内科值班时长灵活性试验中的教育成果
Education Outcomes in a Duty-Hour Flexibility Trial in Internal Medicine.
作者信息
Desai Sanjay V, Asch David A, Bellini Lisa M, Chaiyachati Krisda H, Liu Manqing, Sternberg Alice L, Tonascia James, Yeager Alyssa M, Asch Jeremy M, Katz Joel T, Basner Mathias, Bates David W, Bilimoria Karl Y, Dinges David F, Even-Shoshan Orit, Shade David M, Silber Jeffrey H, Small Dylan S, Volpp Kevin G, Shea Judy A
机构信息
From the Departments of Medicine (S.V.D.), Epidemiology (A.L.S., J.T., D.M.S.), and Biostatistics (J.T.), Johns Hopkins University, Baltimore; the Departments of Medicine (D.A.A., L.M.B., K.H.C., M.L., A.M.Y., J.M.A., J.A.S.), Psychiatry (M.B., D.F.D.), and Medical Ethics and Policy (K.G.V.) and the Department of Statistics, the Wharton School (D.S.S.), University of Pennsylvania, the Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.H.C., K.G.V.), and the Department of Pediatrics, Children's Hospital of Philadelphia (O.E.-S., J.H.S.) - all in Philadelphia; the Department of Medicine, Brigham and Women's Hospital, Boston (J.T.K., D.W.B.); and the Department of Surgery and Center for Healthcare Studies, Northwestern University, Chicago (K.Y.B.).
出版信息
N Engl J Med. 2018 Apr 19;378(16):1494-1508. doi: 10.1056/NEJMoa1800965. Epub 2018 Mar 20.
BACKGROUND
Concern persists that inflexible duty-hour rules in medical residency programs may adversely affect the training of physicians.
METHODS
We randomly assigned 63 internal medicine residency programs in the United States to be governed by standard duty-hour policies of the 2011 Accreditation Council for Graduate Medical Education (ACGME) or by more flexible policies that did not specify limits on shift length or mandatory time off between shifts. Measures of educational experience included observations of the activities of interns (first-year residents), surveys of trainees (both interns and residents) and faculty, and intern examination scores.
RESULTS
There were no significant between-group differences in the mean percentages of time that interns spent in direct patient care and education nor in trainees' perceptions of an appropriate balance between clinical demands and education (primary outcome for trainee satisfaction with education; response rate, 91%) or in the assessments by program directors and faculty of whether trainees' workload exceeded their capacity (primary outcome for faculty satisfaction with education; response rate, 90%). Another survey of interns (response rate, 49%) revealed that those in flexible programs were more likely to report dissatisfaction with multiple aspects of training, including educational quality (odds ratio, 1.67; 95% confidence interval [CI], 1.02 to 2.73) and overall well-being (odds ratio, 2.47; 95% CI, 1.67 to 3.65). In contrast, directors of flexible programs were less likely to report dissatisfaction with multiple educational processes, including time for bedside teaching (response rate, 98%; odds ratio, 0.13; 95% CI, 0.03 to 0.49). Average scores (percent correct answers) on in-training examinations were 68.9% in flexible programs and 69.4% in standard programs; the difference did not meet the noninferiority margin of 2 percentage points (difference, -0.43; 95% CI, -2.38 to 1.52; P=0.06 for noninferiority). od Institute and the ACGME; iCOMPARE ClinicalTrials.gov number, NCT02274818 .).
CONCLUSIONS
There was no significant difference in the proportion of time that medical interns spent on direct patient care and education between programs with standard duty-hour policies and programs with more flexible policies. Interns in flexible programs were less satisfied with their educational experience than were their peers in standard programs, but program directors were more satisfied. (Funded by the National Heart, Lung, and Blo
背景
医学住院医师培训项目中僵化的值班时间规定可能会对医师培训产生不利影响，这一担忧依然存在。
方法
我们将美国63个内科住院医师培训项目随机分为两组，一组遵循2011年研究生医学教育认证委员会（ACGME）的标准值班时间政策，另一组遵循更灵活的政策，后者未对轮班时长或轮班之间的强制休息时间作出限制。教育体验的衡量指标包括对实习医生（一年级住院医师）活动的观察、对学员（实习医生和住院医师）及教员的调查，以及实习医生的考试成绩。
结果
在实习医生用于直接患者护理和教育的平均时间百分比方面，两组之间没有显著差异；在学员对临床需求与教育之间适当平衡的认知方面（学员对教育满意度的主要指标；回复率为91%），以及在项目主任和教员对学员工作量是否超出其能力的评估方面（教员对教育满意度的主要指标；回复率为90%），两组之间也没有显著差异。另一项对实习医生的调查（回复率为49%）显示，在灵活政策项目中的实习医生更有可能对培训的多个方面表示不满，包括教育质量（优势比为1.67；95%置信区间[CI]为1.02至2.73）和总体幸福感（优势比为2.47；95%CI为1.67至3.65）。相比之下，灵活政策项目的主任对包括床边教学时间在内的多个教育过程不太可能表示不满（回复率为98%；优势比为0.13；95%CI为0.03至0.49）。灵活政策项目的培训期间考试平均成绩（正确答案百分比）为68.9%，标准政策项目为69.4%；差异未达到2个百分点的非劣效性界限（差异为 -0.43；95%CI为 -2.38至1.52；非劣效性检验P = 0.06）。（由美国国立心肺血液研究所和ACGME资助；iCOMPARE临床试验注册号，NCT02274818。）
结论
在遵循标准值班时间政策的项目和遵循更灵活政策的项目中，医学实习医生用于直接患者护理和教育的时间比例没有显著差异。灵活政策项目中的实习医生对其教育体验的满意度低于标准政策项目中的同行，但项目主任的满意度更高。（由美国国立心肺血液研究所资助）
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