Education Outcomes in a Duty-Hour Flexibility Trial in Internal Medicine.
Education Outcomes in a Duty-Hour Flexibility Trial in Internal Medicine.
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DOI：
10.1056/nejmoa1800965
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发表时间：
2018-04-19
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影响因子：
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通讯作者：
iCOMPARE Research Group
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作者：
Desai SV;Asch DA;Bellini LM;Chaiyachati KH;Liu M;Sternberg AL;Tonascia J;Yeager AM;Asch JM;Katz JT;Basner M;Bates DW;Bilimoria KY;Dinges DF;Even-Shoshan O;Shade DM;Silber JH;Small DS;Volpp KG;Shea JA;iCOMPARE Research Group
人们仍然担心，住院医师项目中不灵活的值班时间规则可能会对医生的培训产生不利影响。我们随机分配了美国63个内科住院医师项目，由2011年研究生医学教育认证理事会（ACGME）的标准工作时间政策或更灵活的政策管理，这些政策没有规定轮班长度或轮班之间的强制性休息时间。教育经验的措施包括观察实习生（第一年的居民）的活动，调查的学员（实习生和居民）和教师，实习生考试成绩。两组间实习生在直接护理和教育病人上所花费的时间百分比以及实习生对临床需求和教育之间适当平衡的看法均无显著差异（受训者对教育的满意度的主要结果;响应率，91%），或者在项目主管和教师评估学员的工作量是否超过他们的能力时，（教师对教育的满意度的主要结果;应答率，90%）。另一项对实习生的调查（回复率为49%）显示，灵活项目的实习生更有可能对培训的多个方面表示不满，包括教育质量（比值比，1.67; 95%置信区间[CI]，1.02至2.73）和整体幸福感（比值比，2.47; 95% CI，1.67至3.65）。相比之下，灵活项目的主任不太可能报告对多个教育过程的不满，包括床边教学的时间（应答率，98%;比值比，0.13; 95%CI，0.03至0.49）。培训考试的平均分数（正确答案百分比）在灵活项目中为68.9%，在标准项目中为69.4%;差异不符合2个百分点的非劣效性边界（差异，-0.43; 95%CI，-2.38至1.52;非劣效性P = 0.06）。有没有显着差异的比例，医学实习生花在直接的病人护理和教育方案之间的标准值班时间的政策和方案，更灵活的政策。灵活项目的实习生对他们的教育经历的满意度低于标准项目的同龄人，但项目主管更满意。（由国家心肺血液研究所和ACGME资助; iCOMPARE ClinicalTrials.gov编号，NCT 02274818。
Concern persists that inflexible duty-hour rules in medical residency programs may adversely affect the training of physicians. 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. 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). 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 Blood Institute and the ACGME; iCOMPARE ClinicalTrials.gov number, NCT02274818.)