),
In-service training exam scores among family practice residents correlated with their amount of “sleep” prior to the test.
Internal medicine residents post-call were less accurate in ECG interpretation.
Emergency Room residents documented fewer components of a history and physical examination depending upon their Shift. They also performed less well during a simulation of intubation skills.
Surgical residents demonstrated more errors and required more time than usual during simulations of common procedures. Measured postoperative complications increased by 45% for resident surgeons for those procedures they performed the day following their night on call.
Cognitive and procedural abilities decline
One study noted that residents working on a traditional schedule (>24 hours worked when on call) made 36% more serious medical errors and 6 times as many diagnostic errors as compared to their colleagues whose work hours were limited to 16 hours while on call.
Twenty percent of anesthesia residents indicated that sleepiness prevented them from performing clinical duties and 12% attributed errors to fatigue. Another study of anesthesia residents found objective evidence of sleepiness when residents were tested after their “normal” (not post call or on-call) sleep period. The same residents were tested again after allowing 2 extra hours in bed. The sleepiness improved and normal scores were obtained, implying that residents sleep deprive themselves even in a non-call situation.
Residents self reported decay of professionalism, empathy, and attentiveness to patient well being when tired.
A national sample of first and second year residents correlated working more than 80 hours per week with a greater likelihood of personal accident or injury, serious conflict, significant medical error, significant weight change, increased use of alcohol and other medications “to cope”. Residents reported sleeping on average fewer than six hours per night.
Well Being
Several studies have examined the relationship between sleep deprivation and fatigue to the well being of the health care provider. Needle stick accidents increase by 50% at night (compared to the day), increasing the risk of exposure to blood borne pathogens.
A study performed with surgical residents after implementation of the new work hour rules suggested that there were less mood disturbances than prior to the new rules.
Motor vehicle collisions increase
Pediatric house officers were more likely than faculty to fall asleep while at the wheel either while driving or stopped at a traffic light (49% of the residents vs. 13% of the faculty) and more likely to have a motor vehicle accident (20 vs. 11). Most incidents occurred post-call. Nearly 60% of ER residents reported a near miss motor vehicle collision, 80 percent of which followed their work on a night shift. The risk increased with the number of night shifts they did per month. Another study found that residents who worked longer than 24 hours were 2.3 times more likely to have a motor vehicle accident.
Mixed Effects on Patient Care
It should be noted that since institution of the duty hour regulations by the ACGME, not all aspects of medical education and patient care have improved. Many studies have noted that residents’ satisfaction with their jobs, personal lives, wellbeing, and overall quality of life is better. However the affects on patient care appear to be mixed. Whereas some studies have not noted any compromise in patient care, other have noticed an improvement and still others deterioration. Studies in which patient care appears to have suffered due to the duty hour regulations is usually due to inadequate communication and signoff between residents.
PREVENTION/TREATMENT/MANAGEMENT OF FATIGUE
It is probably inevitable there will be some sleep loss and fatigue in the course of medical training. However, it must be managed so it doesn’t interfere with patient care and safety, education, and resident well being. Developing strategies to minimize the effects of sleepiness in physicians is paramount. Learning to recognize and manage fatigue is essential. Anecdotal and empirical evidence suggest that limits on work hours in and of themselves do not guarantee well-rested and optimally functioning residents. Work hour limits are difficult to enforce, particularly if residents have workaholic tendencies or if faculty does not support work hour restrictions. In addition, resident behavior outside of the work place is difficult to govern (i.e. moonlighting activities, home responsibilities). Residents are adults who cannot be “forced” to be adequately rested.
The prevention, treatment and management of resident fatigue are therefore a shared responsibility of accrediting bodies, Duke Hospital, programs, faculty and residents.
Accrediting bodies
Accrediting bodies have set “the rules.” These should be construed as minimums. Some states have additional regulations.
Programs/Institutions should:
Duke should provide accessible call rooms with a conducive rest environment. If there are difficulties with call rooms contact the GME office at 681-2999.
Night float systems are increasingly used to comply with duty hours. It takes at least a few “nights” to adjust to the night float schedule and another few nights to adjust to a return to “routine hours.” Individuals on Night Float should consider keeping their Night Float sleep-wake schedule on their days off and adhere to this schedule for the duration of their rotation.”. Over 90% of individuals never habituate to night float even if they work them chronically. When night floats are used, they should be designed to take advantage of the fact that it is easier to change rotations from days to evenings, rather than vice versa.
Program Directors should include specific discussions regarding the management of fatigue in their regular discussions with each resident/residency group
Program directors should directly ask about issues pertaining to getting adequate sleep, resident safety such as concerning post-call driving, and resident concerns about the balance between professionalism and work hour restrictions. Where an individual program has particular issues with fatigue, enlist residents in developing particular program solutions.
Driving home post call is a particular concern for the safety and wellbeing of residents. It takes 4 seconds to drive off the road and have a motor vehicle collision. 4-second “micro sleeps” are common in sleepy residents. Some states (NJ) have adopted laws which now make a criminal, not just civil offense) for motor vehicle collisions after 24 hours without sleep. Other states will probably follow. Trainees may want to live close enough that they don’t have a long drive post call.
For many residents, the ability to manage fatigue will be a necessary life long skill.
Recognize vulnerability and symptoms in residents and colleagues
Although there is individual variation, most adults need ~ 8 hours of sleep per night. The impact of too little sleep is cumulative. You can’t “will yourself” to act against the neurobehavioral effects of sleep loss. Sleepiness is affected by the amount of time since you last slept, whether or not you have any pre-existing sleep debt, as well as the time of day reflecting circadian rhythm. People typically under-estimate their degree of sleepiness. So as with alcohol, by the time you think you’re sleepy you’re probably profoundly affected. Your performance level will fall especially with tasks that require a great deal of attention. Even if you feel you’re not at risk, consider that your colleagues may be. Watch out for your fellow residents.
It is not normal to fall asleep in a lecture
If it is a boring lecture, noted author Dinges says, “You’ll be awake and annoyed but not asleep.” If you are nodding off or falling asleep this is a major symptom that you’re too fatigued. You’re experiencing “microsleep.” Your system is making you sleep without you being able to control this phenomenon. This makes you extremely vulnerable for diminished attention and cognition. You can more easily make poor judgments medically and/or sustain a motor vehicle collision when you’re driving home post call.
Residents must set priorities for “time off”
Residents should be careful stewards of their time off. There is a temptation to cram way too much into the hours free from programmatic responsibilities. During off hours pursuits include time for professional reading, family and friends, hobbies, and spiritual and community connections. Although all of these are important, protect your recovery time.
You should practice setting reasonable priorities, especially if this is something that you have not had sufficient practice with during your years in college and medical school. It will be an important habit for the rest of your career.
Excessive fatigue can affect every facet of your life. Try to be appropriately selfish about your needed sleep time. You can honestly never, for instance, read enough. Do don’t short change your sleep to try to “read it all.”
Sometimes you’re approached about making a swap of schedules and you certainly want to accommodate a colleague. But consider your own sleep need as part of this decision and you may need to pull in a chief resident or program director to see if you’re the best person to meet this need.
Moonlighting
Of particular concern is moonlighting. Residents and program directors need to carefully evaluate moonlighting opportunities so as not to compromise their limited time to obtain rest missed as a part of residency training. Nighttime moonlighting in particular may not be appropriate given its likely contribution to sleep debt. There are certainly marked financial needs faced by today’s residents and the pressure to meet those needs may force housestaff to sacrifice time needed for rest. Inquire in the GME Office about Duke resources and opportunities for deferment. Think carefully through the level of debt burden you are comfortable carrying and the consequences of that debt if it adds to your workload. Come talk to GME about financial planning resources if you would find them useful.
See AAMC’s “Debt Help” http://www.aamc.org/students/financing/debthelp/start.htm; AAMC’s Medical Student: Cost Debt and Resident Stipend Facts http://www.aamc.org/students/financing/debthelp/factcard06.pdf and AAMC Educational Debt Manager http://www.aamc.org/students/financing/debthelp/debtmanager.pdf.
Report duty hours honestly
Duke requires residents to report duty hours through GMED and twice yearly to Duke GME, as well as to the ACGME. Please be honest. Your Program and Duke Hospital need to know where there are potential issues, patient volume or acuity that may keep you here over hours. This documentation is necessary to advocate for additional resources to help all of us care optimally for patients. Duke put over $3.5 million into implementing duty hours in 2003 in large part because of a “gap analysis” in which residents from many services contributed. This gap analysis looked at what would have to happen to pick up additional care if residents were truly to work < 80 hours a week. If you’re working > 80 hours and not letting us know, you keep us from having the documentation needed to justify additional resources. Please answer honestly to duty hours surveys. . If you believe your honest answers put you in any jeopardy for an evaluation, promotion or graduation, consider calling the GME hotline anonymously.
Practical Strategies
To minimize the impact of Fatigue:
Healthy Sleep Habits
Healthy sleep patterns are more likely if you develop a healthy sleep routine. Some of these seem obvious but deserve a reminder.
Naps
Recognize these are general guidelines and there is a great deal of individual variability to napping.
Safe Driving
Driving can put you and others at risk. Motor vehicle collisions increase with fewer than 5 hours of sleep. The first ethical principle of physicians “primum non nocere” (first, no harm) applies to all we do as physicians, including driving. It takes 4 seconds to run off the road. Signs of drowsiness include difficulty focusing on the road or keeping your eyes open, nodding off, yawning, drifting from one lane to another, missing exits, and amnesia for some period of the drive
Caffeine
Using caffeine, a central nervous stimulant, “strategically” can help manage fatigue. It is not a sleep substitute. Tolerance quickly develops. If you intend to use caffeine to counteract fatigue, minimize the regular social use of caffeine so that it will be more effective when consumed. Caffeine may modulate symptoms but does not substitute for sleep.
The effects of caffeine generally occur within 15-30 minutes. If you use it just before you drive home its stimulant effects may not kick in until you are home and ready to go to sleep.
Avoid regular caffeine use (the social use of caffeine) if you plan to use to abate sleepiness. Instead use it for its “drug effect” when you are on call only.
| Substance | Caffeine content |
| 12 ounce cola | 36 mg |
| 12 ounces diet cola | 47 mg |
| 8 ounces brewed Coffee | 133 mg |
| 12 ounces ice tea | 26 mg |
| 1.45 ounce dark chocolate | 31 mg |
| Excedrin, 2 tablets | 130 mg |
| No Doz maximum strength 1 tablet | 200 mg |
Center for Science in the Public Interest
http://www.cspinet.org/new/cafchart.htm accessed 10 30 2007
Other medications/drugs
It is important for residents to avoid self-medicating or prescribing casually for colleagues. The NC Medical Licensing Board does not allow self-prescribing or prescribing for a friend/colleague outside of an established doctor-patient relationship. It is far better for residents, as for patients, to have a regular physician who coordinates their care. Your license can be at risk if you violate the rules of the Board.
Hand Offs
One theory for why patient outcomes aren’t clearly “improved” is that there are more patient handoffs from one clinician to the other with the potential for not clearly communicating “enough” or “The right” information.
Duke has recent adopted a hand offs policy to standardize the hand off process whenever a change of members of the care team takes place. Joe Kelly has also made himself available to work with resident sand services to develop an electronic tool that would automatically populate a PDA with Browser info the service selected. Contact Joe if this would be appealing to your service.
Resources
If a resident or faculty member is concerned about a resident having a potential sleep disorder, they can obtain help through the sleep disorders specialists at Duke including:
Sleep loss and sleepiness are pervasive problems during residency training and can account for serious professional errors and personal problems. Symptoms and signs are often difficult to recognize. Whereas there are many ways to deal with the sleepiness and fatigue, the only real treatment is getting adequate sleep. Other management strategies should be individualized, especially if there is an underlying sleep disorder.
Other References available upon request.
For additional information, consider
1. The SAFER (Sleep, Alertness and Fatigue Education in Residency) program developed by the American Academy of Sleep Medicine (AASM) with representatives from the ACGME and AMA. They have (for purchase) an educational module designed to increase knowledge and awareness about sleep and fatigue among the medical community which includes a slide set, syllabus, and pre and post tests. http://www.aasmnet.org/safer.htm
2. Dr. David Dinges Presentations for ACGME and AAMC. These are available through their respective web sites: www.acgme.org & www.aamc.org.
The GME office has copies of both of all of these resources.
At any time when a fire alarm is sounded never assume that it is a drill. All employees should know the location of fire extinguishers in their departments, how to operate fire extinguishers, and how to report a fire alarm. Employees should also be familiar with the evacuation plans for their buildings and with locations of pull alarms. Duke University is on the 911 emergency system.
Staff with questions concerning fire alarm and evacuation protocols should contact the Safety Office at (919) 684-2794 or (919) 684-5609.
We follow the University’s Gift Policy which prohibits employees from accepting gifts or gratuities from vendors with whom we conduct business. The policy may be found at: http://staff.dukehealth.org
Developed: Prior to 1995
To provide an additional, nonexclusive system of communication, exchange of information, and confidential concerns of individual Graduate Medical Trainees regarding their educational programs. Graduate Medical Trainees may contact their resident or faculty representative on the Institutional Committee for Graduate Medical Education, who have full access to the committee and any ad hoc committees necessary to explore and address Trainee’s concerns, complaints, or grievances not covered under the Corrective Action and Hearing Procedures for Associate Medical Staff of Duke University Hospital. The names of the Graduate Medical Trainee and Faculty representatives will be made available to all Graduate Medical Trainees on an annual basis. Any records regarding these issues will have protected status of peer review.
ICGME Approval: August 12, 1998
ECMS Approval: September 21, 1998
Revised: March 2004
Duke University is committed to maintaining an environment free from harassment and discrimination for all members of the Duke community. Harassment is defined as the creation of a hostile or intimidating environment, in which verbal or physical conduct, because of its severity and/or persistence, is likely to interfere significantly with an individual's work. Sexual coercion consists of unwelcome sexual advances, requests for sexual favors, or other verbal or physical conduct of a sexual nature when: 1) submission of such conduct is made explicitly or implicitly a term or condition of an individual's employment; or 2) submission to or rejection of such conduct is used as a basis for employment decisions affecting an individual 3) Such conduct has the purpose or effect of substantially interfering with an individual’s work performance or environment. The conduct alleged to constitute harassment under the Duke Harassment Policy should be evaluated from the perspective of a similarly situated reasonable person in consideration of the totality of the situation.
Individuals with questions or concerns may contact the Office for Institutional Equity (OIE) at 684-8222. The harassment policy prohibits retaliation for filing a complaint. The full text of the harassment policy is available at the OIE website: http://www.duke.edu/web/equity/har_policy.htm.
I. Background
Graduate Medical trainees are at risk for all the health problems seen in the general population and are expected to function at a superior level as trainees in medicine and as health care providers. The supervision of their care provision and evaluation of their learning is complicated by the fact that their supervisors and evaluators are health care providers. Role confusion can occur which interferes with both clear evaluation of performance and appropriate health care intervention for the trainee.
The policy, procedure and training program below are designed to enhance the quality of the Duke Graduate Medical Education program by providing guidance for handling issues of impairment of performance.
II. Policy
The Duke Office of Graduate Medical Education will address all cases of impaired performance among trainees in order to assure the safety of trainees and the safety of patients and co-workers. Impairment may result from physical and mental/behavioral health problems. Services to support confidential and constructive intervention to resolve impairments will be made available.
III. Procedure
Supervisors of trainees will utilize the impairment checklist to evaluate trainees as appropriate. Concerns arising out of the evaluation will be brought to the Graduate Medical Education Program Directors (Program Directors).
Performance and/or behavioral concerns will be addressed with the trainee. Trainees will be encouraged to utilize the Personal Assistance Service (Employee Assistance) or Dean of Medical Education Counseling on a voluntary basis. PAS is a free and confidential resource available to house staff and immediate family members. PAS provides assessment, short-term counseling and referral. Clear expectations for improvement will be established in writing and evaluation will occur periodically.
Impairment concerns will be reviewed with Duke Employee Occupational Health (EOH) and/or the NC Physicians Health Program (NCPHP). With the concurrence of EOH and/or NCPHP the trainee will be referred by Program Director for mandatory evaluation and removed from patient care responsibilities.
EOH and/or NCPHP will evaluate the trainee and make recommendations for return to work to the Program Director and the Office of Graduate Medical Education.
Any trainee removed from any aspect of their training program for any reason must be returned to work through EOH and the Office of Graduate Medical Education must be notified.
IV. Guidelines
Most trainees are eager, productive learners and colleagues; however, some experience difficulties in learning and/or performance and may demonstrate behaviors that are inappropriate.
How these issues are addressed can have a substantial effect on a trainee's career and Duke's mission as an educational institution. The following suggestions can enhance successful resolution:
· Consult with PAS. PAS is also a consultative resource for supervisors of trainees regarding how concern might be addressed.
· Do not ignore, "push under the rug", or dismiss as a "bad day" inappropriate behavior. Address issues promptly to improve the outcome.
· Document behaviors and incidents that create concern. Request co-observation with a colleague when possible.
· Do not try to diagnose, do not argue. Rather, discuss concerns i.e. specific behavioral terms and expectations for improvement.
· Offer and encourage trainee to use available resources.
· Establish clear, written expectations for improvement and an evaluation plan.
V. Manifestations of Impairment
• Dramatic decrease in performance
• Persistent or repetitive absenteeism/lateness
• Mood swings
• Interactional difficulties
• Patient/colleague complaints
• Disruptive behaviors
• Medications missing from work area
• Disappearances from work
• Disordered thought
• Alcohol on breath, other stigmata of drug use
• Diminished physical appearance
VI. Resources
Personal Assistance Service
2200 West Main Street, Ste 700
Durham NC 27705
919-416-1PAS (416-1727)
Personal Assistance Service (PAS) is the faculty/staff assistance program of Duke University. The staff of licensed professionals offers assessment, short-term counseling, and referrals to help resolve a broad range of personal, work, and family problems. There are no charges for any service provided by the PAS staff.
Employee Occupational Health Services
2200 West Main Street, Ste 600A
Durham NC 27705
(919 )684-3136/286-6000
Employee Occupational Health (EOH) provides evaluation of health issues that involve the safety of the work force and the safety of patients, visitors, and products of Duke University. EOH services faculty and staff.
The North Carolina Physicians Health Program
The North Carolina Physicians Health Program (NCPHP) was established in 1988 by a collaborative effort of the North Carolina Medical Society and the North Carolina Medical Board to help impaired physicians. The NCPHP is set up to identify troubled physicians, get them the appropriate treatment and return them to the productive practice of medicine' Impairment can be caused by alcoholism/chemical dependency, psychiatric disorders, disruptive behavior, professional sexual misconduct and severe stress. Anyone who feels that they themselves or a colleague possibly has an impairment problem can seek assistance anonymously and confidentially by calling the NCPHP at 1- 800-783-6792.
ICGME Approval: September 13, 2000
ECMS Approval: November 8, 2000
University policy enables you to fulfill your civic responsibility of serving on juries or appearing as a subpoenaed witness without loss of pay or benefits. All House Staff Members are eligible for this benefit. When you receive a summons, subpoena, or other legal notice for appearance, you should notify your supervisor promptly. In the case of jury duty, your supervisor will approve the absence and consider it an "authorized absence with full pay." When you return to work, you must submit proof of appearance, including complete dates of service. In those instances when your continued presence is crucial to the operation of the department, your supervisor is authorized to furnish a letter (addressed to the presiding judge) requesting that you be excused and providing a full explanation for that request. Your absence will not be counted as sick pay or vacation regardless of the duration of your jury service.
In addition to Hospital and Federally mandated leave policies, each program will have a description of vacation and sick time, maternity, paternity and other leaves and the consequences of leave upon completion of program. These policies should also be in compliance with the program’s RRC requirements.
At the time each trainee requests a Leave of Absence, a LOA form will need to be completed and signed by the Program Training Director and the Trainee. The trainee will be informed of what affect the leave will have on the completion of training. The form will then be sent to the Office of Graduate Medical Education for the DIO’s signature.
The following is a list of possible leaves for Graduate Medical trainees:
· Family and Medical
· Military
For further information, see the Duke University Personnel Policy Manual at: http://www.hr.duke.edu/policy/ppm/
Developed: August 25, 1970
Revised: December 19, 2000
ICGME Approval: January 10, 2001
ECMS Approval: March 19, 2001
Revised: September 20, 2004
Individuals who are on leave for six months or more, the following checks must occur: 1. Criminal background check; 2. Login information from DHTS; 3. Tax forms; 4. Life insurance; 5. Direct Deposit; 6. Health; 7. Dental; 8. Reimbursement; 9. Parking; 10. Uniforms; 11. Contract; 12. New ID badge; 13. All compliance requirements; 14. House Staff application (waive reference letters)
Legal aid is available to all Duke House Staff Members through the University in connection with any circumstances involving a House Staff member and a hospital patient(s). Any development of a medicolegal nature must be handled through the Risk Management Office. If legal papers relating to a patient are served on a House Staff Member, contact Risk Management at (919) 684-3277.
All Trainees are required to have a Full State License, Resident’s Training License(RTL) or a letter from their PTD stating 100% non-clinical responsibility. Trainees are also required to renew their medical license with documentation of the renewal provided to the GME office on or before their birthday each year.
**Please note - Effective December 31, 2003, anyone on the House Staff roster will need to have either a Full State License or Resident’s Training License. Not having a current medical license will be subject to automatic corrective action including suspension from the HS roster.
· State Law requires hospitals and other entities to report changes in physician privileges to the NCMB.
· There is no cost for a name change unless the licensee wants a new certificate or wall license. The cost is $15 for a new certificate and $25 for a new wall license.
· A doctor newly graduated from medical school does not have to take Parts I and II to receive an RTL
· A doctor has to have taken and passed Part III to apply for a Full State License.
· A Canadian can receive a Full State License if: a) they have taken the equivalent of the USMLE (LMCC) plus have a State License in another state or b) they have taken the USMLE.
See http://www.ncmedboard.org for Laws, Rules, Position Statements, Disciplinary Guidelines and Prescriptions Laws.
License Renewal
All House Staff Members must renew their license with the NC Medical Board and provide documentation of this to the GME office annually 30 to 60 days before their birthday. Go to: http://renewal.ncmedboard.org You will need a credit card and registration ID# (located on the top right hand side of your RTL or registration card). You can call (919) 684-3491 or 1-800-253-9653 with any questions.
Revised: 1998
Solicitation by an employee, for any purpose, is prohibited in the circumstances listed below:
1. When the employee soliciting or the employee being solicited is or should be performing his/her job duties.
2. At all times in those areas of the Medical Center which are immediate patient care areas; immediately adjacent to patient rooms, operating rooms, treatment areas, or other patient care areas; thoroughfares frequently used to transport patients; or other areas where solicitation would disrupt the delivery of health care services.
Distribution of literature by an employee, for any purpose, is prohibited in the circumstances listed below:
1. At all times in work areas.
2. At all times in those areas of the Medical Center which are immediate patient care areas; immediately adjacent to patient rooms, operating rooms, treatment areas, or other patient care areas; thoroughfares frequently used to transport patients; or other areas where solicitation would disrupt the delivery of health care services.
Solicitation or distribution of literature, for any purpose, by non‑employees or non‑students on University property is strictly prohibited. Normal business contacts with University officials by authorized sales representatives are not prohibited by this policy.
All Graduate Trainees are provided a laminated card at orientation to wear with their Duke ID badge. The card lists important information concerning the use of pagers:
·Paging User Options
1. Change page status or coverage
2. Retrieve messages
3. Add or change security code
4. Administer personal greeting
·Paging and on-call Web site:
·Paging Contact Numbers
1. Pager repair (919) 684-2337 (& press 1)
2. Problems, requests (919) 684-6377
Including: Missed pages, Sign-out problems, and Sign out for specific date/time
Position Description for Trainees
1. Purpose of graduate medical education trainee position description:
· To identify by position the individuals covered by this description.
·