the attendance problem

Some anonymous quotes:

"... I have said in the past there needs to be consequence for not coming - not because we need to be people's parents but because it affects other residents' education which is unfair. Dr. Billings has said he has difficulty getting some speakers because we don't have good turn out...There has been discussion about taking half a vacation day away for not coming to conference unless excused absence (on-call, post-call, day off or vacation). The unfortunate part is residents assume conference/seminar is elective, our new residents come but then as they see 2nd and 3rd years choosing not to come they assume it is elective and start not coming. In other residencies the expectation is that they attend conferences/seminar - no exceptions!...I guess I seem crude/harsh but I feel bad and that it is disrespectful to our speakers and to you (and Dr. Gill and Dr. Billings) who try to arrange good talks for us..."


"...attendance has always been a problem at conference, and even more so at grand rounds. Food helps with attendance but then you always have those that just show for the food and leave...which isn't right either I know. There needs to be consequences for not attending unless you are excused for being on call or post call. Even at that, maybe we need to do a better job of telling our residents and the off service rotations they are on that they need to have coverage in order to attend."

"...if you figure out a way to increase attendance and get people there, please let us know - we've been battling that problem for ages! It's unfortunate."

The problem

The problem is poor attendance.  It leads to difficulty in getting good speakers.  It ultimately results in a poor learning experience during residency.  It's impact is not small.

Required conferences include Thursday Weekly Conference, Thursday Monthly Seminar, Friday Monthly Grand Rounds, Quality Improvement, and Balint.

The current policy

Mayo Family Medicine Residency

"The program requires that we maintain 75% attendance at conferences. 

"DVD's of all conferences, seminars, and grand rounds are available through me in the Academic Center in Kasson. Beginning January 2009, if on-call, post-call, away rotation or on vacation, you have the option to watch all conferences at workstations to obtain credit. The links for webcasts can be found at: http://mayoweb.mayo.edu/fam-res/WebcastsforCredit.html.

"If you are not away due to the above reasons, you still need to attend "live" whenever possible. Recordings will not take place of your attendance if your schedule permits you to attend in person."

ACGME

"Continuous on-site duty, including in-house call, must not exceed 24 consecutive hours. Residents may remain on duty for up to six additional hours to participate in didactic activities, transfer care of patients, conduct outpatient clinics, and maintain continuity of medical and surgical care."

"A Review Committee may grant exceptions for up to 10% or a maximum of 88 hours to individual programs based on a sound educational rationale."

Excused absences

For the Family Medicine OB service, it is expected (at date this document was prepared) that the resident begins work at 8 am when taking call.  The 30-hour mark for the resident on FMOB, therefore, would be 2 pm the following day.  Conferences/didactics, therefore, would only be excused beyond that time period.

For the Family Medicine Inpatient service, the starting time for work is more variable.  Assuming the resident begins work at 7:00 am when taking call, the 30-hour mark for the resident on FM-Inpatient, therefore, would be 1:00 pm the following day.  Conferences/didactics, therefore, would only be excused beyond that time period.

Motivational strategies

Consequences

The main penalty involved is related to graduation.  If we're getting close to graduation then we possibly receive notification that are attendance is below the required level.

There are no other consequences currently in place.  These might include a meeting with the program director, chief, or mentor to discuss the issue.  I don't think removal of vacation days would go over well and it does seem harsh, but that would probably be a strong penalty for particularly egregious cases.

Inducements

This is where all the possibilities are.  

Small monetary inducements work in research and they would work well with residents, too.  The cost to the department would be nominal and the yield would be great.  

Food always motivates attendance.  

I think vacation days are very motivating.  One problem with offering vacation days is that it is very difficult to take vacation in the first two years, and by the last year, the yield in motivational strategies for seniors is very small.

One motivating inducement for 1st and 2nd years might be scheduling priority.  This would be a very strong motivator.

Public recognition is a strong motivator.  

Acknowledgment in a detailed formal performance appraisal can be motivating. 

Competition

What we are missing is that this demographic is one of the most competitive groups on the planet.  Young doctors have been competing for test scores and academic rank for years.  High school, organic chemistry, medical school, etc.  It does probably foster a respectful learning environment to remove competition from some of the performance-related aspects of residency training.  However, healthy competition with regards to attendance seems to have little downside.

Competition does require a few elements:  a desirable ultimate reward (an undesirable ultimate penalty is not suggested), knowledge of ordinal position, and a persistent hope of reaching a goal.  

Desirable ultimate reward:  outside of inner drive to succeed (which is huge, but is a personal, internal thing), rewards do have the ability to motivate us.  Recognition both to the department and in performance assessments could be implemented for the resident with the best attendance for each training year.  A gift certificate for a small amount could be used.  An additional half-day of vacation could be used.  Any inducement from above could be a part of this.

Knowledge of ordinal position:  having an idea what your own personal attendance rate is, as well as, where you stand in the pack would help with encouraging participation.  This is pretty much common sense.  I think that we need to have more frequent updates of our performance.  It should either be 1) directly accessible by each resident or 2) provided to the resident with frequency and at a motivating time (such as Wednesday night or Thursday morning).

I've prepared an online spreadsheet which performs attendance calculations and could be used by residents and staff to track attendance.  The output could be used in performance evaluations.  It also distinguishes between attendance needed to graduate and attendance regardless of excused/unexcused status.  It's ready to be used right now.

Persistent hope of reaching a goal:  the online video setup is great, however, my gut feeling is that the presence of the video possibility wipes out any chance the excused residents will attend.  For this reason, I think the raw number of attended conferences should be the goal that residents work to improve.  This is a factor that motivates speakers:  speakers like to have an audience.  There should be absolutely no reward for simply viewing videos at home since this does nothing for the program and is a distant second to attending and participating in person.  The reward for watching the videos is learning and being able to graduate.

The persistent hope of reaching the goal of a high personal attendance rate could be helped by giving more credit to those who attend when it would have been excused for them not to.  I don't know the work hours rules behind this, but it would not be patient care, so hopefully this could be formally encouraged.  Additionally, partial credit for non-required activities (such as journal club or board review) could foster healthy competition and improve attendance at those activities, as well.

Swipe-n-dash

I don't think this is the biggest part of the problem, but it's worth addressing and it could be addressed in a few ways.  It seems to be possible because the device we swipe in to is always outside of the conference room.

Swipe out

Timing the system so that swiping can only occur after half the presentation has passed might help.

Sign in sheet

To the extent that this is a serious problem, maybe temporarily resorting to paper attendance would be helpful.  This could be used to verify the swipes.  Forging someone's name might provoke a little more cognitive angst than just using their access card.

Logistical Concerns

Simply by beginning noon conferences at noon and by completing them by 1:00 pm, we would improve conference attendance by at least 2 residents for each conference.

By placing the onus on the resident to justify (to some extent) their absence from our (very few) conferences while on away rotations, this may capture some of the absences seen when residents rotate on ICU, cardiology, pediatrics, ER, etc.  Formal policy/curriculum should be outlined for each off-service rotation to delineate which rotations have scheduled didactics which should supersede Family Medicine didactics.  To the extent that this is unclear, it is a loophole.