["Breaking the Silence Barrier", a simulation program to address psychological distress]

Although several strategies have been developed to support medical students during their studies in order to prevent burnout, depression and suicide, not all of them are equally effective. Simulation is an interesting strategy: it gives students the tools to detect and intervene in signs of distress in their colleagues, and helps them break the barrier of silence in the face of psychological distress.

Medicine and History: a Surgical Model for National Integration

Historians and physicians have struggled to incorporate history into American medical education for over a century. Most efforts focus on local initiatives targeting a narrow audience. We describe a novel method involving the American College of Surgeons, a national organization with tens of thousands of members. Capitalizing on its infrastructure and influence over the field, we have implemented a variety of ventures that include panel sessions at meetings, poster competitions, travel grants, themed breakfasts, online communities, and other such projects. This programming has reached thousands of participants, ranging from pre-medical students to retired physicians, and it has increased both the exposure to and production of surgical history. Our article describes the process of establishing this nationally coordinated enterprise in the hopes that other medical specialties can emulate it and further the study of and appreciation for medical history.

An age-friendly residency: Geriatrician and internist perspectives on geriatric education in an internal medicine residency

BACKGROUND

General internists and subspecialists need skills to deliver age-friendly care to older adults, yet a minority of Internal Medicine (IM) residency programs provide robust geriatric-specific clinical instruction. We sought to explore internist and geriatrician perspectives regarding current strengths and weakness of geriatric education, and perceived supports, barriers, and strategies to enhance geriatric education in an IM residency program.

METHODS

Using social learning theory as a conceptual framework, we conducted a needs assessment using focus groups and semi-structured interviews with IM residency leadership and geriatricians at an academic medical center. Interviews were recorded and transcribed; thematic analysis was performed on deidentified transcripts.

RESULTS

We recruited faculty by e-mail in 2021; eight geriatricians and seven internists participated (60% female, 13% Hispanic/Latino, and 73% White). Six participated in two virtual focus groups and nine participated in virtual one-on-one interviews. All had at least monthly teaching contact with residents and six were associate program directors. We identified five key themes: (1) professional role models, (2) personal attitudes toward aging, (3) the powerful influence of patients, (4) clinical complexity of geriatrics, and (5) branding and prestige of the field. Participants offered multiple suggestions for improvement, especially faculty development for non-geriatrician faculty.

CONCLUSIONS

Geriatric education for IM residents is impacted by multiple factors, but uniformly viewed as important. Moving forward, programs could capitalize on opportunities for closer collaboration between residency leadership, internists, and geriatricians to train the next generation of IM residency graduates to deliver age-friendly care.

A Nurse/Intern Partnership Program Accelerates Positive Relationship Formation Between Pediatric Interns and Pediatric Nurses

BACKGROUND

The relationship between nurses and interns affects the quality of patient care; efforts to improve this relationship are necessary for optimal care. Previously, relationship formation was found to depend on mutual trust, respect, effective communication, and undergoing the process of role formation, all of which require time. This led to the hypothesis that instituting a Nurse/Intern Partnership Program (NIPP) would accelerate relationship formation.

METHODS

Using a semi-structured interview guide, prior to NIPP implementation, one nurse (n = 5) and 2 second-year resident (total n = 6) focus groups were held. After implementation, one nurse (n = 6) and one intern (n = 9) focus group were held. The focus group data were analyzed using the 5 stages of qualitative research framework.

RESULTS

Thematic data analysis with 3 independent coders supported the previously developed model of relationship formation; the NIPP accelerated relationship formation between nurses and interns through creating an early ally, improving communication, and increasing role understanding. The program may have improved the culture of the pediatric unit. The interns reported more of a positive impact of the NIPP on nurse/intern relationship than the nurses.

CONCLUSIONS

The NIPP was positively received by pediatric residents and nurses and successfully accelerated relationship formation between the 2 groups.

A Conceptual Framework for Instructional Design of a High Acuity and Low Occurrence Event - Simulation Based Education Training of Residents, Medical Students, and Nurses in Anaphylaxis Utilizing Curated Educational Theories

The broad goal of this educational curriculum is utilization and optimization of Simulation-Based Education (SBE) in the training of residents, medical students, and nursing staff involved in the rapid and timely recognition of Anaphylaxis and its optimized treatment. A critical gap in Anaphylaxis Diagnosis, Management, and Treatment (ADAM) has been well established across medical disciplines. It is imperative to include all members of the healthcare team, as nurses and pharmacists play key roles in anaphylaxis recognition and care. Nurses and pharmacists are proficiently trained in the initial assessment of acute patient complaints, status, and in proper dosing/administration considerations. Anaphylaxis is a High Acuity and Low Occurrence (HALO) event. Delayed recognition and administration of epinephrine-autoinjector (EAI) is a patient safety concern. Suboptimal technique and expertise in this regard is common. Literature abounds with reports of physician trainee doubts and uncertainties in the recognition and optimized management of Anaphylaxis. Importantly, Anaphylaxis is frequently misdiagnosed in hospital emergency departments. SBE methodologies are ideal for instructing HALO experiences. The framework of the "Zone of Simulation Matrix" supports the utilization of a simulation experience in this instance. Learning will be effective, enhanced, and made durable by embedding numerous specifically curated educational theories. Given the paucity in training of residents and nursing staff in Anaphylaxis, such instruction is imperative. Of note, a special emphasis in this curricular framework is the debriefing experience. Considerations will be given to the psychological safety of the trainees and the importance of the heterogeneity of prior experiences. Precise diagnosis minimizes mortality. In the hospital setting, nurses are the first responders to critical HALO events, and there is a lack of awareness of ADAM by nursing students.

[The role of the health executive with the residents in Ehpad]

The personalized quality support for residents of residential establishments for dependent elderly people, specified in the law of January 2, 2002, is implemented through various tools and regular evaluations. The health executive, as the central link in the chain, has a key role to play in carrying out these actions, which are part of a continuous quality improvement process.

Factors Influencing the Time of Intubation Using C-MAC D-Blade® Video Laryngoscope: An Observational Cross-Sectional Study

Purpose C-MAC D-Blade® (Karl Storz, Tuttlingen, Germany) video laryngoscope (VL) has proved to be of immense utility in difficult intubation. But unfortunately, in an urgent situation, the predictable correct curvature of the endotracheal tube for effortless intubation is not met. We hypothesized that expertise is the most important variable in intubation and that novice students will be unable to intubate if the angle of curvature is incorrect. Methods An observational cross-sectional study was planned with 30 anesthesia residents, categorized into three groups based on their expertise in laryngoscopy. Students had to intubate an airway mannequin using the C-MAC D-Blade® VL with three different stylet angulations. The curvatures were 80, 100, and 120 degrees, which are commonly encountered in routine day-to-day practice. The time to get a stable glottic view, time to intubate, and ease of intubation were measured. Results The mean time to intubate was the least with 100-degree angulation in group C (19.60 ± 0.97) while the maximum time was in group A with 80-degree angulation (61.49 ± 3.69). A significant difference was noted in time to get a stable glottic view when compared between the groups. There was no difference in time to intubate with different stylet angulations when compared between groups. Conclusions Novices and experts could intubate even if the angle of curvature was incorrect taking more time. The time to laryngoscopy is significantly dependent on experience, but the time to intubate is influenced by the angle of curvature of the stylet.

Attention Deficit Hyperactivity Disorder in Medical Learners and Physicians and a Potentially Helpful Educational Tool

Purpose

Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder characterized by functionally impairing levels of inattention and/or hyperactive-impulsive behavior. It affects 3% to 5% of adults. This perspective piece aims to highlight the occurrence of ADHD in medical learners and physicians, including its reported prevalence in these groups, why reported rates may reflect underestimates, consequences of untreated symptoms, and a potentially helpful innovative educational tool to assist these individuals with a critical aspect of medical training and practice.

Results

Despite recent attention being paid to concerning levels of depression, anxiety, and burnout in medical learners and physicians, comparatively little attention has been devoted to the occurrence of ADHD in these groups. Reported rates of ADHD in medical learners and physicians, though low compared to rates of other mental health conditions and compared to rates of ADHD in the general population, may represent underestimates for a variety of reasons. The consequences of untreated ADHD symptoms are likely numerous and significant for these groups. Research has shown that about half of adults with ADHD discontinue prescribed treatment (stimulant medication) over time due to lack of perceived effectiveness, highlighting the need for durable, effective interventions to help medical learners and physicians with ADHD during and after their training. An innovative educational tool to assist medical learners and physicians with ADHD with a critical facet of their training and practice - the reading of scientific articles - is proposed, including a description of the tool, rationale for its design, practical considerations around implementation, and proposed directions for future research.

Conclusion

Untreated ADHD in medical learners and physicians may have numerous and significant consequences that can adversely impact training, practice, and ultimately patient care. These challenges warrant proper support for medical learners and physicians with ADHD via evidence-based treatments, program-based accommodations, and innovative educational tools.

Reassessing the July Effect: 30 Years of Evidence Show No Difference in Outcomes

OBJECTIVE

The aim of this study was to critically evaluate whether admission at the beginning versus end of the academic year is associated with increased risk of major adverse outcomes.

SUMMARY BACKGROUND DATA

The hypothesis that the arrival of new residents and fellows is associated with increases in adverse patient outcomes has been the subject of numerous research studies since 1989. Methods: We conducted a systematic review and random-effects meta-analysis of July Effect studies published before December 20, 2019, looking for differences in mortality, major morbidity, and readmission. Given a paucity of studies reporting readmission, we further analyzed 7 years of data from the Nationwide Readmissions Database to assess for differences in 30-day readmission for US patients admitted to urban teaching versus nonteach-ing hospitals with 3 common medical (acute myocardial infarction, acute ischemic stroke, and pneumonia) and 4 surgical (elective coronary artery bypass graft surgery, elective colectomy, craniotomy, and hip fracture) conditions using risk-adjusted logistic difference-in-difference regression.

RESULTS

A total of 113 studies met inclusion criteria; 92 (81.4%) reported no evidence of a July Effect. Among the remaining studies, results were mixed and commonly pointed toward system-level discrepancies in efficiency. Metaanalyses of mortality [odds ratio (95% confidence interval): 1.01 (0.98-1.05)] and major morbidity [1.01 (0.99-1.04)] demonstrated no evidence of a July Effect, no differences between specialties or countries, and no change in the effect over time. A total of 5.98 million patient encounters were assessed for readmission. No evidence of a July Effect on readmission was found for any of the 7 conditions.

CONCLUSION

The preponderance of negative results over the past 30 years suggests that it might be time to reconsider the need for similarly-themed studies and instead focus on system-level factors to improve hospital efficiency and optimize patient outcomes.

[Inappropriate admissions of Ehpad residents to emergency departments]

After a review of inappropriate admissions of residents of residential care facilities for the dependent elderly (Ehpad) to the emergency room, we propose ways to reduce them. They include giving the coordinating physician a clinical role, organizing continuity and permanence of care in all Ehpad, signing agreements between Ehpad and hospital for direct hospitalization and collaboration with mobile teams and geriatric hotlines, generalizing the level of medical intervention in Ehpad, and deepening the training of Ehpad caregivers in geriatrics.

Whether M.D. Pathology curriculum is sufficient to meet pathology practice requirements in India? A survey of newly qualified pathologists

Background and Objectives

Pathology is a broad subject consisting of various branches, such as hematology, clinical pathology, biochemistry, histopathology, cytology, blood banking, and others. All the subspecialties are difficult to cover in depth in a 3-year MD Pathology course and curriculum. Hence, it was decided to investigate whether the MD Pathology curriculum is able to meet the challenges of today's laboratory medicine practice. So, a survey was conducted among newly qualified pathologists who have passed their exam within last 5 years. Purpose was to know their views about MD Pathology curriculum with special emphasis on challenges they face during their day-to-day practice.

Materials and Methods

Study is designed as cross-sectional survey conducted via web-based Google forms questionnaire. Study population is pathologists qualified within last 5 years. A convenience sample of eligible pathologists was taken by sending a web-based Google form to various pathology groups on social media apps. Data were collected in the Google spreadsheet software and various responses were summarized as percentages, graphs, and pie-charts as necessary. Chi square test was used to find the significance of difference in responses from government, private, and deemed university respondents.

Results

Different numbers of responses were received to different survey questions. Out of 187 respondents, 65 (34.8%) worked in a hospital-based laboratory, 61 (32.6%) did jobs in a private laboratory, 49 (26.2%) worked in a medical college, and 37 (19.8%) worked in their own private laboratories. Out of 193 respondents, 158 (81.9%) were working in hematology, 149 (77.2%) in clinical pathology, 139 (72%) in cytopathology, 118 (61.7%) in histopathology, whereas 103 (53.4%) worked in clinical biochemistry, and least number of respondents, i.e., 38 (19.7%) were working in blood bank. Almost all the respondents had overlapping work in hematology and other areas. The level of confidence rated by the respondents was best in hematology, followed by clinical pathology; it was least for clinical biochemistry and blood bank. Out of 192 respondents, 64.1% (123) felt that the curriculum does not equip them for lab management and administration, 21.9% (42) felt that the curriculum somewhat equipped them; whereas only 14.1% (27) felt that curriculum equips them for this task. There were 191 responses to the question regarding satisfaction with MD Pathology curriculum; out of which, 51.8% (99) were not satisfied, 24.6% (47) said they may be satisfied, whereas 23.6% (45) were satisfied with the curriculum. There was no significant difference in responses from government, private, and deemed university respondents.

Conclusions

The graduating MD Pathology students expressed confidence in reporting routine cases of hematology, clinical pathology, routine cytology, and histopathology. However, there is difficulty in clinical biochemistry, blood banking, and reporting of malignancies. The laboratory management and administration, communication skills, and quality assurance are also other areas of weakness. MD Pathology program needs more focus on these weaknesses, so that newly qualified graduate would feel confident in day-to-day laboratory working.

A consensus list of ultrasound competencies for graduating emergency medicine residents

OBJECTIVES

Emergency ultrasound (EUS) is a critical component of emergency medicine (EM) resident education. Currently, there is no consensus list of competencies for EUS training, and graduating residents have varying levels of skill and comfort. The objective of this study was to define a widely accepted comprehensive list of EUS competencies for graduating EM residents through a modified Delphi method.

METHODS

We developed a list of EUS applications through a comprehensive literature search, the American College of Emergency Physicians list of core EUS benchmarks, and the Council of Emergency Medicine Residency-Academy of Emergency Ultrasound consensus document. We assembled a multi-institutional expert panel including 15 faculty members from diverse practice environments and geographical regions. The panel voted on the list of competencies through two rounds of a modified Delphi process using a modified Likert scale (1 = not at all important, 5 = very important) to determine levels of agreement for each application-with revisions occurring between the two rounds. High agreement for consensus was set at >80%.

RESULTS

Fifteen of 15 panelists completed the first-round survey (100%) that included 359 topics related to EUS. After the first round, 195 applications achieved high agreement, four applications achieved medium agreement, and 164 applications achieved low agreement. After the discussion, we removed three questions and added 13 questions. Fifteen of 15 panelists completed the second round of the survey (100%) with 209 of the 369 applications achieving consensus.

CONCLUSION

Our final list represents expert opinion on EUS competencies for graduating EM residents. We hope to use this consensus list to implement a more consistent EUS curriculum for graduating EM residents and to standardize EUS training across EM residency programs.

No difference in subsequent trainee satisfaction associated with in-person exposure prior to remote interviews

BACKGROUND

In 2020-2021, residency and fellowship applicants participated in virtual interviews. There was concern that trainees who had not been to the area before would potentially have different satisfaction with their new workplace and community.

OBJECTIVE

To compare satisfaction and likelihood to recommend work and community among new trainees with or without prior exposure to a single academic center or its environs.

METHODS

We conducted an IRB-approved cross-sectional survey of new trainees. An electronic survey included demographic items, self-report of prior exposure to the area, satisfaction with the program and area, and likelihood to recommend the program and area. Descriptive statistics were used for responses and Chi square tests for comparisons.

RESULTS

In September 2021 and May 2022 electronic surveys were sent to all 173 trainees who started residency or fellowship in July 2021, which had 87 responses (50.3% response rate) and 31 (18.0% response rate) responses, respectively. At both times, most respondents were interns. The majority of the September group (55.6%), while 38.7% of the May group had prior exposure to the area. Overall, the majority were satisfied with Penn State Health and would recommend their workplace. The majority also agreed they were satisfied with their new community and would recommend it to others. There were no significant differences in the proportions of satisfied trainees for any of the four outcomes at either timepoint.

CONCLUSIONS

Satisfaction with training and the community were not significantly different for trainees with or without prior in-person exposure to the institution or surrounding area.

Evaluating the Impact of Supervision on Surgical Trainees Stress Response During Simulated Surgical Procedures; A Crossover Randomized Trial

OBJECTIVE

The aim of this study was to evaluate the cumulative impact of supervision on technical skills and surrogate stress markers in surgical trainees.

DESIGN

This was a quasi-experimental crossover study to evaluate the impact of attending supervision on orthopedic trainee stress response during a simulated surgical procedure. Enrolled residents performed a proximal femoral nail module with the Precision OS system twice; once independently, and once under direct attending supervision, whilst wearing a heart rate monitor. Mean and maximum heart rates were recorded. Simulated performance was assessed using validated simulator-based metrics. Student's t-test was used to evaluate the impact of supervision on trainee heart rate, and performance ranking.

SETTING

Tertiary trauma center in a Regional Orthopedic Unit PARTICIPANTS: Orthopedic interns and residents within our institution were invited to participate, with 20 participants included for analysis.

RESULTS

Both supervised and unsupervised mean heart rate was significantly higher (p = 0.001) than baseline recorded heart rates. Supervised mean and maximum HR were significantly higher than unsupervised HR during module completion (p = 0.015; p = 0.001). Calories burned demonstrated correlation to surrogate stress markers, significantly higher in supervised sessions (p = 0.004). Performance metrics demonstrated superior performance in senior-level participants, with a decrement in performance during supervision, failing to reach significance.

CONCLUSION

The development of accretion of technical and non-technical skills required in surgical training pathways may derive benefit from the use of simulation-based training in surgical residents with both supervised and unsupervised sessions.

Using Electronic Health Record Meta-Data to Identify Variation in Trainee Progress Note Writing Patterns: Opportunity to Enhance Systems-Based Care

OBJECTIVE

Daily progress notes are the backbone of all inpatient hospitalizations. Progress notes serve as a lasting record of a patient's diagnoses, condition, and planned interventions and are essential communication tools. We designed a study to identify patterns in progress note filing and use on general surgical services.

METHODS

The electronic health record (EHR) data warehouse was queried for general surgical progress notes signed between July 1, 2020, and July 1, 2021. Only notes authored by resident physicians or advanced practice providers (APPs) were included, and those filed on the day of a surgery were excluded. 10 am was identified as a target for note completion as it coincided with multidisciplinary discharge rounds. Physician, case managers pharmacist, physical therapist, dietician, nurse (and collaborating disciplines) progress note views were measured using EHR access log data.

RESULTS

A total of 8384 progress notes were analyzed; 4146 notes (49%) were authored by 81 trainees. A total of 4433 (53%) progress notes were filed before 10 am, 3673 (44%) were filed between 10 am and 6 pm, and 278 (3%) were filed after 6 pm. Variation in progress note file time was observed and associated with individual habits, residents vs APPs, day-of-week, and service structure. Surgery progress notes are viewed by collaborating disciplines throughout the workday, with high-volume viewership occurring by mid-morning. Each individual progress note received an average of 17.6 lifetime views with a range of 1 to 76. An average of 10.2 of those views occurred on the same day that the note was written. Notes that were filed after 10 am received a significantly lower number of same-day views compared to notes filed before 10am (8.4 vs 11.8, p < 0.0001).

CONCLUSIONS

Progress notes are identified as a significant burden by trainees and even considered to contribute to duty hour violations, yet they are used regularly as a source of information for collaborating disciplines. Progress notes filed earlier are viewed more frequently. Efforts to identify barriers to timeliness may help communication and efficiency of inpatient surgical care.

Training in Expression of Authentic Condolences in Healthcare: A Pilot Study

Background: Bereaved parents value receiving support from their children's health care teams. Pediatric residents are important members of the teams that care for children at end of life and can play a meaningful role in communication with bereaved families. Yet formal training in expressing condolences is currently lacking. Methods: We applied Kern's six step approach to develop, implement, and evaluate an innovative curriculum aimed at increasing pediatric residents' comfort levels with and practice of condolence expression. Results: Twelve residents participated in the pilot study. Quantitative and qualitative data demonstrate that residents' comfort levels with expressing condolences increased after implementation of the curriculum and that residents appreciated and benefitted from receiving this education. Conclusion: We successfully developed and piloted a condolence expression curriculum that was well received by pediatric residents and led to increased comfort level with expressing condolences. Research is ongoing to determine the full impact of this curriculum.

Burnout Among Pharmacy Preceptors in Northern California

Objective. The objectives of this study were to investigate the incidence of burnout syndrome among pharmacy preceptors and to identify predictors for the development of burnout in this population.Methods. This cross-sectional survey study examined burnout syndrome among pharmacy preceptors in Northern California. Preceptors were included if they self-identified as a preceptor to advanced pharmacy practice experience (APPE) students or to postgraduate pharmacy residents in their first year of residency. Burnout was assessed using the Maslach Burnout Inventory Human Services Survey, and preceptors were classified as having burnout syndrome if they scored high on emotional exhaustion and also either scored high on depersonalization or scored low on personal accomplishment. Additionally, respondents' demographics, workplace environment, workload, and day-to-day workflow were queried to help determine predictors of burnout syndrome among this population.Result. The study included 113 pharmacy preceptors. Of the preceptors, 22% reported scores consistent with burnout, with 57% of preceptors scoring positive for burnout in one of the three burnout criteria. On multivariate regression analysis, two independent risk factors for burnout syndrome were identified: preceptors who precepted many difficult or unmotivated learners per year and preceptors who did not feel their contributions as preceptors were appreciated by their institution.Conclusion. The rate of burnout among pharmacy preceptors is high, with preceptors exhibiting high emotional exhaustion and low levels of personal accomplishment. Predictors of burnout syndrome for this population appear to be precepting many difficult or unmotivated learners and not feeling that one's contributions as a preceptor are appreciated.

Moving our care home: A qualitative study of the views and experiences of residents, relatives and staff

INTRODUCTION

Involuntary relocation when care homes close can be detrimental to residents' health and well-being and is associated with increased mortality. There is little formal evidence to support whether planning can mitigate the impact of such moves. This study aimed to understand the experiences of a whole care home relocation where staff and residents relocated together using existing published guidance.

METHODS

A longitudinal qualitative research study using individual face-to-face semi-structured interviews was conducted between August 2018 and August 2019. Baseline interviews were conducted 6-8 weeks after relocation with follow-up interviews 10-12 months later. Interviews were recorded, transcribed and analysed using framework analysis.

RESULTS

27 interviews were conducted; 19 baseline interviews (4 residents, 7 family members, 8 staff) and 8 follow-up interviews (2 residents, 2 family members, 4 staff). Participants' feelings about the relocation were mixed: some reported apprehension before the move but others excitement. Residents and families felt variably involved in planning the move, whereas staff expressed lack of involvement. Time, family support and continuity of care helped participants settle in. The new environment shaped participants' experiences and abilities to adjust, especially the lack of a homely feeling with the new home, the larger size and changes in staff organisation and management.

CONCLUSIONS

Despite implementation of existing guidance, relocation was still challenging for residents, staff and family members. Future relocations should increase involvement of staff in the planning and design of the home; offer continuous support to those involved; and ensure continuity of care and management style.

'Safety First': Residents, Families, and Healthcare Staff Experiences of COVID-19 Restrictions at an Irish Residential Care Centre

The COVID-19 pandemic and the need to stem the transmission and protect the most vulnerable in society led to infection control restrictions effectively locking down an entire country. These restrictions were also imposed on residential care settings for older people, initially in March 2020, and subsequently at varying times throughout the year that followed. Furthermore, the restrictions led to the suspension in all visiting to residents expect in exceptional circumstances and on compassionate grounds. The purpose of this research study was to develop an understanding of the experience of residents, their families, and carers in an Irish residential care setting during the COVID-19 lockdown. Data were collected in a residential care centre for older people in Ireland, using semi-structured interviews of residents, family members and staff. Interviews were conducted in person for residents and virtually for family members and staff. In total 29 people were interviewed. Data were analysed using Braun and Clarke's thematic data analysis approach. Four themes and three subthemes were developed from the data. The main themes were 'difficult but safe', 'communication', 'staff going above and beyond', 'what about the future?' Residents, families and staff of the residential care setting had to manage and cope with the challenges of the restrictions imposed during COVID-19 lockdown. This study highlighted the negative impacts of visiting restrictions on staff, residents and their family members during the COVID-19 lockdown.

Surgical checklist adherence across urology expertise levels impacts TURBT quality indicators

OBJECTIVES

To address the association of perioperative surgical checklist across variable surgical expertise with transurethral resection of bladder tumor (TURBT) accuracy and oncologic outcomes in non-muscle invasive bladder cancer (NMIBC).

MATERIALS AND METHODS

we relied on our prospective collaborative database of patients treated with TURBT between 2012 and 2017. Surgical experience was stratified into three groups: resident vs young vs expert consultants. The association of surgical experience with detrusor muscle (DM) presence and adherence to the standardized peri-procedural 9-items TURBT checklist was evaluated with logistic regression models. A Cox regression model was used to investigate the association of surgical experience with recurrence-free survival (RFS).

RESULTS

A total of 503 patients were available for analysis. TURBT was performed by expert consultants in 265 (52.7%) patients, by young consultants in 149 patients (29.6%) and by residents in 89 patients (17.7%). Residents were more likely to have DM in the TURBT specimen than expert consultants (OR: 1.75, 95%CI 1.03-2.99, p=0.04). Conversely, no differences in DM presence were observed between young vs expert consultants (OR: 1.09, 95%CI 0.71-1.70, p=0.69). The median checklist completion rate was higher for both residents and young consultants when compared to experts counterparts (56% and 56% vs 44%, p=0.009). When focusing on patients receiving a 2^nd look TURBT, the persistent disease was associated with resident status (OR: 4.24, 95%CI 1.14-17.70, p=0.037) at initial TURBT. Surgical experience was not associated with 5-years RFS.

CONCLUSION

Surgeon's experience in case of adequate perioperative surgical checklist implementation was inversely associated with the presence of DM in the specimen but directly linked to higher probability of persistent disease at Re-TURBT, although no 5-yr RFS differences were noted.

Single Surgeon versus Co-Surgeons in Primary Total Joint Arthroplasty: Does "Two Is Better than One" Apply to Surgeons?

BACKGROUND

As the demand for total joint arthroplasties (TJA) increases steadily, so does the pressure to train future surgeons and, at the same time, achieve optimal outcomes. We aimed to identify differences in operative times and short-term surgical outcomes of TJAs performed by co-surgeons versus a single attending surgeon.

METHODS

A retrospective analysis of 597 TJAs, including 239 total hip arthroplasties (THAs) and 358 total knee arthroplasties (TKAs) was conducted. All operations were performed by one of four fellowship-trained attending surgeons as the primary surgeon. The assisting surgeons were either attendings or residents.

RESULTS

In 51% of THA and in 38% of TKA, two attending surgeons were scrubbed in. An additional scrubbed-in attending was not found to be beneficial in terms of surgical time reduction or need for revision surgeries within the postoperative year. This was also true for THAs and for TKAs separately. An attending co-surgeon was associated with a longer hospital stay (p = 0.028). Surgeries performed by fewer surgeons were associated with a shorter surgical time (p = 0.036) and an increased need for blood transfusion (p = 0.033). Neither the rate of intraoperative complications nor revisions differed between groups, regardless of the number of attending surgeons scrubbed in or the total number of surgeons.

CONCLUSION

A surgical team comprised of more than a single attending surgeon in TJAs was not found to reduce surgical time, while the participation of residents was not related with worse patient outcomes.

Effects of Practicing With and Obtaining Crowdsourced Feedback From the Video-Based Communication Assessment App on Resident Physicians' Adverse Event Communication Skills: Pre-post Trial

BACKGROUND

US residents require practice and feedback to meet Accreditation Council for Graduate Medical Education mandates and patient expectations for effective communication after harmful errors. Current instructional approaches rely heavily on lectures, rarely provide individualized feedback to residents about communication skills, and may not assure that residents acquire the skills desired by patients. The Video-based Communication Assessment (VCA) app is a novel tool for simulating communication scenarios for practice and obtaining crowdsourced assessments and feedback on physicians' communication skills. We previously established that crowdsourced laypeople can reliably assess residents' error disclosure skills with the VCA app. However, its efficacy for error disclosure training has not been tested.

OBJECTIVE

We aimed to evaluate the efficacy of using VCA practice and feedback as a stand-alone intervention for the development of residents' error disclosure skills.

METHODS

We conducted a pre-post study in 2020 with pathology, obstetrics and gynecology, and internal medicine residents at an academic medical center in the United States. At baseline, residents each completed 2 specialty-specific VCA cases depicting medical errors. Audio responses were rated by at least 8 crowdsourced laypeople using 6 items on a 5-point scale. At 4 weeks, residents received numerical and written feedback derived from layperson ratings and then completed 2 additional cases. Residents were randomly assigned cases at baseline and after feedback assessments to avoid ordinal effects. Ratings were aggregated to create overall assessment scores for each resident at baseline and after feedback. Residents completed a survey of demographic characteristics. We used a 2×3 split-plot ANOVA to test the effects of time (pre-post) and specialty on communication ratings.

RESULTS

In total, 48 residents completed 2 cases at time 1, received a feedback report at 4 weeks, and completed 2 more cases. The mean ratings of residents' communication were higher at time 2 versus time 1 (3.75 vs 3.53; P<.001). Residents with prior error disclosure experience performed better at time 1 compared to those without such experience (ratings: mean 3.63 vs mean 3.46; P=.02). No differences in communication ratings based on specialty or years in training were detected. Residents' communication was rated higher for angry cases versus sad cases (mean 3.69 vs mean 3.58; P=.01). Less than half of all residents (27/62, 44%) reported prior experience with disclosing medical harm to patients; experience differed significantly among specialties (P<.001) and was lowest for pathology (1/17, 6%).

CONCLUSIONS

Residents at all training levels can potentially improve error disclosure skills with VCA practice and feedback. Error disclosure curricula should prepare residents for responding to various patient affects. Simulated error disclosure may particularly benefit trainees in diagnostic specialties, such as pathology, with infrequent real-life error disclosure practice opportunities. Future research should examine the effectiveness, feasibility, and acceptability of VCA within a longitudinal error disclosure curriculum.

Comparison of surgical outcomes of emergent laparoscopic cholecystectomy for acute cholecystitis between attending surgeons and senior residents: A propensity-matched analysis

INTRODUCTION

Emergent laparoscopic cholecystectomy (LC) is routinely performed for acute cholecystitis (AC) at our institution. This study was conducted to investigate the feasibility and safety of emergent LC for AC performed by senior residents.

MATERIALS AND METHODS

Data from 362 patients with AC who underwent emergent LC between January 2012 and June 2020 were retrospectively reviewed. Of these patients, 328 were operated on by senior residents (SR), and 34 were operated on by the attending surgeon (AS). Clinical characteristics and surgical and postoperative outcomes were compared between the SR and AS groups. Propensity score matching was used to minimize selection bias. When the operator was an SR, the LC was assisted by the AS.

RESULTS

Before matching, in the SR group, more patients had a history of abdominal surgery, and C-reactive protein and white blood cell counts were significantly higher. In the image findings, the minor axis of the gallbladder (GB) was longer, and the wall of the GB was thicker in the SR group. After propensity score matching, 28 pairs were identified. There were no significant differences in operative time (83 vs 88 minutes, P = .92), the amount of blood loss (25 vs 10 mL, P = .13), conversion to open surgery (3.6% vs 3.6%, P = 1), postoperative complications (7.2% vs 0%, P = .74), and postoperative hospital stay (4 vs 4 days, P = .87).

CONCLUSION

Emergent LC for AC performed by SR under supervision appears to be feasible and safe.

Are there differences in cardiothoracic surgery performed by trainees versus fully trained surgeons?

OBJECTIVES

We sought to assess the safety of training in cardiothoracic surgery comparing outcomes of cases performed by trainees versus fully trained surgeons.

METHODS

EmBase, Scopus, PubMed, and OVID MEDLINE were searched in August 2021 independently by two authors. A third author arbitrated decisions to resolve disagreements. Inclusion criteria were articles on cardiothoracic surgery reporting on outcomes for trainees. Studies were assessed for appropriateness as per CBEM criteria. Eight hundred and ninety-two results were obtained, 27 represented best evidence (2-meta-analyses, 1-RCT, and 24 retrospective cohort studies).

RESULTS

In all 474,160 operative outcomes were assessed for 434,535 coronary artery bypass grafting (CABG) (431,329 on-pump vs. 3206 off-pump), 3090 AVR, 1740 MVR/repair, 26,433 mixed, 3565 congenital, and 4797 thoracic procedures. In all 398,058 cases were performed by trainees and 75,943 by consultants. One hundred fifty-nine cases were indeterminate. There were no statistically significant differences in the patients' preoperative risk scores. All studies excluded extreme high-risk patients in emergency setting, patients with poor left ventricular function, and reoperation cases that were undertaken by consultants. There were no differences in cardiopulmonary bypass and clamp times for CABG. Times for valve replacement and repair cases were longer for trainees. There were no differences in the postoperative outcomes including perioperative myocardial infarction, resternotomy for bleeding, stroke, renal failure, intensive therapy unit length of stay, and total length of stay. One study reported no differences on angiographic graft patency at 1 year. There were no differences in in-hospital or midterm mortality out to 5-years.

DISCUSSION

Trainees can perform cardiothoracic surgery in dedicated high-volume units with outcomes comparable to those of fully trained surgeons.

Social Media Impact of Articles Published by Dermatology Residents During Medical School: Cross-sectional Study

BACKGROUND

The Altmetric score (AS) is a novel measure of publication impact that is calculated by the number of mentions across various social media websites. This method may have advantages over traditional bibliometrics in the context of research by medical students.

OBJECTIVE

This study aimed to determine whether dermatology matriculants who graduated from higher-ranked medical schools published more articles with greater impact (ie, a higher AS) than those from lower-ranked institutions.

METHODS

A PubMed search for articles published by dermatology residents who started medical school in 2020 was conducted. Demographic information and Altmetric data were collected, and medical schools were sorted according to US News' top-25 and non-top-25 categories.

RESULTS

Residents who completed their medical training at a top-25 institution published more papers (mean 4.93, SD 4.18 vs mean 3.11, SD 3.32; P<.001) and accrued a significantly higher total AS (mean 67.9, SD 160 vs mean 22.9, SD 75.9; P<.001) and average AS (mean 13.1, SD 23.7 vs mean 6.71, SD 32.3; P<.001) per article than those who graduated from non-top-25 schools.

CONCLUSIONS

Our results indicate that students in top-25 schools may have greater access to research resources and opportunities. With a pass/fail United States Medical Licensing Examination Step 1 exam that may increasingly shift focus toward scholarly output from medical students, further discussion on how to create a more equitable dermatology match is essential.

The Impact of COVID-19 Pandemic on Ophthalmology Residency Education

OBJECTIVES

The aim of this study is to investigate the theoretical, practical, and academic effects of the Coronavirus disease 2019 (COVID-19) pandemic on ophthalmology residents.

METHODS

The web-based survey consisting of 28 questions was sent through Email to 37 educators who provides resident training. We divided the pandemic period into three, according to the severity of the pandemic and the measures, compared with pre-pandemic period (PreP), separately. Between March 2020 and June 2020 was named as P1, June 2020-October 2020 was named as P2, and October 2020-March 2021 was named as P3.

RESULTS

Responses received from 35 centers (17 university hospitals, 18 training and research state hospitals). There were totally 458 residents in the hospitals. Two hundred and forty-six of them (53.71%) worked on COVID-19 duties, with an average working time of 69.57 days. There were significant decreases in the number of patients examined by resident doctors and theoretical training time in the P1, P2, and P3 periods compared to PreP (p<0.05 for all). Furthermore, in terms of the total number of surgeries in clinics and surgeries performed by residents, there were significant decreases in P1 and P2 compared to PreP (p<0.001 for both), but there was no significant difference in P3 (p=0.109). In the examinations held in the clinic, in the 1st year of the pandemic, the grade average was lower than before the pandemic (p<0.05). Seventeen residents (3.74%) resigned or moved to another hospital.

CONCLUSION

The COVID-19 pandemic has severely affected the theoretical, practical, and academic training of ophthalmology residents.

Impact of an Ultrasound Demonstration on Vascular Surgery Interest in Pre-Clinical Medical Students

OBJECTIVES

One strategy to address the impending shortage of vascular surgeons is to augment interest in the trainee pipeline. Endovascular procedures are unique to vascular surgery (VS), and endovascular simulations have proven effective at generating VS interest in the past. Like endovascular techniques, the use of ultrasound (US) testing in VS is unique among medical specialties. We hypothesized that an interactive US demonstration would increase VS interest in pre-clinical medical students.

METHODS

We created a 5-point Likert scale survey assessing interest in VS, understanding of VS, likelihood to further investigate VS, choosing VS as a rotational elective, and pursuing VS shadowing and research opportunities. This survey was administered 1 day before and 1 day after the demonstration. Results were compared via paired T-test. A VS attending assisted by a senior registered vascular technologist (RVT) covered physics, B-mode, and continuous, pulsed wave, and color Doppler in an interactive, hands-on experience. Our dedicated ultrasound simulation lab enabled simultaneous interactive virtual broadcast and in-person learning. All first- and second-year students at our medical school were invited via email.

RESULTS

512 students were invited, 39 attended, and 19 students who completed surveys were included. 68% were female. Attendance at the ultrasound demonstration resulted in a significant increase in students' interest in vascular surgery (p=0.012), understanding of vascular surgery (p<0.001), likelihood to further investigate vascular surgery (p<0.001), likelihood to choose a vascular surgery rotation (p<0.001), and likelihood to pursue vascular surgery shadowing and research opportunities (p<0.001). Though only 2 of 6 in-person attendees returned surveys, their increase in average response to all questions was higher than virtual attendees (+1.80 vs +0.91, p=0.043).

CONCLUSIONS

Attending an interactive US demonstration significantly increased pre-clinical medical students' interest in and understanding of VS. In-person and virtual attendance both had positive impact. Such a demonstration may be an effective tool to recruit students. It is imperative that we continue innovating to address the future shortage of vascular surgeons.

TLC-Act: A Novel Tool for Managing Drug Interactions

Background

Clinical decision support systems (CDSS) are used by pharmacists to assist in managing drug-drug interactions (DDIs). However, previous research suggests that such systems may perform suboptimally in providing clinically relevant information in practice.

Objectives

The primary objective of this study was to develop a novel DDI management tool to reflect the clinical thought process that a pharmacist uses when assessing a DDI. The secondary objective was to investigate practitioners' perceptions of this tool.

Methods

This study was conducted in 3 phases: development of the DDI management tool, implementation of the tool in clinical practice, and collection of practitioners' opinions of the tool through an online qualitative survey (although because of circumstances related to the COVID-19 pandemic, the study population for the survey phase included only pharmacy residents). A comprehensive literature search and analysis by an expert panel provided underlying context for the DDI management tool. The tool was validated through simulation against a known list of DDIs before implementation into practice by hospital pharmacists and pharmacy residents. Participating pharmacy residents were invited to provide feedback on the tool. Survey results were analyzed using descriptive statistics.

Results

The novel tool that was developed in this study (called TLC-Act) consisted of components important to a pharmacist when assessing a DDI, including the duration of concomitant use of the interacting medications and patient-specific risk factors. Study participants implemented the tool in clinical practice for a total of 6 weeks. Of the 28 pharmacy residents surveyed, 15 (54%) submitted a response, of whom 11 (73%) found the TLC-Act tool to be slightly more useful for assessing a DDI than usual care with the CDSS alone.

Conclusions

The TLC-Act tool maps out a pharmacist's clinical thought process when assessing a DDI in practice. This novel tool may be more useful than a CDSS alone for managing DDIs, as it takes into account other important factors pertinent to the assessment of a DDI.

The medical activity and satisfaction of geriatric care of Mongolia residents

Nowadays, process of aging of population covers all countries of the world. In current conditions, an important moment is increasing medical activity of elderly population and old persons. The purpose of the study is to investigate social hygienic characteristics of medical activity and satisfaction with geriatric care of the elderly residents of Mongolia. The sociological survey of 726 residents of Mongolia older than able-bodied age, 75 out of which were in nursing homes, was carried out using specially designed questionnaire that included questions on assessing medical activity and satisfaction with geriatric care. The negative correlation was established between good assessment of one's own health and age of respondents. The study revealed that 90.9% of respondents noted presence of chronic pathology, but only 21.1% of them were registered in dispensary. In age group under 65 years, 75.8% of persons capable to serving themselves made up 75.8% and in age group 75 years and older only 48.1%. The analysis established that 50.2% of elderly and senile persons consulted geriatrician, while 48.3% of those who did not consult this specialist were unaware of its existence. The number of cases of respondents visiting geriatric doctor in place of their residence was higher in cities. The respondents who received geriatric medical care were completely satisfied with it in 52.7%. The causes of dissatisfaction with geriatric medical care in aimags (regions) were inattentive attitude of medical staff, low effectiveness of treatment and insufficient availability of free provision of medications. The identified social hygienic characteristics of medical activity and satisfaction with geriatric care of the elderly and senile residents of Mongolia should be taken into account in developing measures to improve this type of care in Mongolia.

A Multi-Center Comparison of Orthopaedic Attending and Resident Learning Styles

OBJECTIVE

Effective education of orthopedic residents requires an understanding of how they process information. To date however no literature has described resident learning styles based on the updated Kolb Learning Style Inventory (KLSI) v4.0. The purpose of this study is to identify common learning styles amongst orthopedic residents and attendings and evaluate the effect that race, gender, and resident/attending status have on learning styles.

DESIGN

The KLSI v4.0 and a demographic survey were distributed to 103 orthopedic attendings and residents at two academic centers during the 2019 to 2020 academic year. Frequencies and descriptive statistics were reported. Learning styles based on gender, race, attending versus resident status, and institution were evaluated. A p-value < 0.05 was considered significant.

SETTING

This is a multi-center study performed at two academic, university based orthopedic surgery departments.

PARTICIPANTS

Orthopaedic surgery residents and attending surgeons.

RESULTS

At both institutions, the combined response rate for the KLSI v4.0 was 66% and 68% for the demographic surgery. The three most common learning styles recorded were: Deciding (26.5%), Acting (17.6%), and Thinking (17.6%). Learning styles were compared by gender, race, attending and/or resident status, and institution with no statistically significant difference found between any of the comparisons (p > 0.05).

CONCLUSION

The majority of orthopedic surgeons have Deciding, Acting, or Thinking learning styles, which are categorized by motivation to achieve goals, disciplined and logical reasoning, and the use of theories and models to solve problems. However, not all residents and attendings utilize these common learning styles. A mismatch in learning styles between residents and attendings could result in poor educational experiences. Understanding the learning styles of orthopedic surgeons has implications for improving evaluation interpretation, mentorship pairing, quality of life, and resident remediation.

Learning Interrupted: Educational Impact of Interruptions on Surgical Residents

OBJECTIVE

The complex workflow of surgical residents in the workplace-based learning environment makes interruptions an unavoidable aspect of clinical work. Interruptions have been shown to affect cognitive load, surgical performance, and medical error. The purpose of this study was to describe the effects of interruptions on surgical resident education.

DESIGN

Junior residents were observed by 2 trained observers using time-motion methodology between September 2018-August 2019. Interruptions were identified and coded retroactively based on predefined criteria. We captured key features of interruptions including frequency, duration, task interrupted, outcome, and learner perceived educational value.

SETTING

This study took place at London Health Sciences Centre in London, Ontario, Canada, a tertiary level academic health care center associated with the Schulich School of Medicine & Dentistry at Western University.

PARTICIPANTS

Junior residents on a General Surgery service were eligible for participation. Participation was voluntary. 8 residents were observed over 24 clinical periods.

RESULTS

A total of 278.2 hours of resident workflow were observed, and 229 interruptions were recorded. Interruptions account for 57.9 minutes/day of a surgical resident (SD = 60.7). Interruptions occur at a frequency of 0.82 interruptions/hour. Disruptive interruptions, that interfere with the continuation or completion of the original task, occur at a frequency of 0.11 interruptions/hour. Disruptive interruptions occurred at a higher frequency of 0.34 interruptions/hour during periods of feedback, coaching and informal teaching.

DISCUSSION

We observed that tasks of higher learner perceived educational value are often interrupted by tasks of lower learner perceived education value. Valuable educational experiences such as feedback, coaching and informal teaching are interrupted at a greater rate and experience disruptions at a disproportionate rate. We identified feedback, coaching and informal teaching as an education task vulnerable to disruptive interruptions that would benefit from interventions targeted toward preventing interruption. Suggested interventions include "formalizing" feedback, coaching and informal teaching.

Medicine in Motion: Addressing Physician Burnout Through Fitness, Philanthropy, and Interdisciplinary Community Building

Physician burnout is a public health crisis. Although recent studies underscore its prevalence, there are few rigorous studies examining its prevention, especially among medical students and residents. Prior interventions have centered on mindfulness techniques and flexible workload scheduling, yielding limited success. However, interventions that combine fitness with philanthropy and community building may be more effective. The purpose of this report is 2-fold: first, to provide a review of physician burnout and potential prevention mechanisms and, second, to present a case study of how Medicine in Motion (MiM) addresses these issues. MiM facilitates various athletic workouts, competitions, and other events for students and professionals in medicine, dentistry, nursing, and physical therapy to support wellness and charitable initiatives. This analysis identifies 4 barriers to physicians and those in the health care profession from participating in wellness activities: (1) insufficient awareness, (2) logistical challenges, (3) lack of purpose, and (4) absence of perceived support. To overcome these barriers, MiM provides a model toolkit for starting a grassroots movement against physician burnout that other health care institutions may emulate. Institutions should provide financial support for these wellness programs. Future research is needed to evaluate these combined exercise, philanthropic, and community building efforts.

Examining the Impact of Fictional Life Story of Resident with Dementia on Staff Levels of Empathy, Self-confidence, Workload Burden, and Perception of Resident: A Cross-sectional Survey in Long-term Care Communities

OBJECTIVES

Determine the impact of fictional life story on staff members levels of empathy, self-confidence, workload burden, and perception of resident before the implementation of care for new resident with dementia in long-term care community.

METHODS

An online cross-sectional survey based on two fictive clinical vignettes was used: one vignette described a resident with typical medical information (e.g., level of autonomy, health status, medication …), while the other contained typical medical information and life story information. The two vignettes were visually similar. The order in which vignettes were read was counterbalanced. Staff members (n = 95) were asked to consider the care needed by these residents and to assess, with a visual analogue scale, the amount of useful information provided by vignettes, their self-confidence and level of empathy, their perception of the resident's level of sympathy, his dependence, and the associated workload.

RESULTS

After reading the vignette containing life story information, staff members considered that they had more useful information and empathy for the resident. They also felt more confident about the care. They perceived the resident as more sympathetic and less dependent, and the workload seemed lighter to them compared to the case described in the vignette that did not contain life story information.

CONCLUSIONS

This quantitative study shows, in clinical fictive situations, the positive impact of life story on staff members before care begins.

CLINICAL IMPLICATIONS

Results highlight the importance of considering life story early. Getting to know residents should be the first step of care.

Osteopathic manipulative treatment use among family medicine residents in a teaching clinic

CONTEXT

Osteopathic Principles and Practice (OPP), including osteopathic manipulative treatment (OMT) is the core foundation of the education provided by osteopathic medical schools. Multiple studies performed over the past 25 years have demonstrated that a dwindling number of osteopathic physicians utilize OMT in their practice, despite 95% of osteopathic family physicians perceiving OMT as an effective treatment modality.

OBJECTIVES

The objective of this study is to quantify how often OMT is being performed by residents in an osteopathically recognized family medicine training clinic and to identify the perceived barriers to performing OMT.

METHODS

Fifteen family medicine residents were given access to an anonymous written survey for three 2 week periods. The survey allowed them to input the total number of patient encounters for their half clinic day, the encounters in which OMT was perceived to be appropriate, the encounters in which OMT was performed, and the reasoning for encounters in which OMT was not performed. Surveys were collected anonymously, and data were input into a datasheet in which results were calculated.

RESULTS

A total of 101 survey responses were collected for a total of 304 patient encounters. OMT was performed in 5/304 (1.6%) encounters, yet it was perceived to be appropriate in 60/304 (19.7%) encounters. The primary documented reason that OMT was deferred was due to time constraints (42/50 responses, or 70.0% of the encounters in which OMT was deemed appropriate).

CONCLUSIONS

This study highlights time as the main reason OMT is deferred by residents in a teaching clinic. This provides insight into potential interventions in a training clinic to increase the use of OMT by family medicine residents.

Parabiosis in Mice to Study Tissue Residency of Immune Cells

Different populations of immune cells rely on their distinct migration patterns for immunosurveillance, immune regulation, tissue specific differentiation, and maturation. It is often important to clarify whether cells are recirculating or tissue resident, or whether tissue-specific cells are derived from blood-borne precursors or a tissue-resident population. Though migration or tissue residency of immune cells critically depends on the expression of different homing molecules (chemokine receptors, tissue retention molecules, etc.), characterization based solely on the expression of homing molecules may not faithfully reflect the migration patterns of immune cells. Therefore, a more reliable method to clarify migration patterns of immune cells is required. Parabiosis is a surgical connection of two mice resulting in a shared circulatory system, which allows reliable distinction of tissue-resident and circulating cells. Here, we describe a set of protocols for parabiosis, including technique details, pitfalls, and suggestions for optimization and troubleshooting. © 2022 Wiley Periodicals LLC. Basic Protocol 1: Preparation of mice for parabiosis surgery Basic Protocol 2: Parabiosis surgery Basic Protocol 3: Recovery and use of mice after parabiosis surgery Basic Protocol 4: Reversal of parabiotic surgery Basic Protocol 5: Analysis of parabionts.

Representativeness of Workplace-Based Operative Performance Assessments for Resident Operative Experience

OBJECTIVE

Workplace-based assessment is increasingly prevalent in surgical education, especially for assessing operative skill. With current implementations, not all observed clinical performances are assessed, in part because trainees often have discretion about when they seek assessment. As a result, these samples of observed operative performances may not be representative of the full breadth of experience of surgical trainees. Therefore, analyses of these samples may be biased. We aimed to benchmark patterns of procedures logged in the SIMPL operative performance assessment system against records of trainee experience in Accreditation Council for Graduate Medical Education (ACGME) case logs.

DESIGN

We analyzed SIMPL longitudinal intraoperative performance assessments from categorical trainees in US general surgery residency programs. We compared overall patterns of how procedures are logged in SIMPL and in ACGME case logs using a Pearson correlation, and we examined differences in how individual procedures are logged in each system using Fisher's exact test.

RESULTS

Total procedure frequency from the SIMPL dataset was strongly correlated with total procedure frequency from ACGME case logs (r = 0.86, 95% CI 0.80-0.90). A subset of these procedures (10 of 116 procedures) was logged more frequently in the SIMPL dataset. These 10 procedures accounted for 56% of SIMPL observations and 30% of ACGME logged cases. Case complexity was comparable for assessments initiated by residents and faculty.

CONCLUSIONS

Samples of intraoperative performance ratings gathered using the SIMPL application largely resemble ACGME case logs. There is no evidence to indicate that residents preferentially select fewer complex cases for assessment.

Can trainees perform Ahmed glaucoma valve surgery as effectively as attendings?

OBJECTIVE

To compare the surgical outcomes and early postoperative complications of Ahmed glaucoma valve (AGV) implantation performed by residents with those performed by attending physicians.

METHODS

This is a retrospective, case-control study. Data were gathered from chart reviews of consecutive cases of AGV model FP7 implantation between January 2014 and July 2017. Postoperative 1-year results of patients who had at least 3 months follow-up were evaluated.

RESULTS

One hundred and forty-four eyes of 144 patients were included in this study: 72 patients in the resident group, and 72 age- and sex-matched patients in the attending group. Hyphema and shallow anterior chamber were significantly more common in the resident group vs. attending group (25% vs. 2.8% and 19.4% vs. 7.0%; P = 0.001 and P = 0.04, respectively). Neovascular glaucoma (NVG) was more common in resident vs. attending group (30.6% vs. 1.4%; P < 0.001). No significant difference in mean intraocular pressure (IOP) was found at any postoperative follow-up visits between the surgery groups (P > 0.05, for all). The number of postoperative visits within 3 months was similar between the groups (P = 0.84).

CONCLUSION

Resident-performed AGV surgery lowered IOP, similar to attending-performed surgery. More frequent complications were observed in the resident group, which might be due to the predominance of NVG in this group.

TeleResidents: Exploring the use of Resident Home Workstations During the COVID Pandemic

RATIONALE AND OBJECTIVES

Since the beginning of the COVID-19 pandemic, numerous strategies have been proposed to allow for continued resident education while following social distancing guidelines. Diagnostic radiology is largely electronic work, allowing for relatively easy transition to telehealth. Our institution deployed home workstations to interested upper level radiology residents and fellows in order to maintain high volume workload and education, while complying with CDC social distancing and quarantine guidelines.

MATERIALS AND METHODS

We deployed 28 home workstations with integrated PACS, electronic health record, and reporting system, supporting workflow that matched our on-site processes and allowing residents to work from home while on diagnostic rotations. Two months into the pilot, surveys were sent to trainees and faculty to assess satisfaction related to education, productivity, and wellness. A retrospective study count was performed for a sample of residents in order to assess productivity.

RESULTS

Residents perceived their remote productivity as unchanged or better than at the hospital, while faculty were more likely to perceive it as decreased, however, objective results showed no difference. Education was largely considered worse or unchanged with very few regarding it as improved. Those utilizing shared-screen signout platforms rated education better than those utilizing voice/telephone communications only. Trainees expressed improvement in wellness and quality of life.

CONCLUSION

Home workstations for trainees represent a feasible solution for implementing social distancing or even quarantine while maintaining operational productivity. There is the added benefit of scheduling flexibility, option to overcome space constraints, and improved quality of life.

Effect of Patient Safety Curriculum for Internal Medicine Residents on a Health Care System

Background

Healthcare organizations seeking to promote a safety culture depend on engaged clinicians. Academic medical centers include a community of physicians-in-training; however, medical residents and fellows are historically less engaged in patient safety (PS) than are other clinicians. Increased attention has been focused on integrating PS into graduate medical education. Nonetheless, developing curricula that result in real-world system changes is difficult.

Objective

To develop an interactive PS curriculum for internal medicine (IM) residents that analyzes real-word PS problems.

Methods

A multidisciplinary group developed a five-session, case-based PS curriculum for IM residents in the context of a 3-year, longitudinal quality-improvement, PS, and high-value-care curriculum. The curriculum was facilitated by a PS analyst and incorporated mock root cause analysis (RCA) based on actual resident-reported PS events. Each mock RCA developed an action plan, and outcomes were tracked. Pre- and postcurriculum assessments with participating residents were conducted to evaluate the curriculum.

Results

Twenty-eight IM residents completed the curriculum during four iterations from 2017 to 2020. The curriculum identified multiple potential PS risks, led to tangible changes in clinical processes, and enhanced resident confidence in improving systems of care.

Conclusions

We describe an active-learning PS curriculum for IM residents that addressed actual resident-reported PS problems. Through RCA, action items were identified and meaningful system changes were made. Leveraging the expertise of local PS experts in the design and delivery of PS curricula may improve the translation of learner recommendations into real system changes and cultivate a positive PS culture.

Doctors' experiences of earlier mandatory postgraduate communication skills training: a qualitative study

OBJECTIVES

This study explored the question: what are doctors' perspectives on and experiences with their earlier mandatory postgraduate communication skills training?

METHODS

The study used a qualitative, exploratory design. We used purposeful sampling based on the principle of maximal variation to ensure different clinical perspectives. Thus, three focus groups were formed with 12 doctors who had attended mandatory postgraduate communication skills training within 1-9 years prior to the study. The doctors were from three specialties: internal medicine, oncology, and general practice. We used a semi-structured interview guide, and the focus groups were video-recorded. Thematic analysis was used to analyze the data material. Through an iterative process, we identified main and sub-themes.

RESULTS

The first-year residency mandatory postgraduate communication skills training provided all participants with skills that had helped them in their ongoing clinical work. In addition, five dominant themes were observed: modes of use, the timing of course, experience with experiential methods, sharing challenges with peers, and need for continuous feedback and follow-up.

CONCLUSIONS

Doctors value early mandatory postgraduate communication skills training even years after attending the course and request similar ongoing initiatives. Their experiences are positive, they found the timing relevant, and they used the learned skills in their ongoing clinical work, even years after the initial course. Our study indicates that more attention should be given to 'early career' postgraduate communication skills training that is tailored to specific clinical contexts, including hospital settings.

Longitudinal assessment of obstetrics and gynecology resident perceptions and comfort following cerclage placement simulation

BACKGROUND

Utilization of simulation training in medical education has increased over time, particularly for less common scenarios and procedures. Simulation allows trainees to practice in a low-stress environment and eliminates patient risk. Cerclage placement has become less frequent, which limits obstetrics and gynecology (OB/GYN) exposure to cerclage placement during training. This exposes an area of training requiring simulation in OB/GYN resident education.

OBJECTIVE

To evaluate resident reception to cerclage simulation, their self-reported comfort with and ability to troubleshoot difficult cerclage placement immediately and 12 months following didactic education and simulation.

METHODS

In 2019, 18/20 (90%) OB/GYN residents in our university program underwent didactic teaching and simulation in cerclage placement using a pelvic model with removable cervix. Residents completed a survey immediately and 12 months following simulation. Wilcoxon signed-rank test was used to analyze resident self-report of comfort with cerclage placement and skill techniques for navigating difficult placement before and after simulation training. Descriptive statistics were analyzed as means and standard deviations.

RESULTS

Eighteen of twenty (90%) residents participated in the education session in cerclage placement. All 18 (100%) completed a postsimulation survey and 17/18 (94%) completed a survey 12 months later. All reported improved comfort with cerclage placement and statistically significant improvement in knowledge on techniques for troubleshooting difficult placement after simulation. All residents reported that the simulation enhanced their learning and recommended the simulation for future educational opportunities.

CONCLUSIONS

Cerclage simulation was well-received by OB/GYN residents in learning and practicing cerclage placement. Residents demonstrated improved comfort with placement following simulation.

Overnight radiology resident discrepancies at a large pediatric hospital: categorization by year of training, program, imaging modality, and report type

BACKGROUND

Overnight radiology resident discrepancies have been described in multiple studies; however, study of resident discrepancies specific to pediatric radiology is limited.

PURPOSE

To examine radiology resident discrepancies as they pertain to a large pediatric hospital system.

MATERIAL AND METHODS

A total of 21,560 preliminary reports issued by 39 residents over a one-year period were scored as agreement, minor discrepancy, or major discrepancy by faculty members using a modification of the 2009 RADPEER scoring system. Residents were trainees of three different diagnostic radiology programs: large university-based, medium-sized community-based, or small community-based. Discrepancy rates were evaluated based on resident postgraduate year, program, and imaging modality. The effect of a general pediatric radiology report versus pediatric neuroradiology report of a CT scan was also tested. CT was the only modality in which there were comparable numbers of studies scored by both general pediatric radiologists and neuroradiologists.

RESULTS

The rate of major resident to faculty assessment discrepancies was 1.01%, and the rate of minor resident to faculty assessment discrepancies was 4.47%. Major discrepancy rates by postgraduate years 3-5 were 1.08%, 0.75%, and 1.59%, respectively. Major discrepancy rates were highest for MR (11.22%), followed by CT (1.82%), radiographs (0.91%), and ultrasound (0.56%). There was no significant difference in discrepancy rate between residency programs and general pediatric radiology report of a CT versus pediatric neuroradiology report of a CT.

CONCLUSION

Radiology discrepancy rates for residents issuing preliminary reports at a large children's hospital system are similar to those reported for adult procedures.

Determining the Impact of an Educational Intervention on Family Medicine Residents' Social Cognitions and Behavior for Discussing Physical Activity

Problem: Primary care providers are recognized as important advocates for physical activity (PA); yet, clinical PA discussions remain infrequent. Educational approaches promoting the uptake of strategies that are proven to increase patient PA levels are effective for improving primary care providers' social cognitions and behavior for discussing PA with patients. However, research on the effectiveness of such educational interventions among family medicine residents is limited. Intervention: Using the Theory of Planned Behavior (TPB), an interactive, educational intervention was developed to increase PA discussion between first year family medicine residents and their patients. This study aimed to determine the impact of the intervention on residents' social cognitions and behavior for discussing PA with all adult (18-64 years) patients. Context: The intervention condition was comprised of 15 first year residents (2017/2018) who: (1) received the full intervention, and (2) completed both the pre- and post-intervention TPB questionnaires assessing changes in PA discussion social cognitions, and (3) had their medical charts reviewed for PA discussion behavior. The nonintervention condition was comprised of 15 first-year residents (2016/2017) who were randomly selected to have their medical charts reviewed for PA discussion behavior. Impact: Although no significant differences in social cognitions were observed pre- vs. post-intervention, intervention condition residents' perceptions of feeling adequately trained to discuss PA increased post-intervention (p = 0.005). A difference in residents' PA discussion behavior was observed between conditions at post (p = 0.01), where PA was discussed at more patient visits among intervention condition residents. Lessons Learned: Findings suggest that the observed effect of resident PA discussion behavior being greater in the intervention condition at post may be attributed to the intervention condition residents having received the theory-based, educational workshops. This study highlights the importance of educating and training residents on strategies for PA discussion; however, future interventions should address both the reflective and automatic processing aspects of behavior and strive to influence organizational factors that impact resident behavior for discussing PA.Supplemental data for this article is available online at at 10.1080/10401334.2021.1891542.

Origin of M2 Mϕ and its macrophage polarization by TGF-β in a mice intervertebral injury model

Introduction

Studies have identified the presence of M1 and M2 macrophages (Mϕ) in injured intervertebral discs (IVDs). However, the origin and polarization-regulatory factor of M2 Mϕ are not fully understood. TGF-β is a regulatory factor for M2 polarization in several tissues. Here, we investigated the source of M2 Mϕ and the role of TGF-β on M2 polarization using a mice disc-puncture injury model.

Methods

To investigate the origin of M2 macrophages, 30 GFP chimeric mice were created by bone marrow transplantation. IVDs were obtained from both groups on pre-puncture (control) and post-puncture days 1, 3, 7, and 14 and CD86 (M1 marker)- and CD206 (M2 marker)-positive cells evaluated by flow cytometry (n = 5 at each time point). To investigate the role of TGF-β on M2 polarization, TGF-β inhibitor (SB431542) was also injected on post-puncture days (PPD) 5 and 6 and CD206 expression was evaluated on day 7 by flow cytometry (n = 5) and real time PCR (n = 10).

Results

The proportion of CD86⁺ Mϕ within the GFP+ population was significantly increased at PPD 1, 3, 7, and 14 compared to control. CD206-positive cells in GFP-populations were significantly increased on PPD 7 and 14. In addition, the percentage of CD206-positive cells was significantly higher in GFP-populations than in GFP+ populations. TGF-β inhibitor reduced CD206-positive cells and Cd206 expression at 7 days after puncture.

Conclusion

Our findings suggest that M2 Mϕ following IVD injury may originate from resident Mϕ. TGF-β is a key factor for M2 polarization of macrophages following IVD injury.