The 80-hour workweek: How to orient residents to their rotations and increase efficiency and effectiveness

Debra A. DaRosa, PhD, and Kevin Bethke, MD
Northwestern University
Feinberg School of Medicine

The 80-hour workweek requires us as faculty to be more efficient and effective in how we orchestrate our residents' educational activities. There is no time for residents to flounder.

A formal rotation orientation held on the first day of the rotation can save time later, and enable residents to hit the floor running rather than wasting time figuring out for themselves how to glean the most from the experience.

An orientation is important for a number of other reasons as well. First, it can clarify expectations and avoid misunderstandings. The messages given during an orientation can set the performance bar high at the start and set the resident up to succeed. It can have a motivational impact as the learning needs associated with each resident level and type (designated preliminary, categorical, preliminary) involved in the rotation can be emphasized. Second, it is a sound educational practice. Faculty members on any given rotation see multiple residents over the years and they know all too well what behaviors correspond to an outstanding, average, and marginal resident. They can forget that the resident starting the rotation is a newcomer to the service and, unless learned through word of mouth, unacquainted with the specific learning objectives and expectations. Some residents are assertive enough to ask, but others wait to figure these out as they progress through the rotation. This can prevent a resident from gaining all they can from the rotation experience and results in lost or delayed teachable moments.

What needs to be included in a rotation orientation will vary by resident level and experience. Below is a list of topics for consideration that will need to be personalized to the individual rotation.

Learning Needs and Rotation Learning Objectives/Curriculum

The orientation should include a discussion on the resident's learning needs relevant to the rotation's learning objectives. A discussion of his or her prior clinical experiences, perceptions of strengths and weaknesses, and learning activities considered useful will help tailor the learning opportunities of the rotation to the resident. Several rotations here at Northwestern University have created rotation pretests, based on the rotation learning objectives, to further identify knowledge and knowledge gaps for residents' and faculty members' information. The test can be re-administered as a post-test to determine knowledge gains and gaps.

A thorough review of what faculty members expect the resident to know and be able to do by the end of the rotation should occur. (Example: See Appendix A) It is helpful to also communicate to the residents the number and type of operative procedures he or she should strive to accomplish, as well as other clinical learning experiences associated with the objectives.

Formats and times for Journal Club and/or the conduct of other rotation specific conferences should be clarified. Recommended readings, computer-based materials, logbook requirements, skills lab practice model availability, any "homework" assignments, and other learning activities should be explained.

Timelines for Formative Feedback and Performance Evaluation

It is helpful to discuss with the resident when formal feedback sessions will be held (preferably at the mid and end of the rotation). It is helpful to review the criteria to be used for making performance judgments and the performance indicators associated with outstanding versus average performance. This is critical to setting the performance bar high, making the parameters trans-parent, and giving a judicious final performance evaluation for the rotation.

Introduction to the Practice

This segment of the orientation includes information such as operating room and outpatient office schedules and hours, locations, and assignments. Names of staff and their roles and responsibilities are very important given the growing number of physician assistants, nurse practitioners, and other health care professionals who residents might be working alongside. Practice policies and preferences could be discussed, along with the unique learning opportunities associated with clinical activities, the service's patient population, as well as faculty clinical and research interests. The level of specificity will depend on the rotation, but some faculty members have specific preferences for what to do when paged in the operating room, what types of patient issues they want to be contacted about in the evenings, formats for dictating operative notes, or other types of practice related preferences. Residents will more likely fit into the practice setting if clear about these details at the start.

Should the Orientation Information be Communicated Electronically, Written Documents, or Face-to-Face?

Having expectations documented and discussing them is important. It is recommended that the above information be summarized in a document that can be posted on your program's Web site or on paper for distribution. This should be supplemented with a one-on-one discussion to emphasize key points and more thoroughly assess residents' learning needs. This will go a long way to making residents' learning on the rotation more efficient and effective from day one.

With the reduced number of hours residents are allowed in the hospital, this is one simple step to making the most of the hours they do have on service.

Appendix A

NORTHWESTERN UNIVERSITY FEINBERG SCHOOL OF MEDICINE
DEPARTMENT OF SURGERY
CLINICAL ROTATION SUMMARY

ROTATION TITLE:	NMH Breast Apprenticeship
LEVEL OF RESIDENTS:	PGY2
LENGTH OF ROTATION:	61 days
TEAM EDUCATION COORDINATOR:	Kevin P. Bethke, MD (office phone: 312-943-2746)
TEAM FACULTY:	Kevin P. Bethke, MD
ROTATION LOCATION:	Breast Center, Galter 13th floor NMH Operating Rooms, Feinberg 7th floor

Unit #1 Breast Anatomy, Clinical Breast Evaluation

A. Patient Care

1. Demonstrate the components of a complete breast history.
2. Demonstrate the components of a complete breast exam.
3. Be able to differentiate between benign background nodular texture and worrisome breast exam changes.

B. Medical Knowledge

1. Describe breast development and its hormonal influences.
2. Describe breast anatomy and be able to diagram simple procedures and physical findings for patient education and documentation.
3. Describe the most common breast development aberrations.

C. Interpersonal and Communication Skills

Be able to utilize effective listening skills and elicit an accurate patient breast history using verbal and nonverbal skills.

D. Professionalism

1. Develop a greater comfort level with the breast exam.
2. Be able to put the patient at ease during the breast exam.

Unit #2 Breast Diagnostics: Imaging, Biopsy Techniques

A. Patient Care

1. Orient a set of mammograms for viewing.
2. Identify mammographic abnormalities such as calcifications, masses, spiculations, etc.
3. Direct the evaluation of a worrisome palpable breast abnormality.
4. Direct the evaluation of a worrisome nonpalpable mammographic abnormality.
5. Perform a fine-needle aspiration biopsy.
6. Perform a palpation-guided core biopsy.
7. Describe the indications for the following surgical breast biopsies:
   a.  Open incisional biopsy
   b.  Open excisional biopsy
   c.  Needle-localization breast biopsy

B. Medical Knowledge

1. Describe the limitations of mammography.
2. Describe the American Cancer Society recommendations for breast screening.
3. List the indications for and difference between screening and diagnostic breast imaging.
4. Describe the indications for breast ultrasound.
5. Develop algorithms for evaluation of palpable and nonpalpable breast abnormalities.
6. Explain the indications for stereotactic and ultrasound-guided breast biopsies.

C. Interpersonal and Communication Skills

Work effectively with the Lynn Sage Breast Center staff.

D. Systems-Based Practice

1. Be cognizant of the costs associated with breast imaging and strive for the most cost-effective breast evaluation possible.
2. Spend two half-days with the Lynn Sage Breast Center mammographers gaining experience in reading diagnostic mammograms and ultrasounds.

Unit #3 Benign Breast Disorders

A. Patient Care

1. Identify a classic probable fibroadenoma on physical exam.
2. Describe the diagnostic evaluation of a fibroadenoma.
3. Describe the special qualities of a phyllodes tumor and their management (benign and malignant).
4. Describe a cost-effective evaluation for breast pain.
5. Describe treatment options for breast pain.
6. Describe the diagnostic evaluation of breast cysts and their management.
7. Describe worrisome nipple changes/discharge, and the evaluation for and management of these findings.
8. Describe duct ectasia and the management of chronic subareolar abscess.
9. Describe the treatment for lactational and non-lactational breast abscesses.
10. Describe the physical signs of gynecomastia, its etiology, and management.

B. Practice-Based Learning and Improvement

Keep a log (provided) of all procedures performed during the Breast Apprenticeship.
Document diagnosis, procedure, histology, etc.

C. Systems-Based Practice

1. Estimate costs associated with the treatment of benign breast disorders.
2. Identify which benign breast problems can be effectively followed by a gynecologist or other primary care physician rather than a breast specialist.

Unit #4 Risk Factors for Breast Cancer, Prevention Strategies

A. Patient Care

1. Describe the American Cancer Society screening guidelines for breast cancer.
2. Determine a patient's estimated risk for breast cancer using the Gail model and know the limitations of this model.
3. Discuss the guidelines for a patient referral to genetic counseling.
4. Discuss the various risk-reducing interventions for high-risk patients.

B. Medical Knowledge

1. Describe the familial, hormonal, and environmental risk factors for breast cancer.
2. Describe the role of BRCA 1 and 2 genes, the risks associated with their mutations, and strategies to treat patients who test positive for the mutation.

C. Professionalism

Be able to reassure patients that their risk of developing breast cancer is not as great as they believe (in most cases).

Unit #5 In-Situ Breast Cancer

A. Patient Care

1. Describe the diagnosis and management of Lobular-Carcinoma-In-Situ (LCIS).
2. Describe the preoperative evaluation of patients diagnosed with Ductal Carcinoma- In-Situ (DCIS).
3. Describe the surgical treatment options for DCIS.
4. Describe the role of radiation therapy for DCIS
5. Describe the management of recurrent DCIS.
6. Describe the role of Tamoxifen as treatment for DCIS.
7. Describe the indications for SLN biopsy in patients with DCIS.

B. Medical Knowledge

1. Describe the histology of LCIS and the associated risks.
2. Describe the histology of DCIS.

C. Practice-Based Learning and Improvement

Keep a log of all procedures performed during the Breast Apprenticeship.
Document diagnosis, procedure, histology, etc.

D. Interpersonal and Communication Skills

Work effectively with the multidisciplinary team of surgical, medical, and radiation oncology.

E. Professionalism

Be able to reassure patients that they are stage 0 (if diagnosed with DCIS) and have an excellent prognosis.

F. Systems-Based Practice

1. Be cognizant of the costs associated with the treatment of in-situ cancer (surgery, radiation, hormonal therapy).
2. Be aware of the medical-legal risks of the delay in diagnosis and missed diagnosis of breast cancer.

Unit #6 Invasive Breast Cancer

A. Patient Care

1. Describe the preoperative evaluation of patients with invasive breast cancer (imaging, labs, other).
2. Describe the surgical treatment options for breast cancer patients:
   a.  Breast conservation
   b.  Mastectomy
   c.  The indications for and limitations of SLN biopsy, dye techniques,
        and   surgical pathology evaluation.
3. Describe the indications for preoperative versus postoperative chemotherapy