2008 Chief Resident Development Conference: Caring for Your Residents Roseanne C. Berger, MD Senior Associate Dean for Graduate Medical Education & ACGME Designated Institutional Official (DIO) for UB

Goal: Effectively assist residents experiencing problems that impair learning such as ….  Fatigue  Academic Difficulty  Harassment  Impairment

Useful Background for Specific Issues

Sign and Symptom Patterns  Change in baseline behavior  Deteriorating personal hygiene  Change in speech pattern  Multiple physical complaints  Unfocused, confused, distracted  Mood swings  Unprofessional demeanor or conduct  Anger/Abusive Language  Frequent lateness, absence or illness  Isolation: avoidance of associates  Inappropriate response to patient needs or staff requests  Ignoring requests to catch up on paperwork  Questionable orders  Uncooperative and defiant approach to problems and/or performance feedback

Impairment/Substance Abuse  Signs & symptoms of impairment  Report to PD or GME – do not handle yourself  Encourage individual to self-report to GME or CPH  Individuals can return to residency programs and have done this quite successfully

Harrassment/Discrimination  Sexual or other forms  Sexual or other forms  If possible, tell harasser to stop  Discuss with PD, Chair, DIO, Office of Equity, Diversity, and Affirmative Action  ubuffalo/ ubuffalo/ ubuffalo/

UB/GME Resources  Susan Orrange, M.Ed.  Roseanne Berger, M.D.  Chief Resident Listserv  Policies on Impairment, Harassment, and Academic Status  Common Program Requirements Common Program Requirements RRC Requirements for your program RRC Requirements for your program  The Joint Commission

LIFE Curriculum (Learning to Address Impairment and Fatigue to Enhance Patient Safety)  Self-directed learning modules in the areas of: Fatigue Fatigue Disruptive Physicians Disruptive Physicians Stress & Depression Stress & Depression Substance Abuse Substance Abuse Burnout Burnout Impairment Impairment Negative Feedback Negative Feedback

UB Human Resources  Work/life balance UB Employee discounts UB Employee discounts Fitness centers, theme parks & attractions, software, wireless phones, moving services, and moreFitness centers, theme parks & attractions, software, wireless phones, moving services, and more  Learning & Development Registration & Course Catalog Registration & Course Catalog Short courses in Career and Personal Development, Software and Computer Productivity, Wellness & Worklife BalanceShort courses in Career and Personal Development, Software and Computer Productivity, Wellness & Worklife Balance Over 1,000 online, self-directed learning modules (Skillsoft)Over 1,000 online, self-directed learning modules (Skillsoft)

Assignment Read and Discuss the case scenarios and answer the following 4 questions. 1. What is your differential diagnosis? 2. How would you confirm or reject your hypothesis? Give specific examples of questions you would pose to the resident. 3. How could you assist this resident? 4. How would you address the situation with the residency program director?

Assignment 1. What is the differential diagnosis for this struggling resident? 2. What is your treatment plan? 3. How will you determine if it is effective? 4. What areas of competence need improvement?

Case 1: Dr. X recently transferred into your program from a different specialty. You learn that the resident was treated for substance abuse during a stressful divorce. She is soft spoken, hard working, and well liked but appears anxious when presenting cases and is not organized or focused. The faculty have openly shared their concerns about her ability to “cut it” with other residents and critique her judgment in front of others.

Case 1 continued Evaluations do not include comments. Most raters circled “3” on a 5-point scale under medical knowledge and patient care and 4 or 5 on professionalism and communication skills. The resident told you the faculty have not directly spoken to her about her performance.

Case 2:  Dr. Y is never able to finish their work. You know they’ve been coming in early and staying late to keep up. BFH (Buffalo’s Finest Hospital) is cracking down on this behavior and even asked the residents to sign an attestation saying they would be subject to dismissal if they violated work hours.

Case 2 cont.  The resident has been nodding off during morning report. You’re concerned because the resident is about to start ‘night float’ and it will be important to finish work in time for the day shift.

Case 3: Dr. Z is performing well clinically but his inservice exam scores are very low. The faculty have warned that he will not be promoted to the next level of training if he does not achieve a minimum standard on a repeat exam. He did particularly poorly in the sections on GI and Renal disease, two areas that you have noticed are not well covered by the faculty.

Case 3 continued  Dr. Z had nearly perfect SAT’s and scored 33 on the MCAT. His USMLE part I score was strong but USMLE II scores were marginal.  Formerly a slave to fashion, he is no longer attentive to his appearance. He often wears scrubs at work and has taken to wearing a ‘play-off’ beard when its still early in the season.

Sleep Deprivation/Fatigue  ACGME requirement for residents AND faculty to receive training in this area

© American Academy of Sleep Medicine American Academy of Sleep Medicine Epworth Sleepiness Scale Sleepiness in residents is equivalent to that found in patients with serious sleep disorders. Mustafa and Strohl, unpublished data. Papp, 2002

© American Academy of Sleep Medicine American Academy of Sleep Medicine Across Tasks Emergency Medicine: significant reductions in comprehensiveness of history & physical exam documentation in second-year residents Bertram 1988 Family Medicine: scores achieved on the ABFM practice in-training exam negatively correlated with pre-test sleep amounts Jacques et al 1990

© American Academy of Sleep Medicine American Academy of Sleep Medicine Surgery: 20% more errors and 14% more time required to perform simulated laparoscopy post-call (two studies) Taffinder et al, 1998; Grantcharov et al, 2001 Internal Medicine: efficiency and accuracy of ECG interpretation impaired in sleep-deprived interns Lingenfelser et al, 1994 Pediatrics: time required to place an intra-arterial line increased significantly in sleep-deprived Storer et al, 1989

© American Academy of Sleep Medicine American Academy of Sleep Medicine *Baldwin and Daugherty, Survey of 3604 PGY1,2 Residents Work Hours, Medical Errors, and Workplace Conflicts by Average Daily Hours of Sleep*

© American Academy of Sleep Medicine American Academy of Sleep Medicine Sleep Loss and Fatigue: Safety Issues 50% greater risk of blood-borne pathogen exposure incidents (needlestick, laceration, etc) in residents between 10pm and 6am. Parks % of emergency medicine residents reported near- crashes driving % post night-shift -- Increased with number of night shifts/month Steele et al 1999

© American Academy of Sleep Medicine American Academy of Sleep Medicine Recognize The Warning Signs of Sleepiness Falling asleep in conferences or on rounds Feeling restless and irritable with staff, colleagues, family, and friends Having to check your work repeatedly Having difficulty focusing on the care of your patients Feeling like you really just don’t care

© American Academy of Sleep Medicine American Academy of Sleep Medicine Napping Pros: Naps temporarily improve alertness. Types: preventative (pre-call) operational (on the job) Length: short naps: no longer than 30 minutes to avoid the grogginess (“sleep inertia”) that occurs when you’re awakened from deep sleep long naps: 2 hours (range 30 to 180 minutes)

© American Academy of Sleep Medicine American Academy of Sleep Medicine Healthy Sleep Habits Go to bed and get up at about the same time every day. Develop a pre-sleep routine. Use relaxation to help you fall asleep. Protect your sleep time; enlist your family and friends! Use time off to sleep! Get adequate (7 to 9 hours) sleep before anticipated sleep loss. Avoid starting out with a sleep deficit!

© American Academy of Sleep Medicine American Academy of Sleep Medicine Healthy Sleep Habits Sleeping environment: –Cooler temperature –Dark (eye shades, room darkening shades) –Quiet (unplug phone, turn off pager, use ear plugs, white noise machine) Avoid going to bed hungry, but no heavy meals within 3 hours of sleep. Get regular exercise but avoid heavy exercise within 3 hours of sleep.

© American Academy of Sleep Medicine American Academy of Sleep Medicine How To Survive Night Float Protect your sleep. Nap before work. Consider “splitting” sleep into two 4 hour periods. Have as much exposure to bright light as possible when you need to be alert. Avoid light exposure in the morning after night shift (be cool and wear dark glasses driving home from work).

© American Academy of Sleep Medicine American Academy of Sleep Medicine Drugs Melatonin: little data in residents Hypnotics: may be helpful in specific situations (eg, persistent insomnia) AVOID: using stimulants (methylphenidate, dextroamphetamine, modafinil) to stay awake AVOID: using alcohol to help you fall asleep; it induces sleep onset but disrupts sleep later on

© American Academy of Sleep Medicine American Academy of Sleep Medicine Caffeine Strategic consumption is key Effects within 15 – 30 minutes; half-life 3 to 7 hours Use for temporary relief of sleepiness Cons: –disrupts subsequent sleep (more arousals) –tolerance may develop –diuretic effects

SUPERCHIEF!