Restoring Emphasis on Ambulatory Internal Medicine Training—The 3∶1 Model

Background Resident dissatisfaction in ambulatory care training has prompted the need for new scheduling models that support a positive learning climate. Intervention We instituted a 3∶1 scheduling model for postgraduate year (PGY)–2 and PGY-3 residents. We hypothesized this model would provide a more structured ambulatory educational atmosphere, better continuity of care, and more exposure to subspecialty outpatient medicine. This model would also eliminate conflict with inpatient duties and contribute to enhance residents′ satisfaction with ambulatory medicine and their ambulatory education experience. The model used weeklong ambulatory blocks every fourth week, consisting of morning continuity clinic and afternoon subspecialty clinics. The PGY-1 residents maintained a traditional schedule. Results Residents were surveyed regarding their ambulatory experience, with an overall response rate of 73 of 80 (91%). The PGY-2 and PGY-3 responses were analyzed descriptively and compared with PGY-1 responses. Residents reported that the 3∶1 model positively affected their satisfaction with residency training in general, their satisfaction with outpatient/primary care training, and their outpatient/clinic educational experience. Residents in the 3∶1 model perceived improvements in continuity of care and in the quality of care they provided for patients. The experience in ambulatory subspecialty training was positive. Conclusions A 3∶1 scheduling model appears to mitigate some of the conflict between inpatient and outpatient duties. Residents agreed the new model promoted an improved ambulatory experience.

Study on the Schedule Management Methods of Projects Based on Critical Chain Technology

In view of the deficiency of the traditional schedule management methods in dealing with practical problems, on the basis of Dr. Goldratt s critical chain project management theory, the thesis optimizes his theory so as to build the critical chain schedule management model according to the actual needs of the program.

Outcomes associated with sunitinib alternative schedule compared to traditional schedule: a single-center experience.

e15611 Background: Sunitinib is a front-line therapy for metastatic renal cell cancer (mRCC). Recommended dose is 50 mg daily; 28 days (d) on/14 d off (traditional schedule; TS). Sunitinib is associated with several adverse events (AEs). An ideal treatment modification algorithm is not known. We sought to identify 1) common AEs, 2) alternative schedules (AS) that maintained dose intensity while decreasing AEs, and 3) the impact of AS on outcomes. Methods: Single-center retrospective review of mRCC pts performed from 1/26/06 to 3/1/11. Pts > 18 years of age with mRCC who received first-line antiangiogenic therapy with sunitinib were eligible. A subset of pts were switched at first intolerable AE from TS to a 14 d/7 d, or further adjusted to 7 d /3 d, or other AS. Control group underwent standard dose reduction. Pt characteristics including demographics, disease status, laboratory data, AEs, AS, and treatment outcomes were analyzed. Results: 186 eligible pts were identified. At baseline, 87% received sunitinib 50 mg and 88% were on TS. 99 pts (53%) continued TS and 87 pts (47%) were switched to AS. Baseline characteristics were similar. Median age was 61 yrs; by MSKCC criteria 5% were good, 50% intermediate, and 45% poor prognosis. Pts had median 2 visceral mets and 42% had primary tumor in place. AEs included fatigue (47%), diarrhea (24%), and hand-foot syndrome (26%). Median time to AS was 126 d with 14 d/7 d the most common (82%). Median time on treatment was 14.9 months (mo) (95% CI:10.2 – 17.0 mo) in AS pts vs 4.2 mo (95% CI: 3.6 – 5.7 mo), respectively (p < 0.0001). Median OS was 32.9 mo (95% CI:28.3-54.1 mo) vs 18.5 mo (95% CI: 10.3-21.5 mo), respectively (p = 0.0001). ECOG PS > 2 (HR 3.9), elevated LDH (HR 2.04), and > 2 mets (HR 1.79) were associated with decreased OS. MSKCC intermediate vs poor (HR 0.57) and AS (HR 0.54) were associated with improved OS by multivariate regression analysis (p < 0.05). Conclusions: In our cohort study, AS sunitinib significantly prolonged time on treatment and was predictive of OS. Prospective investigations of alternate dosing schemas are warranted.

A single-center retrospective review of outcomes associated with sunitinib alternative schedule compared to traditional schedule.

381 Background: Sunitinib is a front-line therapy for metastatic renal cell cancer (mRCC). Recommended dose is 50 mg daily; 28 days (d) on/14 d off (traditional schedule; TS). Sunitinib is associated with several adverse events (AEs). An ideal treatment modification algorithm is not known. We sought to identify (1) common AEs, (2) alternative schedules (AS) that maintained dose intensity while decreasing AEs, and (3) the impact of AS on outcomes. Methods: Single-center retrospective review of mRCC pts performed from January 26, 2006 to March 1, 2011. Pts > 18 years of age with mRCC who received first-line antiangiogenic therapy with sunitinib were eligible. A subset of pts were switched at first intolerable AE from TS to a 14 d/7 d, or further adjusted to 7 d /3 d, or other AS. Control group underwent standard dose reduction. Pt characteristics including demographics, disease status, laboratory data, AEs, AS, and treatment outcomes were analyzed. Results: 186 eligible pts were identified. At baseline, 87% received sunitinib 50 mg and 88% were on TS. 99 pts (53%) continued TS and 87 pts (47%) were switched to AS. Baseline characteristics were similar. Median age was 61 yrs; by MSKCC criteria 5% were good, 50% intermediate, and 45% poor prognosis. Pts had median 2 visceral mets and 42% had primary tumor in place. AEs included fatigue (47%), diarrhea (24%), and hand-foot syndrome (26%). Median time to AS was 126 d with 14 d/7 d the most common (82%). Median time on treatment was 14.9 months (mo) (95% CI:10.2 – 17.0 mo) in AS pts vs. 4.2 mo (95% CI: 3.6 – 5.7 mo), respectively (p < 0.0001). Median OS was 32.9 mo (95% CI:28.3-54.1 mo) vs. 18.5 mo (95% CI: 10.3-21.5 mo), respectively (p = 0.0001). ECOG PS > 2 (HR 3.9), elevated LDH (HR 2.04), and > 2 mets (HR 1.79) were associated with decreased OS. MSKCC intermediate vs. poor (HR 0.57) and AS (HR 0.54) were associated with improved OS by multivariate regression analysis (p < 0.05). Conclusions: In our cohort study, AS sunitinib significantly prolonged outcomes and was predictive of OS. Prospective investigations of alternate dosing schemas are warranted.

The views of teachers toward the Balanced Day schedule in one elementary school in southern Ontario

Using a case study method to describe the experience of the teachers of five Ontario elementary schools to implement the Balanced Day schedule in the 2004-2005 school year, data sources included questionnaires completed by teachers from the pilot schools, which were administered at the beginning of the year and at the end of the year, and three focus group interviews from one school, conducted twice during the year. Findings indicate that, overall, teachers perceived the Balanced Day to be more effective than the traditional schedule for student learning, and that the schedule also resulted in changes to their own instructional practices that positively impacted student learning.

Failure to Thrive: Pediatric Residents Weigh In on Feasibility Trial of the Proposed 2008 Institute of Medicine Work Hour Restrictions

Background In December 2008 the Institute of Medicine (IOM) released a report recommending limits on resident hours that are considerably more restrictive than the current Accreditation Council for Graduate Medical Education duty hour standards. Intervention In March 2009, a large pediatric residency program implemented a 1-month trial of a schedule and team structure fully congruent with the IOM recommendations to study the implications of such a schedule. Methods Comparison of the interns' experience in the trialed intervention schedule was made to interns working a traditional schedule with every fourth night call. Results The residents on the intervention schedule averaged 7.8 hours of sleep per 24-hour period compared to 7.6 hours for interns in a traditional schedule. Participation in bedside rounds and formal didactic conferences was decreased in the intervention schedule. Several factors contributed to increased perceived work intensity for interns in the intervention schedule. Redistribution of work during busy shifts altered the role of senior residents and attending physicians which may have a negative effect on senior residents' ability to develop skills as supervisors and educators. Conclusions The trial implementation suggests it is possible to implement the proposed duty hour limits in a pediatric residency, but it would require a significant increase in the resident workforce (at least 25% and possibly 50%) to care for the same number of patients. Furthermore, the education model would need to undergo significant changes. Further trials of the IOM recommendations are needed prior to widespread implementation in order to learn what works best and causes the least harm, disruption, and unnecessary cost to the system.

INFLUENCE OF CULTIVAR, PLANTING TECHNIQUE AND HARVEST DURATION ON ASPARAGUS YIELD

Crowns and tranplants of `Martha Washington' (MW) and `Jersey Prince' (JP) asparagus were planted in 1985. Plots were harvested for 0,2,4 weeks (traditional schedule); 1,2,6 weeks (moderate harvest pressure); or 2,4,8 weeks (severe harvest pressure) in 1986, 1987, and 1988, respectively. All plots were harvested for 8 weeks after 1988. An AOV was performed to test the main effects of cv, planting technique and harvest schedules and interactions on early and total season yield of large, medium-sized and total spears. MW produced a significantly higher yield of both early and total season large spears than JP in all years. Total yields did not differ between cvs. There was no significant effect of planting technique on yield in any year. Harvest schedules imposed in the first 3 years had significant long term effects on yield. Although severe harvest pressure produced larger yields than the other schedules in 1986-1988, from 1989-1991 yields were lowest in the severe harvest pressure plots. The traditional harvest schedule produced similar yields to the moderate pressure schedule. There were no consistent interactions between cultivar, planting technique and harvest schedule These data indicate that a slightly more aggressive harvest schedule in the early years of an asparagus planting would not have long term deterimental effect on yield. However, severe cutting pressure can reduce yields compared to traditional cutting schedules for at least 3 years after initial harvest pressure treatment

Intensive Cognitive-Behaviour Therapy for Depression: Preliminary Findings with Four Country Residents

Clients who are unable to attend regular therapy sessions over an extended period present a challenge for treatment. This paper describes a brief intensive program of cognitive therapy for depression that was designed for four residents of country towns. Effects were highly consistent with the impact of group treatments delivered on a more traditional schedule. If confirmed in a controlled group study, these results suggest that cognitive therapy may be applied more economically and more widely than was previously realized.