Nighthawk: Making Night Float Education and Patient Safety Soar

Nighthawk Making Night Float Education and Patient Safety Soar.

Brett W. Sadowski, Hector A. Medina, Joshua D. Hartzell, and William T. Shimeall

Journal of Graduate Medical Education: December 2017, Vol. 9, No. 6, pp. 755-758.

Journal Club Entry by Kimberly Dao, TUSM-Maine Track Program, M18

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) adopted an 80-hour-workweek restriction for residents. In response, many residency programs have implemented night float rotations for patient coverage despite the numerous reports of its negative impacts on patient care and safety, education, and resident satisfaction. To address the educational void created by overnight training, the authors explored a pilot supervision program that sought to optimize patient safety and improve education.The authors found that establishing enhanced supervision, increased teaching, a must-call list, and reduced conflicting resident roles improved education and increased resident satisfaction.


Discussion questions:

  1. What is the night float culture like at Maine Medical Center (MMC)?
  2. What are the measures implemented by the MMC residency programs, if any, addressing patient safety and resident education? Which ones work and which ones don’t?
  3. Where is there an opportunity for improvement? Can MMC benefit from piloting a nighthawk system?
  4. What is the value in night float rotations? Does it still have a place in residency training?

Preparing Fourth-Year Medical Students to Teach During Internship by Haber, Bardach, Vedanthan, et al.

Preparing Fourth-Year Medical Students to Teach During Internship by Haber, Bardach, Vedanthan, et al.

Andy Biedlingmaier, Tufts M18 Student on Medical Education Elective

An important responsibility of the medical intern is to teach medical students, however new interns are not always prepared to assume the role of teacher.  There is a lack of training in teaching techniques at the medical school level, and courses in education are usually elective (i.e., not mandatory) for students. 

The medical school in this article sought to fill this knowledge gap by creating a mandatory course at the end of fourth year composed of four, one-hour classroom sessions over two separate afternoons.  The sessions were as follows:

Session 1:  Promoting understanding and retention in the clinical setting

Format:  Lecture with modeled behavior by speaker

Content: Understand that clinical teaching occurs through small, incremental   transfer of knowledge over many “teachable moments” throughout the day

Session 2:  Evaluating students fairly and giving feedback

Format:  Lecture with modeled behavior by speaker and role-play in pairs

Content:  Identifying educational goals, methods of evaluation, and criteria for effective formative and summative feedback

Session 3:  Q&A panel with residents identified as excellent teachers

Format:  Resident panel answers anonymous questions raised by students

Content:  Specific to the students’ questions

Session 4:  Small group discussions and role-playing

Format:  Discussion and role-play in groups of 6-8 students with 1-2 resident leaders per group

Content:  Clinical scenarios provide opportunity to practice teaching skills

The course was elective from 2000-2002 and mandatory from 2003-2005.  Overall course ratings from 2000-2005 had a mean of 4.4 out of 5 (5= excellent, 1=poor) from 224 completed student questionnaires (62% response rate).  The 2004 class was surveyed at the end of their intern year, and 84% of students agreed that the course helped them prepare for their role as teacher (n=45, response rate 60%). 

Questions for discussion:

1) Should a “teaching to teach” course be mandatory in undergraduate medical education? If so, when should the course occur and for how many classroom hours?

2) Do you agree with the overall content of the sessions? Are there any topics that should be omitted, added, or modified?

3) Other than as mentioned in the discussion, how could future research seek to objectively measure whether or not the course produces improved teaching in medical interns?


Haber, RJ, Bardach, NS, Vedantha, R, et al. Preparing fourth-year medical students to teach during internship.  J Gen Intern Med.  2006; 21: 518-520.

Damned If You Do, Damned If You Don’t: Bias in Evaluations of Female Resident Physicians

“Damned If You Do, Damned If You Don’t: Bias in Evaluations of Female Resident Physicians”-Esther K. Choo, MD, MPH

Journal Club Entry by Sarah Couser, TUSM-Maine Track Program, M18

For 20 years, medical schools have been accepting almost the same number of male and female students. Despite this important achievement, there remains significant gender bias when it comes to training female students and future physicians. The author of this paper discusses a recent study that identified gender bias in the evaluation of male and female third-year emergency residents. The study concludes that female residents receive “discordant feedback” regarding issues of autonomy and assertiveness, characteristically male traits. Esther Choo reflects on how this conflicting information may prevent female residents them from improving clinically.

To reference the study, please refer to this link:

“Gender Differences in Attending Physicians’ Feedback to Residents: A Qualitative Analysis”

Anna S. Mueller, Tania M. Jenkins, Melissa Osborne, Arjun Dayal, Daniel M. O’Connor, and Vineet M. Arora

Discussion questions:

1. Mueller et al. note that women only represent 38% of EM residents across the country. At Maine

Medical Center, women represent approximately ~36% of EM residents (10/28). Do you notice any

distinct differences regarding gender in your own department?

2. Can you think of any instances of gender bias in your workplace? Can you think of a situation in which

you might have been susceptible to bias?

3. What can you do to try and counteract implicit gender bias in the workplace? What can we be more

mindful of?

Are you interesting in learning if you have any implicit biases?

Take the quiz here:


Making the Case for History of Medical Education

Making the Case for History of Medical Education David Jones, Jeremy Greene, Jacalyn, Duffin, John Harley Warnert Journal of the History of Medicine and Allied Sciences. Vol 70, No.4 (2014).

Journal Club Entry by Michael P.H. Stanley, TUSM-Maine Track Program, M18

The history of history in medical education has waxed and waned since as far back as the 18th century. At its zenith in the 1950s and 1960s nearly half of all medical schools had some formal historical teaching, if not full-professorships and sometimes entire history of medicine departments.  In 2001, over 100 of 174 medical schools surveyed had no history offerings or were unsure if they did.  The authors of this paper diverge from more traditional arguments that history of medicine should be considered as one of a number of medical humanities offerings primarily in service of the core domain of Professionalism. Instead they propound that history of medicine is “an essential component of medical knowledge, reasoning, and practice.” The authors assert that by demonstrating how the history of medicine readily engages our competency-based educational objectives, the field can gain acceptance as a regular feature in medical educational curricula.

Discussion questions:

  1. If history of medicine has continued to thrive, why has its introduction and maintenance in medical school curricula waxed and waned so considerably over time?
  2. How is history of medicine different from and similar to other medical humanities (such as narrative medicine, medical ethics, medical aesthetics, etc?). How is it different from and similar to reductionist or natural science medical subjects (such as pathophysiology, biochemistry, etc?).
  3. Is trying to justify history of medicine’s inclusion in medical school curricula through competency-based education inappropriately ascribing reductive measurements to an unmeasurable field? How might programs measure competency or otherwise assess medical students in history of medicine?
  4. Where do you find opportunities for inclusion of history of medicine in your own experience of medical education?

Just Fun or a Predjudice? Physician Stereotypes in Common Jokes and their Attribution to Medical Specialties by Undergraduate Medical Students

This month’s Journal Club post was written by Emily Zarookian, MD based on the article: Just fun or a prejudice? – physician stereotypes in common jokes and their attribution to medical specialties by undergraduate medical students by Sigrid Harendza and Martin Pyra.  

“Have you heard this one?”, the surgical resident asks myself and fellow medical students during our third year general surgery rotation. “How do you hide a $100 dollar bill from an orthopedic surgeon? Put it in a textbook! How do you hide a $100 dollar bill from an internist? Put it under a dressing! How do you hide a $100 dollar bill from a general surgeon? Tape it to his wife’s forehead!”

Most medical students are exposed to jokes regarding stereotypical attributes of various specialties during medical school. In this paper, Harendza and Pyra, attempt to analyze what degree of stereotypes exists among medical students at various stages of training by extracting characteristics from common “doctor jokes” and analyzing how medical students assign these to various specialties over time.

Discussion Questions

  1. Reflecting back on your medical school experience, do you think it is possible your specialty selection was influenced by exposure to commonly held stereotypes regarding what type of personality belongs in which specialty?
  2. Do you think the demonstrated increase in congruent assignments of stereotypical characteristics to specialties over the course of medical school is actually due to stereotypical doctor jokes? Or is there any underlying truth within these jokes which medical students discover with exposure to various specialties?
  3. Is it surprising that the most stereotypes seemed to exist regarding general surgeons and psychiatrists? Why would this be?


Seeking Consistency and Fairness in the Assessment of Professionalism

This month’s Journal Club post was written by Alex Fiorentino, MD, Maine Track ’17, based on the following article:  Basing the Evaluation of Professionalism on Observable Behavior: A Cautionary Tale by Ginsburg, Regehr, and Lingard1.

Though an estimated 90% of U.S. medical schools offer some type of formal instruction in professionalism2, it is difficult for medical educators to agree upon what constitutes professionalism, much less apply a consistent standard of professionalism to trainees3.  In the setting of increasing efforts to evaluate trainees via direct observation of competencies, the authors of the above study set out to assess whether observation of student behaviors can serve as the basis for consistent and legitimate evaluation of professionalism.

Discussion Questions:

  1. How would you define professional behavior – and unprofessional behavior – among medical trainees?
  2. Which is more useful for determining whether a lapse in professionalism has occurred: an account of exactly what a trainee did, or an explanation of why they did it?
  3. Are there situations in medicine in which truthfulness represents an unprofessional course of action, or is lying always unprofessional?
  4. Can professionalism be taught? If so, what would be your ideal method for teaching it?



  1. Ginsburg S, Regehr G, Lingard L. Basing the evaluation of professionalism on observable behaviors: a cautionary tale. Academic Medicine, 2004 Oct;79(10 Suppl):S1-4.
  1. Swick HM, Szenas P, Danoff D, Whitcomb ME. Teaching professionalism in undergraduate medical education. JAMA, 1999 Sep 1;282(9):830-2.
  1. DeAngelis CD. Medical professionalism. JAMA, 2015 May 12;313(18):1837-8. doi: 10.1001/jama.2015.3597.


How Do Residents Spend Their Shift Time? A Time and Motion Study with a Particular Focus on the Use of Computers

How Do Residents Spend Their Shift Time? A Time and Motion Study with a Particular Focus on the Use of Computers

This month’s journal club was written by Benjamin Levin, MD, Maine Track ’16, with reference to the following article: How do residents spend their shift time? A time and motion study with a particular focus on the use of computers, Lena Mamykina, PhD, David Vawdrey, PhD, George Hripcsak, MD, MS, Academic Medicine, Published online March 29, 2016. 

Medicine is constantly evolving; we live in an era where copious amounts of medical information are at our fingertips. With a mandate on EHR usage, residents are spending more time on the computer documenting and looking up patient information.   This access to information and creation of information has altered the practice of medicine and changed resident education.

A recent study published in Academic Medicine recorded and analyzed how residents on a general medicine service used their time with a focus on how they utilize computers. I’ll leave it up to the reader to decide if the results are surprising or not and to think about the following questions.

-Does the distribution of documentation and clinical activity correspond with your own experience?

-Are we experiencing documentation and information overload?

-Is resident education suffering due to the burden of documentation?

-Should there be concerns about quality after examining the results of this study?


Mens sana in corpore sana: Student Well-Being and the Development of Resilience

Mens sana in corpore sano: Student Well-being and the Development of Resilience 

This month’s journal club post references a Medical Education article:  Mens sana in corpore sana: Student Well-Being and the Development of Resilience by Diana F. Wood

We’ve all heard the seasoned attending lamenting the modern era of work-hour restrictions and 24 hour attending support in comparison to their training wild wild west. For decades, residents learned medicine through a baptism by fire, with those trained in the era recounting 100+ hour work weeks, unsupervised paracenteses in the ED with nothing more than an EKG probe and an LP needle, and shifts long enough to make a stretcher in the corner look more comfortable than the penthouse suite of a Hilton. Much like military boot-camp, many survivors of this antiquated training herald it as the only way to develop the resiliency needed to become an exceptional physician. However, as study after study has shown, this resilience (if truly gained) comes at a high price to patients and trainees alike.

Yet in the modern world of elongated terms of parental support and petting zoos to alleviate student’s stress, is it possible that well-intended institutional support has crippled the development of resilience and may even counterintuitively be contributing to physician burn-out? Studies show that medical students, particularly males, continue to show signs of burnout manifested in depression, reduced empathy, and changed attitudes toward palliative care and cadaveric dissection.

  1. How can students be taught resilience without compromising patient safety or contributing to burnout?
  2. What, if any, unique attributes did physicians learn prior to work-hour restrictions?
  3. What, if any, unique attributes do physicians learn now after emplacement of work-hour restrictions
  4. Are there any forms of resident/medical student support which may be deleterious to the development of resilience?


1. Farnan JM, Petty LA, Georgitis E, Martin S, Chiu E, Prochaska M, Arora VM. A systematic review: the effect of clinical supervision on patient and residency education outcomes. Acad Med 2012;87:428–42.
2. Quince T, Abbas M, Murugesu S, Crawley F, Hyde S, Wood D, Benson J. Leadership and management in the undergraduate medical curriculum: a qualitative study of students’ attitudes and opinions at one UK medical school. BMJ Open 2014;4:e005353.
3. Goldie J, Dowie A, Cotton P, Morrison J. Professionalism. In: Walsh K ed. Oxford Textbook of Medical Education. Oxford university press; 2013. p. 274–6.
4. Papdakis MA, Hodgson CS, Teherani A, Kohatsu ND. Unprofessional behavior in medical school is associated with subsequent disciplinary action by a state medical board. Acad Med 2004;79:244–9.
5. Dyrbye L, Shanafelt T. A narrative review on burnout experienced by medical students and residents. Med Educ2016;50(1):132–149.
6. Dyrbye LN, West CP, Satele D, Boone S, Tan L, Sloan J, Shanafelt TD. Burnout among US medical students, residents and early career physicians relative to the general US population. Acad Med 2014;89:443–51.
7. Briggs ARJ, Clark J, Hall I. Building bridges: understanding student transition to university. Quality in Higher Education 2012;18:3–21.
8. Adams R. Surge in young people seeking help for exam stress. [Accessed 11 August 2015].
9. Cohen D, Winstanley S, Palmer P. Allen J, Howells S, Greene G, Rhydderch M. Factors that impact on medical student wellbeing – perspectives of risks. 2013. Accessed [26 August 2015].
10. Shapiro J. From strength to strength. Accessed [11 August 2015].
11. Havergal C. Partnership agreements ‘infantilise’ students. Accessed [11 August 2015].
12. Quince TA, Wood DF, Parker RA, Benson J. Prevalence and persistence of depression among undergraduate medical students: a longitudinal study at one UK medical school. BMJ Open 2012;2:e001519.
13. Quince TA, Parker RA, Wood DF, Benson JA. Stability of empathy among medical students: a longitudinal study at one UK medical school. BMC Med Educ 2011;11:90.
14. Quince T, Barclay S, Spear M, Parker R, Wood D. Student attitudes towards cadaveric dissection at a UK medical school. Anatomical Sciences Education 2011;4:200–7.
15. Barclay S, Whyte R, Thiemann P, Benson J, Wood DF, Parker RA, Quince T. An important but stressful part of their future work: medical students’ attitudes to palliative care throughout their course. J Pain Symptom Manage 2015;49:231–42.
16. Whyte R, Quince T, Benson J, Wood D, Barclay S. Medical students’ experience of personal loss: incidence and implications. BMC Med Educ 2013;13:36.
17. Thiemann P, Quince T, Benson J, Wood D, Barclay S. Medical Students’ Death Anxiety: Severity and Association with Psychological Health and Attitudes Toward Palliative Care. J Pain Symptom Manage 2015;50:335-–342.e2.
18. Howe A, Smajdor A, Stöckl A. Towards an understanding of resilience and its relevance to medical training. Med Educ 2012;46(4):349–56.

The Effect of Burnout on Medical Errors and Professionalism in First-Year Internal Medicine Residents

The Effect of Burnout on Medical Errors and Professionalism in First-Year Internal Medicine Residents 

This month’s journal club was written by Jenny MacDowell, M’17, with reference to the following article: The Effect of Burnout on Medical Errors and Professionalism in First-Year Internal Medicine Residents by Kwah, MD, Weintraub, MD, Fallar, PhD, and Ripp, MD, MPH. 

The relationship between resident burnout, professionalism, and medical errors is unclear.   This cohort study aimed to determine whether burnout correlated with objective measures of medical errors and professionalism such as medication prescription errors.  Burnout was measured using the Maslach Burnout inventory following three domains: emotional exhaustion, depersonalization, and sense of personal accomplishment.  Medication prescription error rate was the chosen medical error metric measured.  Professionalism was measured by examining discharge summaries completed within 48 hours, outpatient charts completed within 72 hours, and the average time to review outpatient laboratory results.

The study found that residents with burnout at the end of the year had a lower rate of medication prescription errors (0.553 vs. 0.780, p=0.007).  The professionalism metrics had no significant difference between residents with or without burnout.

Discussion questions:

  • How do the results of this study conflict with the concept of the Yerkes-Dodson curve?
  • Are you surprised by the results of this study and why?
  • What could be the underlying reason residents with burnout had a decrease in medical error?
  • Are the results clinically significant?


Kwah, Jason, Jennifer Weintraub, Robert Fallar, and Jonathan Ripp. “The Effect of Burnout on Medical Errors and Professionalism in First-Year Internal Medicine Residents.” Journal of Graduate Medical Education 8.4 (2016): 597-600.

Respect: An Analysis of Medical Student Narratives Concerning Respect/Disrespect in the Clinical Environment

Respect: An Analysis of Medical Student Narratives Concerning Respect/Disrespect in the Clinical Environment

This month’s journal club was written by Nate Rogers, MS4, with reference to the following article:  Exploring the Meaning of Respect in Medical Student Education: an Analysis of Student Narratives by Karnieli-Miller O, Taylor AC, Cottingham AH, et al.

Respect is an aspect of communication that is vital in developing a trustful and a supportive environment, whether in educational, professional, or clinical settings. Widely recognized in society and the medical literature as a requisite characteristic of a good physician, respect has variably been described as:

  • Positive attitudes towards the dignity and value of others
  • Remaining non-judgmental toward diversity and the uniqueness of others
  • Ensuring patient autonomy
  • Attention to codes of conduct
  • Maintenance of confidentiality and privacy

Disrespectful behavior towards students affects more than the individuals experiencing the disrespect—patients suffer too. Research shows that medical students’ ability to provide respectful care to their patients declines when those students feel abused and belittled. Despite wide recognition of respect as a crucial physician attribute, relatively little research has been performed to clarify the definition and experience of respect in social interactions. The following research by Karnieli-Miller et al. aims to initiate the bridging of this knowledge gap by describing narratives of respect and disrespect experienced by third-year medical students during their internal medicine training. Please consider the following questions for discussion as you review the attached article:

  1. As can be seen above, disrespect is quite a broad term with many possible interpretations. List some general examples of disrespectful behavior, whether intended or unintended. Is there a difference between these types of disrespectful behavior? Why or why not?
  2. What incidents of disrespect have you witnessed in your medical training? Consider all the different possible interactions in the hospital (e.g., between attending physicians, residents, medical students, nurses, administration, janitorial staff, etc.). What was the outcome of this event?
  3. What are examples of times you have been treated with disrespect? How did they make you feel? Do you believe the disrespect was intended? How did you respond? Why?
  4. What is an example of a time you may have treated someone else with disrespect? How did it make you feel? Was the disrespect intended? How do you believe it made the other person feel? How did they respond?
  5. What are concrete steps you can take to reduce disrespect in the clinical environment and in medical education? Steps you can take to become kinder/more respectful personally? How would you respond to disrespect now, whether as a victim or a bystander?


  1. Karnieli-Miller O, Taylor AC, Cottingham AH, et al. Exploring the Meaning of Respect in Medical Student Education: an Analysis of Student Narratives. J Gen Intern Med. 25(12):1309-14. doi:10.1007/s11606-010-1471-1.
  2. Baldwin DC Jr, Daugherty SR, Eckenfels EJ. Student perceptions of mistreatment and harassment during medical school—A survey of ten United States schools. West J Med. 1991;155:140–5.