In 2006, the Association of Program Directors in Internal Medicine (APDIM) charged the APDIM Learning Environment Task Force to review issues related to the resident learning environment and identify principles for change. The task force identified several principles, including decreasing work intensity, enhancing time at the bedside, improving conference attendance, promoting daily reflection, reducing errors, increasing efficiency, and improving transitions of care. In carefully considering these principles, the task force developed 11 recommendations in a report approved by the APDIM Council on March 17, 2009:
Recommendation 1: Admission and census caps for any given service must be based on a resident work formula.
Recommendation 2: Residents must not be required to schedule routine tests and procedures for inpatient and outpatients, nor should they be required to schedule patient appointments.
Recommendation 3: Programs must have a standardized sign out process that at a minimum includes a standard template for sign out and face-to-face handoffs. The quality of the sign out should be assessed at regular intervals by supervising physicians. Consideration should be given to computerized sign outs that integrate with the medications and electronic notes.
Recommendation 4: Programs must have a policy that specifies the parameters for paging. Consideration should be given to having two-way communication devices to promote safe and efficient patient care.
Recommendation 5: Programs must have a transition of care policy that specifies the type of communication required when a patient moves from one level of care to another.
Recommendation 6: Programs should have clinical decision support systems available for patient care. This may include but is not limited to computerized physician-order entry, order sets, or clinical practice guidelines.
Recommendation 7: Sleep hygiene should be incorporated into the duty hour language of the program requirements. Specifically, fatigue management strategies such as napping should be included for programs using extended duty periods.
Recommendation 8: Formal sleep education that covers the effects of fatigue and fatigue management must be included in each year of training.
Recommendation 9: For rotations that require night shifts, shifts should be grouped so they occur consecutively to enable acclimation to night work. Night shifts should also move forward in time to respect natural circadian rhythms. Programs must not regularly require single night shifts spread out over time.
Recommendation 10: Since the best fatigue management strategy is sleep, programs should have a transportation plan in place as well as space for prophylactic napping for individuals completing shifts longer than 16 continuous hours.
Recommendation 11: Programs should have at least three months per year with overnight duty periods limited to no more than two per month to ensure adequate time for recovery sleep.