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Lost in transition: The experience and impact of rapid changes in the inpatient learning environment.

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Bernabeo EC. — American Board of Internal Medicine

Holtman MH. — National Board of Medical Examiners

Ginsburg S. — University of Toronto

Rosenbaum JR. — Yale School of Medicine

Holmboe ES. — American Board of Internal Medicine

Presented: ACGME Annual Educational Conference, March 2010

Background: The traditional “rotating” model of inpatient training continues to be the gold standard of residency, requiring residents to move through different systems every two to four weeks. It is assumed that rapid transitioning is necessary to expose trainees to a diversity of experiences that lead to specialty choice and clinical expertise, yet little is known about whether or how this happens in practice. If redesigning residency in internal medicine is a national priority, then an effort to gain a greater understanding of the pedagogical impact of the experience of frequent transitions is warranted. In this paper, we examined the experience of the “rotating” model on which residency training is constructed.

Methods: Focused group interviews were conducted at three residency training programs selected to reflect broad geographic and structural diversity. At each site, we held four focus groups comprised of (1) residents only, (2) faculty only, (3) nurses, social workers and ancillary staff only, and (4) a mixed group. Focus groups were conducted at the individual sites over a period of eight weeks from February to March 2009, and lasted 60-90 minutes. Grounded theory analysis was used to develop themes through an iterative coding process. We examined the experience and impact of frequent transitions from the resident perspective and explored differences in perspectives among residents, faculty, nurses and additional non-clinical staff.

Results: Residents described several strategies used to prepare for a transition to a new clinical rotation, including establishing relationships (particularly other residents and nurses), and preparing patients for transitions. Very few mentioned studying content areas of medicine as important preparation subject matter, stating that the expectation is to learn as you go, conveying a strong message of self-directed learning and autonomy. The majority of residents further reported a strong reliance on each other, highlighting peer to peer learning as a critical strategy to prepare for transitions.

Perceived benefits of frequent transitions included the ability to adapt to new environments and clinical challenges, improved organization and triage skills, increased comfort with stressful situations, teamwork and flexibility. Additional workarounds were described, including writing fewer progress notes, deliberately not answering telephones or pages, lying about the status of a test or lab, hiding information and walking away from situations in which they were needed. Nearly all residents acknowledged that frequent transitions contributed to a lack of ownership in patient care.

Conclusion: Our findings challenge the value of the traditional “rotating” model in graduate medical education. Transitions are perceived by residents to be chaotic and stressful. Faculty, nurses and residents agreed that little effective support or supervision is provided to help residents prepare for or cope with transitions. As residents learn to adapt to frequent transitioning, they implicitly learn to value flexibility and efficiency over relationship-building and deep system knowledge. This highlights an important element of the hidden curriculum that seems to be embedded within the current training model.

For more information about this presentation, please contact Research@abim.org.