Resident Fatigue

Gopi Desai, MD

Gopi Desai, MD

WORKLOAD, NOT HOURS, CONTRIBUTE TO RESIDENT FATIGUE
Generation R: The Rushed Resident

As a medical student, I recall senior physicians commenting how current residents have it easy because of strict, 80-hour workweek limitations. These senior doctors reminisced about their training and described stretches of 2-3 days when they did not leave the hospital. As I started residency, I thought to myself, “This can’t be so bad,” compared to working 72 hours consecutively.

In an attempt to ease my anxieties I convinced myself that while residency would be challenging, it would be manageable because we had laws to limit the amount we worked.

Then reality set in – residency was far from easy. At first, I figured there were growing pains and once I became more efficient and confident, this “paradise residency,” senior doctors described would magically appear.

Now as a 3rd year resident I have come to realize that this paradise does not exist.

My generation of trainees is challenged with cramming an increasing amount of work into a shorter amount of time. From 1990 to 2010, annual admissions to major teaching hospitals increased by almost 50%. In the same time period, residency positions grew by only 13%[1]. While physician extenders such as nurse practitioners and physician assistants have mitigated some of this increase – there is no doubt that overall workloads have increased.

As our nation collectively focuses on decreasing healthcare costs, length-of-stay is decreasing, leading to an increased turnover of patients in the hospital – many of whom have complex medical histories, complex co-morbid conditions and higher levels of acuity than even a decade ago.

Further, each of these admissions and discharges carries an exponential increase in the amount of resident-generated paperwork, much of which does not improve care but results from compliance with ever-changing insurance and medical-legal concerns.

This translates to increased volume of resident duties with less time to do it all. To cope with these realities, residents have evolved to become more efficient and to multitask. This inevitably sacrifices certain areas of medical care and training, by detracting from time that could be spent with patients or in didactics[2].

The issue of resident fatigue and burnout is not a simple one. Decreasing the amount of time spent in the hospital, with the aim to reduce medical error and resident fatigue, is a good start. However this is an insufficient intervention to tackle the complex problem at hand. Studies regarding the benefits of reduced resident work hours are inconclusive[3],[4]. On the other hand, studies that reduce resident workload have been associated with improved resident satisfaction, increased duty hour compliance and increased participation in educational activities[5],[6].

As the medical field begins to take more seriously the issues of resident burnout and fatigue, one thing is clear: it is the workload, not the work hours which needs to be addressed.

Dr. Gopi Desai, MD is a third-year pediatric resident at Weill-Cornell Medical Center and NY Presbyterian Queens and a member of the New York State (District II), Chapter 2 (Long Island) Resident Committee of the American Academy of Pediatrics.

 [1]Goitein LLudmerer KM. Resident workload-let’s treat the disease, not just the symptom. JAMA Intern Med. 2013 Apr 22;173(8):655-6.

[2] Block L1Habicht RWu AWDesai SVWang KSilva KNNiessen TOliver NFeldman L. In the wake of the 2003 and 2011 duty hours regulations, how do internal medicine interns spend their time? J Gen Intern Med. 2013 Aug;28(8):1042-7.

[3] Choma NNVasilevskis EESponsler KCHathaway JKripalani S. Effect of the ACGME 16-hour rule on efficiency and quality of care: duty hours 2.0. JAMA Intern Med. 2013 May 13;173(9):819-21

[4] Sen SKranzler HRDidwania AKSchwartz ACAmarnath SKolars JCDalack GWNichols BGuille C. Effects of the 2011 duty hour reforms on interns and their patients: a prospective longitudinal cohort study. JAMA Intern Med. 2013 Apr 22;173(8):657-62

[5] McMahon GT, Katz JT, Thorndike ME, Levy BD, Loscalzo J. Evaluation of a redesign initiative in an internal-medicine residency. N Engl J Med. 2010; 362(14):1304-1311.

[6] Thanarajasingam U, McDonald FS, Halvorsen AJ, et al. Service census caps and unit-based admissions: resident workload, conference attendance, duty hour compliance, and patient safety. Mayo Clin Proc. 2012;87(4):320-327.


 

Mental Health, September 2015

Quarterly Report September 2015

The CAPPC grant is being renewed for another 5 years.

The hotline hours will expand from the current 9 am to 5 pm, to 8 am to 7 pm in January 2016.

Other deliverables will continue such as webinars and evening teleconferences on subjects chosen by pediatricians.

A new ‘coordinating structure’ is currently in the midst of the RFP process and outcome will not be known until year’s end.

This entity will have responsibility for training, like the r.e.a.c.h. minifellowship.  Current uncertainties about how this entity will operate with CAPPC should get clarified once the grantee is announced.

In the past year, I have gone out to several practices for 2 to 4 hour time blocks to deliver training on topics such as ADHD depression, anxiety, and aggression.  I am happy to do more of this. Interested parties should feel free to call me at 718 470 3550.

With the expanded phone hours, there is an expectation of greatly increased use of the hotline.  This is where we need any and all help to get the word out and facilitate registration and engagement of many more pediatricians in using the hotline.  I am happy to hear any advice from you and the membership that can help make this happen!

Respectfully submitted,

Carmel Foley, MD
Mental Health Liaison

Youth and Adolescence, September 2015

Quarterly Report, September 2015

The Committee on Youth and Adolescents had its last meeting on 6/17/15 and a review of the responses to the Concussion Survey comprised the bulk of the meeting.

The outcome of the discussion was to:

  1. Prepare an Abstract for SAHM to be distributed and to serve as the beginning of a manuscript
  2. Develop a plan to create a Webinar by soliciting names of experts for the Webinar – perhaps reaching out to NYC and Cornell existing programs as well as University of Pittsburgh Concussion Center, Heads Up program at CDC
  3. Will review Canadian Neurology Guidelines and investigate curriculum for Webinar given the disparate modes of evaluation and care in practice

Some discussion was had regarding the Next Project – Educational Agenda was adopted with planned content to address:

  1. LGBTQ – working and reaching out to youth – standards of care; some work in place currently beginning with Pride for Youth; Pediatricians need support and education
  2. HIV & STI updates – implementation of early identification and treatment approaches; some practices STI test all teens regardless of history over age 15yo
  3. PrEP and PEP guidelines
  4. Vaccine acceptance/resistance

Respectively submitted,

Linda Carmine, MD, FAAP
Chair, Committee on Youth and Adolescence

International Child Health, September 2015

Quarterly Report September 2015

International Children’s Health continues to follow current issues that affect children throughout the world.

These issues are discussed with our committee and pertinent information is communicated to the Chapter or Societies.

Initiatives that are being supported by the AAP, such as Helping Babies Breathe are strongly promoted to interested parties.

Respectfully submitted,

Gonzalo Sabogal, MD, FAAP
Co-Chair, Committee on International Child Health

Bullying, September 2015

Quarterly Report, September 2015

  • Dr. Welles gave Grand Rounds at Cohen Children’s Medical Center on August 21, 2015.  The talk was titled: “Sticks and Stones May Break Your Bones but Words Can Really Hurt You”
  • Dr. Fagan submitted a blog to Dr. Shetal Shah for posting on the AAP Chp 2 website about Bullying Prevention and the role of the Pediatrician
    .
  • The Bullying Prevention Committee’s Third Annual Anti-Bullying Conference for middle school students will be held on October 23rd at Hofstra University.

Respectfully submitted,
Mark Welles, MD, FAAP

David Fagan, MD, FAAP
Co-Chairs, Committee on Bullying Prevention

 

Inpatient Pediatrics, September 2015

Quarterly Report, September 2015

The NYC Pediatric Hospital Medicine Forum which includes many members from Chapters 2 and 3 had their 4th annual conference on June 12 at Children’s Hospital at Montefiore.  The conference was entitled: Hot Topics in the Care of the Hospitalized Child: Optimizing Care, Safety, & Quality.  Chapter 2 members Laurie Gordon (NYHQ) and Helen Scott (CCMC) were on the planning committee.   The conference was well attended and a great opportunity to learn and network with fellow hospitalists in the New York Metropolitan area.  Dr. Gordon was a plenary speaker on “Hot Topics in Pediatric Hospital Medicine.”

The annual Pediatric Hospital Medicine conference was held in San Antonio, Texas on July 23-July 26.  This is the major annual meeting for Pediatric Hospitalists, jointly sponsored by the American Academy of Pediatrics, the Academic Pediatric Association and the Society for Hospital Medicine.  There were close to 1000 attendees.  Dr. Gordon did two presentations on Life Threatening Rashes.

ICD-10 will be will be implemented October 1.  The new coding will impact on inpatient documentation and coding.  The AAP has many resources to assist during the transition.  The weblink is:  https://www.aap.org/en-us/professional-resources/practice-support/Coding-at-the-AAP/Pages/default.aspx

Respectively submitted,

Laurie Gordon MD, MA, FAAP
Chapter Liaison, Inpatient Pediatrics

Resident, September 2015

Quarterly Report September 2015

The resident committee will focus on advocacy, social media and organizing a community fair in Brooklyn in Spring 2016.  We have begun to make a list of advocacy goals for the year and have helped to set up the chapter’s Twitter account. For the community fair, we are currently choosing a date and venue and have come up with a list of activities that we will host.  The goal is community outreach but also to involve residents from as many residency programs as possible.

Respectfully submitted,
Gopi Desai, MD
Chair, Resident Committee

Legislative, September 2015

The Committee has been active at the Federal, and State and County level advocating for pediatric healthcare issues.

At the federal level, district meetings were held on September 10, 2015 to follow-up on six major legislative issues/bills supported by the national American Academy of Pediatrics for which the chapter authored letters of support. House Resolution 1462, the “Protecting Our Infants Act,” aimed to increase funding and direct federal institutions to create a national standard for the treatment of neonatal abstinence syndrome. The bill passed the House of Representatives on September 9th and the chapter helped obtain co-sponsorship by Reps. Grace Meng and Steve Israel. A letter of support for the Child Liquid Nicotine Poisoning Act (HR 3342), which would mandate child-proof packaging on liquid nicotine products is now co-sponsored by Rep. Kathy Rice after her staff received our letter earlier this month. House Resolution 1552, the “Preserving Antibiotic Treatment in Medicine Act (PAMTA) would help reduce the emergence of antibiotic resistance partially by increasing funding for antibiotic stewardship programs. After receiving our letter this summer and speaking with Anthony Lemma, her district staff chair, Rep. Meng is a now a co-sponsor of this bill. A bill titled, “Bringing Post-Partum Depression Out of the Shadows,” (HR 3235), would nationally grant pediatricians the ability to expand the scope of practice to include screening for post-partum depression – thus allowing our colleagues across the country the same privileges we have in New York for combating this condition. To date, we have no local co-sponsors for this legislation. Finally, HR 1859, the “Ensuring Children’s Access to Subspecialty Care,” would allow pediatric subspecialists to enroll in the Federal National Health Service Corps debt-relief program and is co-sponsored by Rep. King. At all meetings we discussed the need for funding the Agency for Healthcare Research and Quality, whose budget is threatened this legislative season.

Washington D.C. based meetings at these offices are in the process of being scheduled for Tuesday, October 27th in conjunction with the National Conference and Exhibition, “White Coat Rally” for children on the steps of the Capitol. Any chapter members who are attending are encouraged to contact the office and we will facilitate a legislative meeting. I will also be meeting with Denzel Singletary of Sen. Gillibrand’s office to discuss support for the neonatal abstinence bill given House passage.  As the chapter re-designs and expands web content, copies of all letters to legislators are being readied for posting on the website so they can be easily accessed as templates by other chapter members.  Finally, Dr. Shah was awarded a Leonard Rome CATCH Visiting Professorship in Advocacy to the University of Arkansas to take place later this year.

At the state level, the committee’s resolution on mandating insurance coverage for donor breast milk in the NICU (endorsed by the District and the Section on Breastfeeding Medicine) passed the Annual Leadership Forum last March but did not advance in the state legislature. Meetings with local state legislators to outline the state AAP Agenda, including this bill will be scheduled for October/November after the agenda is outlined by the State Advocacy Committee on its conference call later this month.

At the county level, an Opinion-Editorial on the need to raise the age for tobacco sales to 21 years was published by CNN.COM in the late spring. In hopes of advancing the legislation in Nassau County (the only county which does not have it), we are hoping to arrange a ½ day of advocacy in Mineola. I attended the summer meeting of the Nassau Pediatric Society and they are in support. However, scheduling a date has been difficult. The initial date, October 7th was abandoned because the county calendar scheduled budget talks that day. We have requested other possible dates from Legislator Jacobs and have yet to hear. After consultation with the Nassau County counsel, it was determined that the county has no authority to limit the age of retail-based clinics in the county as this is a state issue.

The Committee is actively seeking new members interested in advocacy, child health policy or advancing child health. Please contact me if interested.

Respectfully submitted,

Shetal I. Shah, MD, FAAP
Chair, Legislative Committee

Pediatric Council, September 2015

Quarterly Report, September 2015
ICD-10 is just around the corner, and those of you requiring further guidance should check the Chapter and District’s previous emails about resources for understanding and making the transition. The CMS and AAP websites are another great source for guidance.

The mission of the Pediatric Council is to act as a liaison between the Chapter’s members and insurers to create a forum to resolve coverage issues, advocate for access to services and quality pediatric care, foster discussion when managed care decisions adversely affect the provision of care, and enhance communication between pediatricians and payers. The development of a network of contacts at the local, state and national levels with government and insurers helps speed the resolution of issues that arise.

Recently, Amerigroup, the Medicaid Managed Care Plan of Empire Blue Cross sent out recoupment notices for those physicians that received payment for immunization administration code 90461. 90461 is the add-on code for vaccine administration involving counseling and education by a qualified provider when a vaccine has more than one component. The VFC program does not recognize this as a required code for payment, and work at the national level is in progress to rectify this situation. Amerigroup paid many physicians for this code between 2013 and 2015, although it was not required to do so. Some practices with multiple practitioners received requests for a large recoupment. There is an ongoing dialogue with Dr. Sajidah Husain, the Medical Director of Amerigroup, to resolve this issue. Our last request was to postpone recoupment until the issue is resolved, and I am waiting for a response. Some of you may remember when Americhoice, the United HealthCare Managed Medicaid Care Plan asked for return of fees going back two years, and we were able to resolve that issue. I am optimistic that this issue can be resolved.

Amerigroup is changing its name as of October 1st, 2015 and will be known as Empire BlueCross BlueShield HealthPlus.

I believe that the Pediatric Council’s work creates value for our members by its actions and advocacy with insurers. Chapter AAP backing helps ensure that insurers consider the concerns of our members. Resolution of even a small matter by our intervention can pay for AAP membership many times over. Please continue to inform me of your concerns and payer issues—and let others know about our work on behalf of children and pediatricians.
Respectfully submitted,
Steven J. Goldstein, M.D., F.A.A.P.
Chair, Pediatric Council, Chapter 2, District II
SJG34@Cornell.edu

Fetus & Newborn, September 2015

Quarterly Report September 2015
The Committee so far has been successful in inspiring neonatologists from Brooklyn, Queens, Nassau & Suffolk counties in networking, discussing policies and other neonatal issues through our annual meetings.
Goals:

  • Keep enthusiasm and increase membership
  • Encourage networking
  • Discuss policies
  • Invite renowned speakers to discuss state-of-the-art topics
  • Bring new research ideas through meetings
  • Encourage pediatricians to attend meetings to better understand neonatal issues in providing follow-up care to infants

Last meeting date – November 6, 2014
Topic: “Preventing Blindness from Neonatal Retinal Disease: Digital Imaging, Treatment and Beyond”
Understand anatomy and physiology of premature eye development, its morbidities and possible complications beyond the neonatal period.
Respectfully submitted,
Renu Aggarwal, MD, FAAP
Chair, Fetus and Newborn Committee