Table 1.

Attending Perspective: How Has Your Role as an Educator Changed with the Implementation of Duty-Hour Regulations and What Adaptive Strategies are Effective?

Theme	Example	Adaptive Strategy
Increased clinical role
Increased delegation of work to attending	“I'm writing more notes, orders, conferring with consultants and implementing treatment plans”	Use the electronic medical record to learn about patients in advance Explain the more active attending role in covering residents
Make more of the primary diagnoses	“I'm talking to residents about cases before they've had time to formulate their thoughts Consequently, I make more of the primary diagnoses”	Allow time for team members to briefly describe their thoughts before giving feedback
More solo rounding	“I'm seeing patients a lot more on my own”	Carve out time outside of rounds to see patients Explain to patients the team concept of care
Altered time management
Increased time spent on ward attending	“I'm doing attending work earlier and later in the day” “I'm here at 5:30 am reviewing admissions on post-call days, to be prepared for rounds …” “I have limited time for non-ward attending work”	Plan personal and team schedule in advance of ward attending to anticipate conflicts Anticipate decreased availability for other responsibilities Emphasize to residents the importance of early sign-out and delegation of unfinished work Create “to do” lists for the attending postcall
Increased preparation for rounds	“I'm more prepared for the day's schedule”	Develop a game-plan at the beginning of rounds Review key data before rounds
Change in structure of rounds	“Attending rounds are like work rounds; emphasis is on efficiency” “I'm more directive managing rounding time” “The most organized person on the team drives rounds”	Emphasize at orientation the expectation for efficiency during rounds and limit clinical discussions to key issues Address less critical issues outside of rounds. Attending sees established patients solo postcall Round with 1 intern at a time post-call
Decreased time spent as a team	“Divide and conquer mentality results in loss of team cohesion” “My rounds are like controlled chaos”	Prospectively carve out round days to come together as a team for learning and social interaction
Change in presentations	“I ask for more succinct presentations of patients including only assessment and plan. Their task is to provide a framework for expressing how they drew their conclusions”	Abbreviate patient presentations; start with clinical questions and concerns Minimize external disruptions during rounds
More focused teaching	“I used to do a complete demonstration of physical findings, now I focus on 1 aspect of the exam”	Improved skills for teaching in compressed time
Changes in teaching
Less teaching time	“It was difficult to find teaching time before but now it's well nigh impossible, particularly given increased patient turnover …” “Postcall, my team presented a patient with cellulitis that I saw later on my own. Well, it was actually vasculitis. I called dermatology, got the biopsy, had a discussion and learned a ton. The teachable moment for the residents was gone …”	Anticipate time to teach in advance Consistently protect 5-10 minutes of teaching time in rounds Have learners proactively identify their learning needs Close “the loop” on missed clinical teaching opportunities as soon as possible
	“I have less time for teaching preparation” “There is less question asking, and group discussion” “There is decreased bedside rounding” “There is less time for formal didactics and more teaching on-the-fly”	Emphasize the teachable moment and teaching “off the cuff” Focus on 1 teaching point in an article, not the whole article Utilize web resources in rounds Keep track of clinical questions Engage all team members in answering questions Focus on 1 aspect of history or physical exam Carve out time specifically devoted to physical findings on rounds Limit didactics to appropriate days of the call cycle Hone skills for brief teaching
Impact on resident autonomy	“I'm finding there are things the residents don't know about the patients because I have written the orders and done the follow-up”	Keep resident “in the loop” on all patient care issues Preserve resident patient care decision making as much as possible Always ask for resident's perspective before giving your input
Challenges for learners	“I find it hard to keep students meaning fully involved it the new system” “Student presentations are usurped and occur after rounds” “It's even harder to teach a sub par learner in this system; it creates chaos”	Encourage opportunities for one-on-one teaching, presentations and physical exam skill development with students outside of rounds, not necessarily involving the ward attending Teach students succinct presentation skills Check in regularly with student about level of team involvement
Changes in feedback	“There is less opportunity to give feedback because of time constraints”	Document illustrative examples for specific feedback Schedule times to deliver feedback Brief, specific feedback postcall