Conceptual Frameworks in the Study of Duty‐Hour Changes in Graduate Medical Education: A Review

Purpose Conceptual frameworks are approaches to a research problem that specify key entities and their relationships. The 2009 Institute of Medicine (IOM) report on resident duty hours, subsequent studies, and published responses to the report present a variety of conceptual frameworks for the study of the impact of duty-hour regulations. The authors sought to identify and describe these conceptual frameworks and their implications. Method The authors reviewed the IOM report and articles in both peer-reviewed and non-peerreviewed literature for the period January 2008 through April 2010, identified using multiple electronic databases including Pubmed, EMBASE, CINAHL, BEME, and PsycInfo. Studies that explicitly described or argued for the effect of resident duty hours on any other outcome, as judged by consensus of multiple reviewers, were included. The authors selected 239 of 858 studies reviewed. Several of the authors reviewed articles to identify conceptual frameworks used implicitly or explicitly to describe the relationship between duty hours (or duty-hours regulations) and outcomes. Identification was by consensus. Results Twenty-three conceptual frameworks were identified, several of which made contradictory predictions about the impact of duty-hour regulations on patient outcomes, resident education, and other key outcomes. 4 Conclusions The concept of duty hours itself is contested, and little attention has been paid to the nature and intensity of the activities that occupy residents' hours. Much research focuses on isolated outcomes of duty-hour changes without considering mediation or moderation. More studies are needed to define tradeoffs between outcomes and the value society places on these tradeoffs

Provider and Practice Characteristics Associated with Use of Rapid HIV Testing by General Internists

Background. Rapid HIV testing could increase routine HIV testing. Most previous studies of rapid testing were conducted in acute care settings, and few described the primary care providers’ perspective. Objective – To identify characteristics of general internal medicine physicians with access to rapid HIV testing, and to determine whether such access is associated with differences in HIV-testing practices or perceived HIV-testing barriers. Design – Web-based cross-sectional survey conducted in 2009. Participants - 406 physician members of the Society of General Internal Medicine who supervise residents or provide care in outpatient settings. Main measures. Surveys assessed provider and practice characteristics, HIV-testing types, HIV-testing behavior, and potential barriers to HIV testing. Results. Among respondents, 15% had access to rapid HIV testing. In multivariable analysis, physicians were more likely to report access to rapid testing if they were non-white (OR 0.45, 95% CI 0.22, 0.91), had more years since completing training (OR 1.06, 95% CI 1.02, 1.10), practiced in the Northeastern US (OR 2.35; 95% CI 1.28, 4.32), or if their practice included a higher percentage of uninsured patients (OR 1.03; 95% CI 1.01, 1.04). Internists with access to rapid testing reported fewer barriers to HIV testing. More respondents with rapid than standard testing reported at least 25% of their patients received HIV testing (51% versus 35%, p =.02). However, access to rapid HIV testing was not significantly associated with the estimated proportion of patients receiving HIV testing within the previous 30 days (7.24% vs. 4.58%, p=.06). Conclusion. Relatively few internists have access to rapid HIV testing in outpatient settings, with greater availability of rapid testing in community-based clinics and in the Northeastern U.S. Future research may determine whether access to rapid testing in primary care settings will impact routinizing HIV testing