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Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References

Medical Education 2012: 46: 1189–1193

Context  Learning in the clinical environment is believed to be a crucial component of residency training. However, it remains unclear whether recent changes to postgraduate medical education, including the implementation of work hour limitations, have significantly impacted opportunities for experiential learning. Therefore, we sought to quantify opportunities to gain clinical experience within medical-surgical intensive care units (ICUs) over time.

Methods  Data on the numbers of patients admitted and invasive procedures performed per day between 1 July 2001 and 30 June 2010 within three academic medical-surgical ICUs in Calgary, Alberta, Canada were obtained from electronic medical records. These data were matched to resident doctor on-call schedules and residents’ opportunities to admit patients and participate in procedures were calculated and compared over time using Spearman’s rho.

Results  We found that over a 9-year period, the opportunities afforded to residents (n = 1156) to admit patients (n = 17 189) and perform procedures (n = 52 827) during ICU rotations decreased by 32% (p < 0.001) and 34% (p < 0.001), respectively.

Conclusions  Our results suggest that there has been a significant decrease in residents’ clinical experiences in the ICU over time. Further investigations to better understand these changes and how they may impact on performance as residents become independent practising doctors are warranted.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References

During postgraduate training, resident doctors (residents) acquire the knowledge, skills and professional attitudes necessary for independent medical practice. Experiential learning, or ‘learning by doing’, has been identified as a key component in this process.1 Because of the tighter limits on the number of consecutive and cumulative hours available to trainees for clinical activities, both programme directors and residents have expressed concerns regarding the impact of these changes on the educational experience during training.2,3 However, the results of three recent systematic reviews suggest that the implementation of work hour limitations has not negatively impacted residents’ opportunities to gain clinical experience.4–6

The reasons for this discrepancy are unclear. However, the studies included in the reviews4–6 typically evaluated changes to only one or two types of clinical experience within an entire training programme, and infrequently investigated whether other aspects of these residency training programmes had been sacrificed in order to maintain the experiences being measured. Additionally, there remains very little information about how these changes have impacted opportunities to learn from clinical experiences outside the operating room environment.

Therefore, we set out to describe how residents’ opportunities for experiential learning in the intensive care unit (ICU) have changed over time. We hypothesised that opportunities for residents to admit patients to the ICU and perform basic invasive procedures (endotracheal intubation, central venous catheter, arterial catheter and chest tube insertion) have declined significantly.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References

For this study, we utilised a retrospective cohort design. We identified all residents rotating through the three medical-surgical ICUs (53 beds in closed units) in the city of Calgary, Alberta, Canada (population: 1.2 million) between 1 July 2001 and 30 June 2010. Each ICU rotation (4 weeks) is designed to provide two to five residents (per ICU team) with classroom (lectures), self-study (self-study guide), simulation (procedures and resuscitation) and experiential (consultation and management of patients under the supervision of an attending intensive care doctor) opportunities to learn about diagnosis and management in severely ill patients. The rotation includes on call which begins at 08.00 hours and lasts 24 hours, during which on-call residents are responsible for patient admissions and procedures.

Resident call schedules were linked to an electronic medical record (which includes doctor and bedside nurse documentation of invasive procedures) of all patients admitted to the ICU. Opportunities to admit patients and participate in procedures were calculated as the total numbers of admissions and procedures (proxy measures for experiential learning opportunities) divided by the total number of residents by date and aggregated according to the number of residents on call (as these residents perform admissions and procedures). A non-parametric test was used to test for a monotonic trend of training opportunities over time (Spearman’s rho) and presented with 95% normal confidence intervals. Statistical analyses were performed using sas Version 9.2 (SAS Institute, Inc., Cary, NC, USA) with two-tailed significance levels of 0.05. The Conjoint Health Research Ethics Board at the University of Calgary approved this study and waived the need to obtain informed consent from patients and residents. The work was carried out in accordance with the Declaration of Helsinki, including, but not limited to, there being no potential harm to participants. The anonymity of participants was guaranteed.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References

During the study 1156 residents (of whom 14.1% were in year 1, 60.3% in year 2, 20.1% in year 3 and 5.5% in year 4 or further of residency training), primarily from family medicine (32%), internal medicine (29%), surgery (22%), anaesthesia (10%) and emergency medicine (4%), completed rotations. The number of rotating residents per year increased from 89 to 171 during the 9 years, whereas the mean number of calls per resident in the ICU decreased from 10.3 to 7.6 (p < 0.001) (Fig. 1a).

image

Figure 1.  Opportunities for experiential learning during intensive care unit rotations. (a) Number of residents and calls. (b) Patient admissions and invasive procedures performed by residents. (Vertical lines above and below point estimates denote 95% confidence intervals)

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During this period, 17 189 patients were admitted to the ICU; numbers rose at a mean annual increase of 3.4%. Patients underwent 52 827 invasive procedures (endotracheal intubation, central venous catheter, arterial catheter and chest tube insertion) at a mean of 3.1 procedures per patient. Over the period of study, resident opportunities to admit patients decreased by 32% from a mean of 17.2 in 2001 to a mean of 11.8 in 2009 (p < 0.001). Similarly, resident opportunities to perform invasive procedures decreased by 34% from a mean of 54.3 in 2001 to 35.5 in 2009 (p < 0.001) (Fig. 1b). These included reductions in opportunities for residents to perform central venous catheter insertion (from a mean of 17.2 to 10.2 opportunities; p < 0.001), endotracheal intubation (from a mean of 14.2 to 10.1 opportunities; p < 0.001), arterial catheter insertion (from a mean of 18.1 to 12.4 opportunities; p < 0.001) and chest tube insertion (from a mean of 4.8 to 2.9 opportunities; p < 0.001). Secondary analyses according to resident year of training and base specialty demonstrated similar findings.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References

We found that the number of patients admitted to the ICU by residents and the number of invasive procedures performed by residents each decreased by approximately one third over the 9-year period of study. This reduction in individual clinical experience occurred despite an increase in total potential opportunities of 30% over the same time period. Our findings contrast with those of three recent reviews that evaluated the impact of work hour restrictions on learning experiences occurring almost exclusively in the operating room environment,4–6 but are congruent with those of Mickelsen et al.,7 who demonstrated a decrease in resident exposure to Code Blue events by almost half over a 6-year period.

Residency may represent one of the most intense times of learning over the course of a doctor’s career as the trainee transitions from medical student to attending physician. This period is subject to expectations of dramatic increases not only in knowledge level, technical skills and efficiency of clinical reasoning, but also in the honing of skills in communication, leadership, administration and scholarship. This is also a crucial time for developing a professional identity. Both residents and attending physicians have highlighted the fundamental role that learning in the clinical environment plays in these processes.1,8 They have also expressed concerns that the introduction of work hour limitations will negatively impact residency training by reducing opportunities to obtain adequate clinical experience.2

However, because it is challenging to define exactly what competency means and difficult to accurately assess it, the optimal amount of clinical experience required during residency remains unclear. It is possible that further reductions in experiential learning may lead to the loss of opportunities for residents to acquire not only basic knowledge and technical skills through context-dependent learning,9 but also higher-order skills such as diagnostic acumen and the ability to manage complex patients.10 As a result, although they may still achieve a level of competence deemed to be acceptable by certifying bodies, they may not attain the same level of clinical expertise by the end of their training as previous generations of doctors have done.9,10

It is also possible, however, that residents were previously asked to see and do too much and that changes to postgraduate training now provide for a better balance between service, education and quality of life. As a result, residents may be better able to participate in structured and self-directed learning activities and may still gain the experience they require to achieve clinical competence. For example, a recent review demonstrated that the use of simulation technology with deliberate practice was a more effective method for teaching clinical skills than traditional clinical education.11 It is possible that additional reductions in work hours may improve learning and patient outcomes and even allow for reductions in length of training.12

What makes this process even more challenging is the fact that although it is necessary to gain experience in order to become an expert,13 expertise is not guaranteed by simply gaining experience.14 Numerous other factors including the quality of the experiences, the motivation of the learner and the techniques used by the learner to maximise the gains from each experience all play important roles and should be considered in depth when changes to the structure of residency training are necessary.14

For example, faced with regulations to reduce work hours, programme directors would ideally eliminate components in all aspects of the training programme that are deemed to be of little educational value, so-called ‘scut-work’, and strive to improve overall efficiency of learning. However, as a result of many factors, including tight timelines within which to make changes, demands to maintain clinical coverage, lack of resources and institutional culture, this may not be possible. Instead, entire aspects of residency training may be eliminated or reduced, regardless of their educational value, in order to maintain certain existing experiences that are deemed to be of most value by residents, examination boards or accreditation bodies. For example, surgical training programmes may maintain operating room experience for trainees at the cost of reducing both the quantity of ambulatory experience15 and the continuity of patient care.16 This may help to explain why the earlier systematic reviews4–6 found no difference in clinical experience after the introduction of work hour limitations because the vast majority of the studies included evaluated surgical or anaesthesiology training programmes.

Not only did our study occur outside the operating room environment, but it also evaluated changes that occurred for residents from multiple specialties completing one rotation over many years, whereas the typical study design has assessed changes to the longitudinal experience of residents in one specialty over many rotations. By focusing on one rotation that did not undergo changes to its structure over the course of the study, we were able to avoid concerns about whether or not other aspects of the residency training programme were being sacrificed to maintain clinical experience. Interestingly, a study of similar design that evaluated Code Blue events also reported findings of a large reduction over time in residents’ opportunities to gain clinical experience.7 This suggests that there may be important heterogeneity in the experiences evaluated and the methodologies employed in studies assessing changes to residents’ experiences. Therefore, we believe further research is urgently needed to help us understand how best to structure our residency programmes to maximise learning in the era of work hour limitations.

The results of our study should be interpreted within the context of its limitations. Firstly, our study used procedure and admission counts as surrogates for experiential learning opportunities and did not evaluate trainee competence. Therefore, our data outline changes to maximum experiential learning opportunities (some admissions and procedures may have been performed by fellows and attending doctors) and are relevant if minimum clinical exposures are important for establishing competence. Secondly, we employed a retrospective single-centre cohort design. Our data are likely to reflect experiences at other institutions, but do not allow for an evaluation of causality. Finally, changes in both the number and length of on-call shifts for residents and an increase in the number of residents per rotation occurred over the study period; given our study design, further investigations are required to determine the relative contributions of each of these changes to the results.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References

Our results suggest that during ICU rotations, opportunities for residents to learn by admitting patients and performing common invasive procedures decreased by approximately a third over a recent 9-year period. As postgraduate medical programmes change the numbers of residency positions and the duration of work hours, it is urgently important to understand clinical experience during residency and how it impacts on performance as an independent practising doctor so that training conditions can be optimised.

Contributors:  both authors had full access to all of the data in the study and take responsibility for their integrity and the accuracy of data analysis. ADP contributed to the study concept and design, and to the analysis and interpretation of data. HTS contributed to the study concept and design, to the acquisition, analysis and interpretation of data, and to the administrative, technical and material support of the study. Both authors contributed to the drafting and revision of the article and approved the final manuscript for publication.

Acknowledgements:  none.

Funding:  ADP is supported by a Junior Scholar Award from the Centre for Health Education Scholarship at the University of British Columbia. HTS is supported by a New Investigator Award from the Canadian Institutes of Health Research and a Population Health Investigator Award from Alberta Innovates–Health Solutions. Funding sources had no role in the design, conduct or reporting of this study.

Conflict of interest:  none.

Ethical approval:  this study was approved by the University of Calgary Conjoint Health Research Ethics Board.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References
  • 1
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    Teunissen PW, Boor K, Scherpbier AJJA, van der Vleuten CPM, van Diemen-Steenvoorde JAAM, van Luijk SJ, Scheele F. Attending doctors’ perspectives on how residents learn. Med Educ 2007;41:10508.
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    Maxwell AJ, Crocker M, Jones TL, Bhagawati D, Papadopoulos MC, Bell BA. Implementation of the European Working Time Directive in neurosurgery reduces continuity of care and training opportunities. Acta Neurochir 2010;152:120710.