How one physician is making the most of overnight medical education

Lois Margaret Nora, MD, JD, MBA

In medical school, I experienced some of my favorite and least-favorite experiences during overnight call.  And I have been dismayed at the substantial reduction in overnight experiences that more recent generations of medical students have had. So, I was excited to hear about some particularly interesting work by Dr. Jessica Chambers of Dell Medical School at the University of Texas at Austin. I was delighted to have time to talk and to learn more about her career and how she’s made the overnight rotation much more than something to simply endure. The following post is a synopsis of our conversation.

Dr. Chambers attended medical school at Texas A&M University before pursuing residency at UT. Now a practicing nocturnist and assistant professor of internal medicine, she’s been working to transform learning in the overnight hours. As we spoke, it became clear that she’s done so through a combination of passion and leadership.

Anyone who has worked overnight call knows the hospital environment is quite different at night. There are fewer patients and visitors coming and going, and the staff is smaller. Certain issues are more common in the evening, fewer specialists are available, and there is reduced access to hospital services, such as some types of imaging and surgery. However, Dr. Chambers says that’s also part of what makes overnight medicine so beneficial to learners: “I think your decision-making and triage skills are different than those developed in the daytime.”

Medical students and residents on the night rotation are part of small, highly interprofessional teams, giving them valuable experience communicating and collaborating with colleagues, and valuable exposure to team-based care. Dr. Chambers says overnight teams also spend more time on functions like admission and bedside management, enabling learners to interact with patients in a more holistic way. “We get to understand the perspective of the nursing staff, what the charge nurse does, the interplay with the respiratory therapists and the social worker in the ER. Instead of focusing on how to get the patient out of the hospital, we’re really focused on how to best take care of the patient in the hospital,” she says.  “That, I think, is why I found this niche. It’s such an ideal time for education because we often don’t have other things we have to focus on.”

A dedicated curriculum for the overnight rotation

The overnight medicine curriculum Dr. Chambers developed came out of early bedside talks she gave while working with residents. As common issues like shortness of breath, chest pain, headache – “very rote things, but out of them comes a lot of medicine” – became favorite lecture topics among residents, it became clear to Dr. Chambers that there was value in developing a defined list of areas that should be covered on the overnight rotation. Some arise organically in a hospital where the overnight team can be responsible for well over 100 internal medicine patients, and others can be worked in as short lectures during downtime.

About six months into her first faculty role as a nocturnist, Dr. Chambers recognized opportunities for a more structured approach to educating learners on the overnight shift before they reached residency. “I thought, wouldn’t it be great if you had practice doing this as a fourth-year medical student, because this was the scariest rotation I had as an intern.” She went on to establish an elective with a reasonable schedule – 11 p.m. to 7 a.m., four nights a week – to entice students who might be reluctant to try something more time-intensive. “This is not about overloading them with patient care; this is very particular to how to cross-cover patients at night,” she said.

As Dr. Chambers built out her course objectives, she saw an opportunity to help students and residents build communication skills. Overnight medicine provides more opportunity for connection with patients, who may feel especially vulnerable and alone after visitors leave. Clinicians often find they have more time for bedside conversations, where they can enhance their understanding not only of a patient’s medical condition, but also the patient experience. While these skills are important for nocturnists, they are valuable for any clinician.  

Dr. Chambers also asks learners to build skills for working with the care team, and I was especially intrigued by the way she approaches this teaching with fourth-year medical students who take part in her elective rotation. Students are asked to be the point of contact for a subset of patients, meaning they gain experience talking with nurses, pharmacists, and respiratory therapists; entering orders into the EMR; and making decisions about care.

The work is guided – a qualified physician is always present when a medical student is answering pages or replying to messages from the care team, and any order placed in the EMR by a student needs to be activated by a physician. But she encourages students to draw conclusions and also to ask questions when they are unsure of next steps. Modeling behavior helps; Dr. Chambers herself invites input from residents in the presence of medical students before making decisions, demonstrating to students that the nocturnist must have knowledge of many specialties but simply can’t be expert in everything. “They have to really embrace that level of not knowing, which is something we see every night.”

To that end, Dr. Chambers has also developed a Night Medicine Guide that draws on the expertise of her colleagues in other specialties. Listening to her describe the collaboration involved with creating the resource, I was impressed with her leadership in bringing multiple stakeholders together to develop this valuable resource.

The Night Medicine Guide reflects the guidelines of specialty medicine and outlines protocols for scenarios that can be handled by the overnight team, as well as scenarios that warrant a call to the attending physician. “A lot of the fright of doing a night shift is, when do I call cardiology? Should I call the GI doctor? Am I taking good care of this patient? Am I doing the standard of care at 2 a.m.?” she said. A grant from the medical school ensures every learner gets a copy of the guide.  

I remember from my own days on the overnight rotation, one of the more challenging scenarios is trying to navigate the line between clinical issues you can handle and those that warrant a call to another specialist. It is a gray area that can be stressful and a source of conflict. As I thought about this, I wondered if Dr. Chambers’ guide might also be a useful tool for supporting clinician well-being. The clarity it provides for handling situations like pain, delirium, suicide risk, and others strikes me as reassuring and empowering for clinicians across the healthcare team.

A culture change for overnight medicine

Talking to Dr. Chambers was particularly interesting as I thought about how overnight rotations have been commonly perceived. Although it’s easy to understand that patients have needs around the clock, persuading others to see the unique value in learning at 2 a.m. seems less easy. It’s clear that leveraging the learning opportunity as Dr. Chambers has done has required a shift in perceptions about overnight medicine.

That change has taken time, Dr. Chambers says, and since she cannot work every night, it has also taken advocacy and leadership to shift views about how learners and clinicians can make the most of the overnight rotation. It has also taken work on her part to foster a positive team culture. Things like shared meals build community. And open conversation about what’s important to stay healthy while working overnight normalizes challenges and helps colleagues – particularly those who are still getting accustomed to the schedule. She is also a strong advocate for reasonable hours that allow for, for example, dinner with family before a shift begins. “I think that connection time is very important; it’s what leads to me loving this job. I don’t go to work missing my family more than I would any other job.”

While I knew I would learn from Dr. Chambers about the possibilities of learning as part of overnight medicine, I also learned some things I didn’t know about the health effects of night work.  Resisting the body’s natural sleep cycle alone is challenging enough, but Dr. Chambers noted that overnight work is linked with poor eating habits, weight gain, metabolic syndrome, breast cancer, and potentially fertility issues.  She also said the life of a nocturnist is likely not a good fit for people who do not sleep easily.  It’s important, too, that nocturnists have a supportive home environment to facilitate daytime sleep, and a supportive working environment that includes scheduling important meetings at a reasonable time for someone who must sleep during the day.

I was thrilled to learn that Dr. Chambers is working as part of organized medicine to lead change beyond her institution. She has what sounds like an interesting talk planned at an upcoming meeting of the Society of Hospital Medicine about managing the health consequences of overnight medicine, and she’s been active with a number of other societies.  Her efforts to reimagine overnight education and the culture of the overnight shift have also helped her find a growing community of like-minded physicians who have been on the forefront of changing perceptions of nocturnal medicine and seizing its unique learning opportunities. “You could obviously do this job very easily, but to do it well, to make sure the academic opportunities are very useful, you have to put in more time. However, I find it very easy if you love what you do, which I do. I love what I do.”

Putting accreditation on the faculty retreat agenda – why and how

Lois Margaret Nora, MD, JD, MBA

It’s common during the summer months and the early weeks of fall for medical schools to host annual educational retreats for faculty – both those who are employed and those who teach on a voluntary basis. These events provide a chance for attendees to connect and share information. They also provide an opportunity for leaders from across the school to express appreciation for the invaluable work done by faculty, bring attendees up-to-date on what’s new at the school, and provide faculty development opportunities.

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A recent discussion about planning content for such a retreat reminded me that these gatherings offer a wonderful opportunity to help faculty learn more about LCME accreditation. Members of the faculty may not be aware of the ways in which accreditation expectations affect their work.  For example, a school faces real challenges from an accreditation perspective if narrative feedback is not provided or if evaluations are not submitted in a timely manner. Drawing a link between policies for student assessment and accreditation can help faculty understand the importance of following those policies. It can also help convey how expectations that may feel picky or onerous have real importance for the institution.

This is where the leadership of accreditation professionals comes in.  While accreditation is never far from the minds of those who deal with these processes regularly, it takes work to keep it on radars across the school and beyond high-profile periods like site visits. Talking with faculty about the role they play in accreditation and its importance to the school is one step in the right direction. And retreats, with their collegial atmosphere and attention to learning, may be just the right environment.

Integrating accreditation into retreat content plans

As retreat planners consider how to integrate accreditation into learning, it may help to draw cues from the accreditation cycle itself. Schools that are embarking on a self-study are at a very different place from schools that are years away from reaccreditation. The treatment of accreditation topics in retreat curricula should be adapted accordingly. Here are a few thoughts that may inspire ideas for your planning:

Considerations for schools in a self-study

If a school is poised to begin a self-study, consider focusing the entire retreat around this process.  Start by explaining how the school is accredited and outlining the timing and benchmarks involved (document submission, site visit timing, etc.)  It can be worthwhile to review past accreditation challenges, along with unique aspects of the school that may draw questions from the site visitors, such as distributed campuses or past issues with the learning environment.  Breakout groups can explore specific areas within student support, diversity, faculty affairs, and the educational program.  Involving key committee chairs and members can reinforce the importance of these discussions.

When schools are in the middle of the self-study process, consider sharing early findings from the process and discussing actions being taken to address these findings. Accreditation professionals can present topics themselves, but often this information is best presented by the faculty leaders and area administrators who work directly in these areas. 

Discussions about accreditation can help prepare faculty for conversations with the site visit team by helping them understand what they may be asked about and related expectations for compliance. These discussions also allow medical education professionals to draw a clear line between the everyday work of faculty and the accreditation process. And, importantly, they may open the door to a broader discussion of continuous quality improvement (CQI). The actions of noting red flags through student feedback, GQ and ISA responses or other sources; considering possible changes and then implementing them; and defining how the institution will follow up on outcomes are powerful illustrations of CQI.  Underscoring this message may help foster the collaboration needed for accreditation – and for improving the quality of medical education at your institution.   

Considerations for midcycle schools

Although accreditation is a common topic of concern at schools that are working on a self-study, most schools are elsewhere in the accreditation cycle.  While it can be tempting to set compliance considerations aside after reaccreditation is achieved, there are plenty of midcycle tasks —  CQI; ensuring policies and procedures are up-to-date; and building systems to support compliance — that are important and worthy of discussion at any point in the cycle.

Including an accreditation component in all annual retreats allows for review of this ongoing work.  Doing so also keeps accreditation top of mind. New expectations and standards, feedback about progress addressing past findings, and a conversation about the school’s CQI processes are all worthy topics for discussion.

There are numerous possible approaches realizing these ideas. Consider planning a short, focused session that covers accreditation “highlights.”  Conversely, accreditation could be woven throughout the retreat by asking all speakers to take a few minutes to provide an update within their area of focus (e.g., student support, faculty affairs, curriculum, etc.) Or, for retreats with a specific theme, look for ways in which that theme intersects with accreditation to inspire ideas.

Schools should pursue the approach that makes the most sense for their retreat and their institution. However they proceed, they will derive great value from involving the school’s accreditation professionals in retreat planning.  The unique lens brought by accreditation professionals is about more than preparing the school to do what is necessary for compliance. It’s also about helping the school leverage the LCME standards and processes for improving the quality of medical education at the institution.

Underscoring the value of accreditation, and the accreditation professional

At MSAG, we believe continual reinforcement of the value and principles of accreditation keeps the standards front and center at the school and enhances the quality of the education it provides.

Keeping accreditation top of mind also helps integrate accreditation professionals into the life of the school. As accreditation professionals are given (or create) opportunities to talk about how their work links to priorities across the institution, they clarify their role and value as helpful colleague, while positioning themselves as a resource on a topic of great importance to their institution.

The COVID-19 crisis may be easing; here are 5 lessons we must carry forward

Lois Margaret Nora, MD, JD, MBA

As COVID-19 mortality in the US surpasses 1 million, it is difficult to see much good in the pandemic that has dominated life over the past two years. However, while the losses are devastating, the pandemic has shed new light on important issues and accelerated progress that I hope will continue well into the future.

Some of these are conversations we should have been having all along. Others involve newer trends that hold potential to benefit many if we can seize this moment of opportunity. Creating change in a system as large and complex as healthcare has never been easy – but the pandemic has shown us how much we can do when we are aligned around a common goal.

Medical schools and other institutions of health professions education will play a key role in applying the lessons of COVID-19 and facilitating progress toward a better system of care.

Here are five lessons that we should carry forward.  

We must bridge the health equity gap

The health disparities laid bare during the pandemic were well known to public health professionals long before the crisis, but the exacerbation of those disparities as COVID-19 took hold captured a new level of attention from the general public. Reports that people of color were at higher risk of developing COVID-19, faced greater likelihood of severe disease outcomes, and often held jobs that put them on the front lines of the pandemic converged with increased attention to issues of social justice and systemic inequities.

It is difficult to overstate the scope of the challenge. The causes of health inequity are “diverse, complex, evolving, and interdependent in nature,” according to a 2017 report from the National Academies of Sciences, Engineering, and Medicine. In medicine, they involve access to care, how care is provided, and even the underlying assumptions of biology and disease on which care is based. Because inequity is omnipresent, action on the part of a few committed stakeholders will not be enough. We will need all hands on deck. And we must seize this moment.

Fortunately, many have risen to the challenge. And some of the most interesting efforts have bubbled up in our institutions of health professions education.

Consider efforts by medical students Pooja Chandrashekar and Victor A. Lopes-Carmen to ensure COVID-19 information is accessible in dozens of languages. Early in the crisis, students across the country put together small armies of volunteers to help with outreach, and they worked with leaders of their schools to take action. Meanwhile, medical education programs are leading research, examining and overhauling curricula, training faculty, and striving to expand the diversity of the student population.

The disparate health outcomes we have seen through the pandemic and throughout history are unacceptable. And yet, the momentum coming out of the pandemic is promising. We – students, educators, clinicians, leaders -- must put the plans and systems in place to ensure we do not lose it.

Clinician burnout is an urgent priority

Clinician burnout was a serious issue before the pandemic, but it didn’t necessarily register beyond the ranks of those most affected. The early pandemic’s focus on the heroism of nurses, physicians, and other clinicians (coupled with attention to inadequate supplies of personal protective equipment and other issues) put healthcare working conditions in the spotlight.

Two years later, burnout has sparked not only an alarming mental health crisis, but also staffing challenges that will have ramifications for years, if not decades. McKinsey found that while 20% of nurses were looking to leave the profession early last year, that figure was 32% by the end of 2021. In some specialties, the picture is far worse. The American Association of Critical-Care Nurses found that 66% of critical care nurses have considered leaving the profession through the pandemic, and 92% believe the experience has cut their careers short.

It is difficult to see the good in any of this, but persistent shortages of nurses and other clinicians have forced a conversation about healthcare workplaces that might otherwise not have happened. To solve workforce challenges, we must address their root causes – in particular, asking too much of professionals while providing too little support. I have been heartened by attention to these issues on the part of institutions like the US Health Resources and Services Administration, the National Academy of Medicine, and the Accreditation Council for Graduate Medical Education, which are leading productive conversations about what has gone wrong and how to reverse it. Meanwhile, the Dr. Lorna Breen Health Care Provider Protection Act, recently signed into law, will provide resources to help ensure clinicians have the support they need.   

Telehealth needs a permanent place in our systems of care

For some care, there is no substitute for an in-person visit.  But amid the rapid escalation of telemedicine early in the pandemic, many healthcare professionals were surprised by how much care could be administered from afar, with the right technology.

Mental healthcare is a particularly interesting example. While the promise of remote mental healthcare had been discussed prior to the pandemic, it took a crisis to increase uptake beyond the low single digits.  One study reported that telehealth was used by more than half of those with a behavioral health condition during the first two months of the pandemic – a higher rate of utilization than reported even for chronic physical conditions. Telehealth also opened the door to people who might otherwise forgo mental healthcare.

The flexibility to obtain care from anywhere may be particularly important given persistent shortages of mental health professionals that are expected to worsen. Across the US, just 28.1% of need for psychiatric care was met as of Sept. 30, 2021, according to the Kaiser Family Foundation. Meanwhile, worsening shortages for marriage and family therapists, mental health and substance abuse social workers, and others may be on the horizon. This is a crisis that won’t be entirely alleviated by remote care, but telehealth tools are certainly useful for managing the wide regional variation in unmet need.

Access to care is an important piece of the puzzle, but it is not the only reason to fully explore the possibilities of telehealth for behavioral and other health needs. Remote care channels also offer healthcare professionals an interesting window into the lives of their patients and clients. For example, licensed therapist Jenn Turner, who specializes in trauma in her work with individuals and couples, has noticed people are less guarded when they join therapy from home, potentially allowing care to progress more rapidly. Meanwhile, psychiatrist Dr. Alisa Burch and colleagues note life complications such as caregiving and work schedules are less likely to interfere with remote care. These considerations are important for continuity of care while also helping ease persistent business challenges like cancellations.   

Much of the flexibility that allowed the rapid escalation of telehealth was granted on a temporary basis. While it’s clear that telehealth is not going away, nor should it, it will take commitment to make the necessary changes to enable its use on a permanent basis. We also have work to do as we determine the optimal use of remote, in-person, and hybrid care. As we do so, we will help ease workforce challenges, enhance convenience for patients and professionals, and improve health outcomes.

We should make better use of our interprofessional care teams

As COVID-19 surges have strained supplies of nurses, physicians, respiratory therapists, and others, we have seen the limitations of our healthcare workforce. We have also discovered and leveraged previously untapped flexibility that holds promise for continuing to expand access and enhance continuity of care after the pandemic subsides.

Consider the wide variety of professionals who joined the effort to administer COVID-19 vaccines. Not just physicians, nurses, and other traditional providers of vaccines, but also dentists, emergency medical technicians, veterinarians, and others. The contributions of these health professionals not only rapidly expanded the vaccinator workforce; they also opened up new access points for vaccination at a time when it was important to remove all possible barriers to care.

The pandemic also opened new avenues for enabling care continuity even as practices and hospitals managed overwhelming patient volumes. Physicians shifted from their usual specialization to emergency departments, critical care units, and other places where need was high. Meanwhile, we saw allied health professionals like respiratory therapists take on new tasks for which they are trained but not always engaged. And advanced practice professionals stepped into expanded roles that allowed them to work at the top of their game while relieving burdens on their colleagues, some of whom were needed elsewhere.

The flexibility we gain when we expect and allow professionals to practice at the top of their training is important for a crisis, but it can also be a solution to challenges in ordinary times, particularly in underserved areas. We should look for opportunities to enable all professionals to make the most of their skills. We should also look beyond our hospital and practice walls to community health workers, who have been a lifeline in many areas where physicians are in short supply. What progress could we make if we better channel the expertise of all health professionals after the worst of this crisis has passed?

Our public health system needs attention and resources

Public health professionals often say the most effective public health systems go largely unnoticed by the general public. People do not see the outbreaks that are prevented and the disasters that are thwarted. Unfortunately, this means problems like chronic underfunding, poor organization, and communication gaps also go unnoticed until crisis hits.

The pandemic put a spotlight on these issues. While a novel virus would have posed a challenge to even the most robust framework, the public health system in the US lacks the clear and consistent organization and structure needed to coordinate preparation and response to a threat like COVID-19. It is no surprise that testing, contact tracing, even communication about how to stay safe were so difficult to manage. Agencies that have long seen their budgets raided to fund other priorities had neither the technology and staff, nor adequate empowerment and coordination to effectively do this work.

The public health system also lacks a consistent approach to more routine but no less important aims like reducing tobacco use and conducting injury and disease surveillance. It is difficult to overstate the consequences of not attending to these priorities. However, addressing them holds promise for improving the state of health in America — and for solving many of the challenges that became clear during the COVID-19 crisis.

Looking toward a better healthcare system

Perhaps the most important takeaways from the pandemic involve the interconnectedness of our world. It does not take long for an emerging disease threat in one part of the world to reach people everywhere. And what started as a health issue quickly affected our financial, educational, and political systems. In healthcare, COVID-19 was not just a problem for infectious disease professionals and critical care teams to manage. It challenged us all.

The solutions may also be similarly interconnected, and we may see some interesting and beneficial emergent properties arise as we build them out.  These outcomes may in fact ease some of the most pressing issues in medicine.

For example, as we develop more effective interprofessional teams, we may also uncover opportunities to enhance clinician well-being. Moving from concentrated workflows where physicians are heavily involved in all care for all patients to shared-responsibility models that spread tasks across the practice team may even help restore joy to the practice of medicine, to borrow a phrase from Dr. Christine Sinsky, whose work heavily focuses on these issues. These changes may also have implications for practice management. In fact, Sinsky and Dr. Mark Linzer argue that some of the administrative and documentation changes put in place temporarily during the pandemic transformed practice efficiency with seemingly simple changes such as allowing physicians to relay orders verbally to colleagues for entry into the electronic health record. Yet another change that we should be learning from as we move forward.

These lessons and changes will affect existing healthcare professionals. They will also have an indelible impact on the institutions of health professions education, which form the foundation of our healthcare workforce. Today’s students are tomorrow’s leaders, and those who embark on their careers with the right skills will play an outsized role in making the most of the lessons of the pandemic.

As COVID-19 evolves into an endemic disease and an unfortunate fact of life, the crisis phase of this experience will pass. However, the pandemic has shaped and scarred our world. It is my hope that we can honor the sacrifices made by so many, including so many in healthcare, by applying the hard lessons we have learned to make our healthcare and health professions education systems better.

This piece was first published on LinkedIn.