内科住院医师培训中重新设计方案的评估。

Evaluation of a redesign initiative in an internal-medicine residency.

机构信息

Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA.

出版信息

N Engl J Med. 2010 Apr 8;362(14):1304-11. doi: 10.1056/NEJMsa0908136.

DOI:10.1056/NEJMsa0908136

PMID:20375407

Abstract

BACKGROUND

Several organizations have advocated for comprehensive redesign of graduate medical training, but the effect that residency redesign will have on measures of patient satisfaction, resident and intern (trainee) satisfaction, and patient care is unknown.

METHODS

We designed an experimental inpatient-medicine service with reduced resident workload comprising two teams, with each team consisting of two attending physicians, two residents, and three interns. Attending physicians, selected for their teaching prowess, supervised the teams throughout the workday and during bedside team-teaching rounds. This experimental model was compared with a control model comprising two teams, with each consisting of one resident and two interns, plus multiple supervising attending physicians who volunteered to participate. Patients were alternately assigned to the experimental teams and the control teams, subject to limits on the number of patients interns are allowed to admit.

RESULTS

Over a 12-month period, 1892 patients were assigned to the experimental teams and 2096 to the control teams; the average census per intern was 3.5 and 6.6 patients, respectively. Overall satisfaction was significantly higher among trainees on the experimental teams than among those on the control teams (78% and 55%, respectively; P=0.002). As compared with the control teams, the experimental teams were not associated with a higher average length of patient stay or readmission rate; adherence to standards for quality of inpatient care was similar in both groups of teams. Interns on the experimental teams spent more time in learning and teaching activities than did interns on the control teams (learning: 20% of total time vs. 10%, P=0.01; teaching: 8% of total time vs. 2%, P=0.006).

CONCLUSIONS

As compared with a traditional inpatient care model, an experimental model characterized by reduced trainee workload and increased participation of attending physicians was associated with higher trainee satisfaction and increased time for educational activities.

摘要

背景

一些组织主张对住院医师培训进行全面重新设计，但住院医师培训设计的改变对患者满意度、住院医师和实习医师（受训者）满意度以及患者护理的衡量标准有何影响尚不清楚。

方法

我们设计了一个具有降低住院医师工作量的实验性内科住院服务，该服务包括两个团队，每个团队由两名主治医生、两名住院医师和三名实习医师组成。主治医生根据其教学能力进行选择，在整个工作日以及床边团队教学轮次中监督团队。该实验模型与一个对照模型进行比较，该对照模型由两个团队组成，每个团队由一名住院医师和两名实习医师组成，外加多名自愿参加的监督主治医生。患者根据实习医师允许收治的患者数量限制，被交替分配到实验组和对照组。

结果

在 12 个月的时间里，1892 名患者被分配到实验组，2096 名患者被分配到对照组；每位实习医师的平均患者人数分别为 3.5 和 6.6 人。实验组的受训者的总体满意度明显高于对照组（分别为 78%和 55%；P=0.002）。与对照组相比，实验组的患者平均住院时间或再入院率并没有更高；两组团队对住院患者护理质量标准的遵守情况相似。实验组的实习医师在学习和教学活动上花费的时间多于对照组（学习：总时间的 20%比 10%，P=0.01；教学：总时间的 8%比 2%，P=0.006）。