ONG WORK HOURS ARE A TIMEhonored tradition in most residency programs. Demanding schedules are often said to be necessary for learning and development of professionalism. The use of resident physicians to provide relatively inexpensive coverage has also become an important economical factor for teaching hospitals within the United States. Recent studies of the negative effects of sleep loss and fatigue, however, call this model into question. Any consideration of the impact of sleep loss and fatigue on medical training and patient care should be based on relevant data. In this article, we concentrate on 3 questions. First, is the quality of patient care jeopardized when residents are deprived of sleep? Second, is the well-being of residents at risk when they have not had adequate sleep? Third, what strategies are effective for overcoming the negative effects of sleep loss? We answer these questions by summarizing data on the effects of sleepiness and fatigue on cognitive function, the impact of sleep loss on residents' performance and health, and the effectiveness of countermeasures for sleep loss. REGULATION OF SLEEP AND ALERTNESS Sleep and wakefulness are highly regulated states of brain activity and behavioral responsiveness, governed

Background: Various organizations and universities have developed competencies for health professionals and other emergency responders. Little effort has been devoted to the integration of these competencies across health specialties and professions. The American Medical Association Center for Public Health Preparedness and Disaster Response convened an expert working group (EWG) to review extant competencies and achieve consensus on an educational framework and competency set from which educators could devise learning objectives and curricula tailored to fit the needs of all health professionals in a disaster. Methods: The EWG conducted a systematic review of peer-reviewed and non-peer reviewed published literature. In addition, after-action reports from Hurricane Katrina and relevant publications recommended by EWG members and other subject matter experts were reviewed for congruencies and gaps. Consensus was ensured through a 3-stage Delphi process. Results: The EWG process developed a new educational framework for disaster medicine and public health preparedness based on consensus identification of 7 core learning domains, 19 core competencies, and 73 specific competencies targeted at 3 broad health personnel categories. Conclusions: The competencies can be applied to a wide range of health professionals who are expected to perform at different levels (informed worker/student, practitioner, leader) according to experience, professional role, level of education, or job function. Although these competencies strongly reflect lessons learned following the health system response to Hurricane Katrina, it must be understood that preparedness is a process, and that these competencies must be reviewed continually and refined over time. (Disaster Med Public Health Preparedness. 2008;2:57-68)

OBJECTIVES: The purpose of this study was to examine empirically the relationship between physicians' race or ethnicity and their care for medically underserved populations. METHODS: Generalist physicians who received the MD degree in 1983 or 1984 (n = 1581) were surveyed. The personal and background characteristics of four racial/ethnic groups of physicians were compared with the characteristics of their patients. RESULTS: When the potentially confounding variables of gender, childhood family income, childhood residence, and National Health Services Corps financial aid obligations were controlled, generalist physicians from underrepresented minorities were more likely than their nonminority counterparts to care for medically underserved populations. CONCLUSIONS: Physicians from underrepresented minorities are more likely than others to care for medically underserved populations.

Many forces, including the influential report of Abraham Flexner, acted to reform medical education in the early 20th century. Most physicians were not prepared to adopt recent advances in health care due to their poor medical training. This deficit was recognized in the 20 years before Flexner's report by several organizations, including the Illinois State Board of Health, the American Medical Association, and the Association of American Medical Colleges. Before 1910, each organization had engaged in at least one review of medical schools using defined standards and had identified many of the existing deficits. The number of medical schools already had begun to decrease, dropping from 160 in 1905 to 133 in 1910. Flexner drew heavily, but not exclusively, on the standards for medical education previously developed by other organizations. He visited 155 medical schools in the United States and Canada between December 1908 and April 1910. His 1910 report included a conceptual model of how modern medical education should be conducted and descriptions of each medical school that were explicit in both praise and censure.In the decade following the Flexner Report the number of medical schools decreased from 133 to 85. The actions of state medical licensing boards to deny recognition to poor schools sealed their fate. The remaining schools had higher entrance requirements, longer terms, and better resources. The author describes key factors that contributed to the success of the changes recommended by Flexner and others, and then posits why Flexner is still remembered.

CQI can enhance educational program quality and outcomes, if the process is designed to collect relevant information and the results are used for program improvement.

No abstract

This is a time of considerable uncertainty about the future of medical education. There are threats to medical school finances from state and federal levels. While medical schools derive only an average of about 11% of total revenues from state and local sources, these funds potentially give states the basis for imposing specific mandates on medical schools, in areas such as enrollment levels, curriculum content, and a desired specialty mix of graduates. Medical schools appear to be changing at varying rates in response to the health care system, including the growth of managed care. While the total number of full-time faculty members continues to increase, there are regional differences. It is unclear how the faculty size and composition ultimately will be affected or what implications this will have for educational programs. A number of medical schools are expanding into the community to ensure a patient base, and educational opportunities for medical students appear to be increasing in the community, including some limited use of managed care organizations. as educational settings. Medical school practice sites in the community have the potential to exacerbate "town-gown" tensions in the increasingly competitive health care environment. This, in turn, could jeopardize community-based medical education by the large number of practicing physicians who serve as volunteer faculty members and who are a valuable resource. Care will need to be taken to minimize these tensions as much as possible. As the health care system becomes even more competitive, concerns are being raised about whether volunteer faculty will continue to serve without compensation. The ability to begin to compensate community physicians who serve as teachers could be affected by decreasing medical school revenues from patient care, which, in the past, have been used to support activities such as community-based education. This is a time for strong and visionary academic leadership: medical schools must not only adapt to a changing health care system, but also maintain excellence in education, research, and patient care. This annual article will continue to describe the efforts of educational programs to do so.

The difficult issues surrounding discussions of sleep, fatigue, and medical education stem from an ironic biologic truth: physicians share a common physiology with their patients, a physiology that includes an absolute need for sleep and endogenous circadian rhythms governing alertness and performance. We cannot ignore the fact that patients become ill and require medical care at all times of the day and night, but we also cannot escape the fact that providing such care requires that medical professionals, including medical trainees, be awake and functioning at times that are in conflict with their endogenous sleep and circadian physiology. Finally, we cannot avoid the reality that medical education requires long hours in a constrained number of years. Solutions to the problem of sleep and fatigue in medical education will require the active involvement of numerous parties, ranging from trainees themselves to training program directors, hospital administrators, sleep and circadian scientists, and government funding and regulatory agencies. Each of these parties can be informed by previous laboratory and field studies in a variety of operational settings. including medical environments. Education regarding the known effects of sleep. circadian rhythms, and sleep deprivation can help to elevate the general level of discourse and point to potential solutions. Empiric research addressing the effects of sleep loss on patient safety, education outcomes, and resident health is urgently needed: equally important are the development and assessment of innovative countermeasures to maximize performance and learning. Addressing the economic realities of any changes in resident work hours is an essential component of any discussion of these issues. Finally, work-hour regulations may serve as one component of improved sleep and circadian health for medical trainees. but they should not be seen as substitutes for more original solutions that rely less on enforcement and more on collaboration. By working together to address the problems of sleep and fatigue in its own trainees, the medical field can provide a valuable legacy to patients and to future generations of healthcare providers--a legacy or optimal medical education, healthy doctors, and healthy patients.