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That's LIFE

By Kathleen Yount

To life | Hot topics | Paying attention

Medical students work hard for four years, making social, familial, and physical sacrifices not often called for in other professional training programs. They tax their intellects and emotions to their limits, doing whatever is necessary to master their coursework and retain the oceans of information flooding their minds.

And then comes residency.

Stress and fatigue cannot be avoided during the rigorous training of young doctors. “Physicians experience stressors that put them at risk for fatigue, impairment, and burnout in ways that other professionals are not,” says Kathryn Andolsek, MD, MPH, associate director of graduate medical education at Duke. “Evidence shows that serious problems with impairment start early in medical training.” Andolsek, an emphatic advocate of the relationship between patient outcomes and the well-being of health-care providers, says that residency directors must make sure these new generations of physicians are caring for themselves, so that they are in an appropriate condition to care for their patients.

To life
In 2002 the ACGME (Accreditation Council for Graduate Medical Education) mandated education for all interns, residents, fellows, and faculty about fatigue and impairment. So Andolsek and the UNC School of Medicine’s Robert Cefalo, MD, PhD, recruited a committee of other North Carolina residency program leaders to help design educational content specific to the stresses inherent in physician training. They amassed local and national expertise -- from senior professors and practitioners to medical students and residents themselves -- to create the LIFE Curriculum. The Josiah Macy Jr. Foundation has granted nearly $1 million over three years for the project.

The curriculum consists of workshops on 12 topics: fatigue, disruptive behavior, stress and depression, substance abuse, burnout, boundary violations, impairment, giving effective feedback, generational issues, recruiting the right applicants, maintaining the appropriate program director role, and legal challenges. Andolsek conducts workshops locally and at national and international conferences. There also is a comprehensive Web site and a free CD-ROM set that contains all the workshop material: trigger vignettes, in which an impairment scenario is enacted with two different courses of action; transcripts of these scenarios to allow role-playing; educational content on each topic; and a teaching guide to allow programs to create their own workshops close to home.

Hot topics
Of all the topics, Andolsek says fatigue and disruptive behavior are the issues that attract the most attention. She also says that she, too, learns a lot from conducting the workshops. “Once I showed the disruptive physician tape [in which a physician berates a nurse, in front of a patient’s open exam-room door] to a group of very young doctors in training. The conclusion of that group was that there was nothing wrong with the physician’s behavior. It ended up being a very different discussion than I expected.

“In another workshop we discussed the substance-abuse trigger tape, in which a physician asks his colleague for a narcotic prescription. The group couldn’t believe that would actually happen. So I asked what they would say if a colleague asked them for a pack of birth control pills or a Z-pack for her bronchitis. Everyone said those things would be fine -- but actually it’s a violation of North Carolina Medical Board rules for a physician to prescribe outside the formal doctor-patient relationship.”

Paying attention
The objective of the LIFE Curriculum is to help physicians and residency programs sort through potential issues proactively, so that they know what their policies are, what resources are available, and what problem areas are helpful to think through before problems arise.

“We can’t anticipate everything,” says Andolsek. “But in the case of Duke, we have about 900 residents -- that’s the size of a small town. One could anticipate that the same kinds of things that go on in any other group of 900 people will eventually happen among the residents. Not all on the same year or in the same program, but if you’re not finding any residents with these issues in a hospital of that size, then you’re probably not looking closely enough.”

Physicians can earn CME credit for participating in the LIFE Curriculum workshops or completing the CD-ROM set, which is free and can be ordered online. For more information, visit www.lifecurriculum.info.

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