Gender Differences in the Amount and Type of Student Participation During In-Person and Virtual Classes in Academic Medicine Learning Environments

This cohort study examines gender differences in the amount and type of student participation during in-person and virtual classes in graduate-level academic medicine learning environments.

Frontline Reporting from the Epicenter of a Global Pandemic: A Survey of the Impact of COVID-19 on Plastic Surgery Training in New York and New Jersey

BACKGROUND

Since the first documented case of coronavirus disease of 2019 (COVID-19), the greater New York City area quickly became the epicenter of the global pandemic, with over 500,000 cases and 50,000 deaths. This unprecedented crisis affected all aspects of health care, including plastic surgery residency training. The purpose of this study was to understand the specific impact of the COVID-19 pandemic on plastic surgery residencies.

METHODS

A survey of all plastic surgery residency training programs in the greater New York City area was conducted. The impact to training during the peak months of infection (March and April of 2020) was evaluated using resident education as measured by case numbers, need for redeployment, and staff wellness as primary outcome variables.

RESULTS

A total of 11 programs were identified in the region, and seven programs completed the survey, with a response rate 63.6 percent. When comparing productivity in March and April of 2019 to March and April of 2020, a total decrease in surgical volume of 64.8 percent (range, 19.7 to 84.8 percent) and an average of 940 (range, 50 to 1287) cancelled clinic visits per month were observed. These decreases directly correlated with the local county's COVID-19 incidence rates (p = 0.70). A total of 83 percent of programs required redeployment to areas of need, and correlation between local incidence of COVID-19 and the percentage of residents redeployed to non-plastic surgical clinical environments by a given program (ρ = 0.97) was observed.

CONCLUSION

As the first COVID-19 wave passes the greater New York area and spreads to the rest of the country, the authors hope their experience will shed light on the effects of the ongoing COVID-19 pandemic, and inform other programs on what to expect and how they can try and prepare for future public health crises.

Novel method to link surgical trainee performance data to patient outcomes

BACKGROUND

A significant roadblock in surgical education research has been the inability to compare trainee performance to the outcomes of those surgeons after they enter independent practice. We describe the feasibility of an innovative method to link trainee performance data with patient outcomes.

METHODS

We extracted surgeon NPI numbers from Medicare claims data for common general surgery procedures between 2007 and 2017. Next, American Board of Surgery (ABS) trainee performance data was cross-referenced with additional resources to supplement NPI data. The patient and trainee datasets were linked using NPI number and a linkage rate was calculated.

RESULTS

We identified 12,952 unique surgeons in the Medicare file. Medicare surgeons were matched with ABS records by NPI number, with 96.2% (n = 12,460) of surgeons linked successfully.

CONCLUSIONS

We demonstrated a novel process to link patient outcomes to trainee performance. This innovation can enable future research investigating the relationship between surgical trainee performance and patient outcomes in independent practice.

Assessment of Discrimination, Bias, and Inclusion in a United States Hematology and Oncology Fellowship Program

IMPORTANCE

Medical trainees frequently experience discrimination. Understanding their experiences is essential to improving learning environments.

OBJECTIVE

To characterize trainee experiences of discrimination and inclusion to inform graduate medical education (GME) policies.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study used an anonymous telephone interview technique to gather data from hematology and oncology fellows. All current trainees and recent graduates were eligible. Interviews were conducted anonymously with interviewer and participant in separate locations and recorded and transcribed. Data were analyzed in an iterative process into major themes using a general inductive analysis approach. Demographic information was obtained via anonymous survey. Data collection and analysis were conducted from July 2018 to November 2019.

MAIN OUTCOMES AND MEASURES

Emergent themes illustrating bias and inclusion in a GME program.

RESULTS

Among 34 fellows and recent graduates who were approached for this study, 20 consented and 17 were interviewed. Of those interviewed, 10 were men, and the median (range) age was 32 (29-53) years. The racial and ethnic distribution included 6 Asian individuals, 2 Black individuals, 3 Hispanic individuals, 2 multiracial individuals, and 4 White individuals. All fellows reported having experienced and/or witnessed discriminatory behavior. The themes elucidated were (1) foreign fellows perceived as outsiders, (2) US citizens feeling alien at home, (3) gender role-typing, (4) perception of futility of reporting, (5) diversity and inclusion, and (6) coping strategies. The majority of reported biases were from patients. Only 1 trainee reported any incidents. Reasons for not reporting were difficulty characterizing discrimination and doubt action would occur. Participants reported that diversity of cotrainees, involvement in committees, and open discussions promoted inclusivity.

CONCLUSIONS AND RELEVANCE

In this study, reports of discriminatory behavior toward trainees were common. The anonymous hotline methodology cultivated a safe environment for candid discussions. These findings suggest that GME programs should assess their learning climate regarding bias and inclusivity anonymously and develop processes to support trainees.

Perspectives of Stakeholders About an Early Result Acceptance Program to Complement the Residency Match in Obstetrics and Gynecology

IMPORTANCE

The residency application process is flawed, costly, and distracts from the preparation for residency. Disruptive change is needed to improve the inefficiencies in current selection processes.

OBJECTIVE

To determine interest in an early result acceptance program (ERAP) among stakeholders in obstetrics and gynecology (OBGYN), and to estimate its outcome in future application cycles.

DESIGN, SETTING, AND PARTICIPANTS

Surveys of stakeholders in March 2021 queried interest in ERAP across the US. Respondents included OBGYN residency applicants, members of the Association of American Medical Colleges Group on Student Affairs, OBGYN clerkship directors, and residency program directors. Statistical analysis was performed from March to April 2021.

EXPOSURES

Respondents completed surveys sent by email from the Association of American Medical Colleges (to OBGYN applicants and members of the Group on Student Affairs), the Association of Professors of Gynecology and Obstetrics (to clerkship directors), and the Council on Resident Education in Obstetrics and Gynecology (to program directors).

MAIN OUTCOMES AND MEASURES

Applicants and program directors indicated their interest in participating in ERAP, and clerkship directors and members of the Group on Student Affairs indicated their likelihood of recommending ERAP using a 5-point Likert scale.

RESULTS

Respondents included 879 (34.0%) of 2579 applicants to OBGYN, 143 (50.3%) of 284 residency program directors, 94 (41.8%) of 225 clerkship directors, and 51 (32.9%) of 155 student affairs deans. The majority of respondents reported being either somewhat or extremely likely to participate in ERAP, including 622 applicants (70.7%) and 87 program directors (60.8%). Interest in ERAP was independent of an applicant's reported board scores, medical school type, race, number of applications submitted, or number of interviews completed. Among program directors, those at university programs were more likely to participate. Stakeholders supported a limit of 3 applications for ERAP, to fill 25% to 50% of residency positions. Estimating the outcome of ERAP using these data suggests 26 280 to 52 560 fewer applications could be submitted in the regular match cycle.

CONCLUSIONS AND RELEVANCE

Stakeholders in the OBGYN application process expressed broad support for the concept of ERAP. The majority of applicants and programs indicated that they would participate, with potentially substantial positive impact on the application process. Careful pilot testing and research regarding implementation are essential to avoid worsening an already dysfunctional application process.

Trends in Race and Ethnicity Among Matriculants to US Oncology Training Programs, 2015-2020

This cross-sectional study assesses underrepresented minority trends across oncology specialties from 2015 to 2020.

Exploring the Association Between USMLE Scores and ACGME Milestone Ratings: A Validity Study Using National Data From Emergency Medicine

PURPOSE

The United States Medical Licensing Examination (USMLE) sequence and the Accreditation Council for Graduate Medical Education (ACGME) milestones represent 2 major components along the continuum of assessment from undergraduate through graduate medical education. This study examines associations between USMLE Step 1 and Step 2 Clinical Knowledge (CK) scores and ACGME emergency medicine (EM) milestone ratings.

METHOD

In February 2019, subject matter experts (SMEs) provided judgments of expected associations for each combination of Step examination and EM subcompetency. The resulting sets of subcompetencies with expected strong and weak associations were selected for convergent and discriminant validity analysis, respectively. National-level data for 2013-2018 were provided; the final sample included 6,618 EM residents from 158 training programs. Empirical bivariate correlations between milestone ratings and Step scores were calculated, then those correlations were compared with the SMEs' judgments. Multilevel regression analyses were conducted on the selected subcompetencies, in which milestone ratings were the dependent variable, and Step 1 score, Step 2 CK score, and cohort year were independent variables.

RESULTS

Regression results showed small but statistically significant positive relationships between Step 2 CK score and the subcompetencies (regression coefficients ranged from 0.02 [95% confidence interval (CI), 0.01-0.03] to 0.12 [95% CI, 0.11-0.13]; all P < .05), with the degree of association matching the SMEs' judgments for 7 of the 9 selected subcompetencies. For example, a 1 standard deviation increase in Step 2 CK score predicted a 0.12 increase in MK-01 milestone rating, when controlling for Step 1. Step 1 score showed a small statistically significant effect with only the MK-01 subcompetency (regression coefficient = 0.06 [95% CI, 0.05-0.07], P < .05).

CONCLUSIONS

These results provide incremental validity evidence in support of Step 1 and Step 2 CK score and EM milestone rating uses.

Overall Impact of the COVID-19 Pandemic on Interventional Radiology Services: A Canadian Perspective

PURPOSE

The aim of this national survey was to assess the overall impact of the coronavirus disease 2019 (COVID-19) pandemic on the provision of interventional radiology (IR) services in Canada.

METHODS

An anonymous electronic survey was distributed via national and regional radiology societies, exploring (1) center information and staffing, (2) acute and on-call IR services, (3) elective IR services, (4) IR clinics, (5) multidisciplinary rounds, (6) IR training, (7) personal protection equipment (PPE), and departmental logistics.

RESULTS

Individual responses were received from 142 interventional radiologists across Canada (estimated 70% response rate). Nearly half of the participants (49.3%) reported an overall decrease in demand for acute IR services; on-call services were maintained at centers that routinely provide these services (99%). The majority of respondents (73.2%) were performing inpatient IR procedures at the bedside where possible. Most participants (88%) reported an overall decrease in elective IR services. Interventional radiology clinics and multidisciplinary rounds were predominately transitioned to virtual platforms. The vast majority of participants (93.7%) reported their center had disseminated an IR specific PPE policy; 73% reported a decrease in case volume for trainees by at least 25% and a proportion of trainees will either have a delay in starting their careers as IR attendings (24%) or fellowship training (35%).

CONCLUSION

The COVID-19 pandemic has had a profound impact on IR services in Canada, particularly for elective cases. Many centers have utilized virtual platforms to provide multidisciplinary meetings, IR clinics, and training. Guidelines should be followed to ensure patient and staff safety while resuming IR services.

The RCA ReCAst: A Root Cause Analysis Simulation for the Interprofessional Clinical Learning Environment

PROBLEM

The Accreditation Council for Graduate Medical Education calls for resident participation in real or simulated interprofessional analysis of a patient safety event. There are far more residents who must participate in these investigations than available institutional root cause analyses (RCAs) to accommodate them. To correct this imbalance, the authors developed an institutionally sponsored, interprofessional RCA simulation program and implemented it across all graduate medical education (GME) residency programs at the Hospital of the University of Pennsylvania.

APPROACH

The authors developed RCA simulations based upon authentic adverse events experienced at their institution. To provide relevance to all GME programs, RCA simulation cases varied widely and included examples of errors involving high-risk medications, communication, invasive procedures, and specimen labeling. Each simulation included residents and other health care professionals such as nurses or pharmacists whose disciplines were involved in the actual event. Participants adopted the role of RCA investigation team, and in small groups systematically progressed through the RCA process.

OUTCOMES

A total of 289 individuals from 18 residency programs participated in an RCA simulation in 2019-2020. This included 84 interns (29%), 123 residents (43%), 20 attending physicians (7%), and 62 (21%) other health care professionals. There was an increase in ability of GME trainees to correctly identify factors required for an RCA investigation (62% pre vs 80% post, P = .02) and an increase in intent to "always report" for each adverse event category (3% pre vs 37% post, P < .001) following the simulation.

NEXT STEPS

The authors plan to expand the RCA simulation program to other GME clinical sites while striving to involve all GME learners in this educational experience at least once during training. Additionally, by collaborating with health system patient safety leaders, they will annually review all new RCAs to identify cases suitable for simulation adaptation.

Resident operative experience in pediatric neurosurgery across the United States

OBJECTIVE

Neurosurgical residents receive exposure to the subspecialty of pediatric neurosurgery during training. The authors sought to determine resident operative experience in pediatric neurosurgery across Accreditation Council for Graduate Medical Education (ACGME)-accredited neurosurgical programs.

METHODS

During 2018-2019, pediatric neurosurgical case logs for recent graduates or current residents who completed their primary pediatric exposure were collected from US continental ACGME training programs. Using individual resident reports and procedure designations, operative volumes and case diversity were analyzed collectively, according to training site characteristics, and also correlated with the recently described Resident Experience Score (RES).

RESULTS

Of the 114 programs, a total of 316 resident case logs (range 1-19 residents per program) were received from 86 (75%) programs. The median cumulative pediatric case volume per resident was 109 (IQR 75-161). Residents at programs with a pediatric fellowship reported a higher median case volume (143, IQR 96-187) than residents at programs without (91, IQR 66-129; p < 0.0001). Residents at programs that outsource their pediatric rotation had a lower median case volume (84, IQR 52-114) compared with those at programs with an in-house experience (117, IQR 79-170; p < 0.0001). The case diversity index among all programs ranged from 0.61 to 0.80, with no statistically significant differences according to the Accreditation Council for Pediatric Neurosurgery Fellowships designation or pediatric experience site (p > 0.05). The RES correlated moderately (r = 0.44) with median operative volumes per program. A program's annual pediatric operative volume and duration of pediatric experience were identified as significant predictive factors for median resident operative volume.

CONCLUSIONS

Resident experience in pediatric neurosurgery is variable within and between programs. Case volumes are generally higher for residents at programs with in-house exposure and an accredited fellowship, but case diversity is relatively uniform across all programs. RES provides some insight on anticipated case volume, but other unexplained factors remain.

Medicare Support for Dental and Podiatry Graduate Medical Education Programs

IMPORTANCE

Oral health care faces ongoing workforce challenges that affect patient access and outcomes. While the Medicare program provides an estimated $14.6 billion annually in graduate medical education (GME) payments to teaching hospitals, including explicit support for dental and podiatry programs, little is known about the level or distribution of this public investment in the oral health and podiatry workforce.

OBJECTIVE

To examine Medicare GME payments to teaching hospitals for dental and podiatry residents from 1998 to 2018, as well as the distribution of federal support among states, territories, and the District of Columbia.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study was conducted using data from 1252 US teaching hospitals. Data were analyzed from May through August 2020.

EXPOSURES

Dental and podiatry residency training.

MAIN OUTCOMES AND MEASURES

Medicare dental and podiatry GME payments were examined.

RESULTS

Among 1252 teaching hospitals, Medicare provided nearly $730 million in dental and podiatry GME payments in 2018. From 1998 to 2018, the number of residents supported more than doubled, increasing from 2340 residents to 4856 residents, for a 2.1-fold increase, while Medicare payments for dental and podiatry GME increased from $279 950 531 to $729 277 090, for a 2.6-fold increase. In 2018, an estimated 3504 of 4856 supported positions (72.2%) were dental. Medicare GME payments varied widely among states, territories, and the District of Columbia, with per capita payments by state, territory, and district population ranging from $0.05 in Puerto Rico to $14.24 in New York, while 6 states received no support for dental or podiatry residency programs.

CONCLUSIONS AND RELEVANCE

These findings suggest that dental and podiatry GME represents a substantial public investment, and deliberate policy decisions are needed to target this nearly $730 million and growing investment to address the nation's priority oral and podiatry health needs.

MD-PhD Program Graduates' Engagement in Research: Results of a National Study

PURPOSE

To determine if specialty, among other professional development and demographic variables, predicted MD-PhD program graduates' research engagement.

METHOD

The authors merged the 2015 Association of American Medical Colleges (AAMC) National MD-PhD Program Outcomes Survey database with selected data from the AAMC Student Records System, Graduation Questionnaire, and Graduate Medical Education (GME) Track Resident Survey. At the person level, they tested variables of interest for independent associations with MD-PhD graduates' research engagement using chi-square, Pearson correlations, and analysis of variance tests and logistic and linear regressions.

RESULTS

Of 3,297 MD-PhD graduates from 1991-2010 who were no longer in GME training in 2015, 78.0% (2,572/3,297) reported research engagement. In models controlling for several variables, a neurology (vs internal medicine; adjusted odds ratio [AOR]: 2.48; 95% confidence interval [CI]: 1.60-3.86) or pathology (vs internal medicine; AOR: 1.89; 95% CI: 1.33-2.68) specialty, full-time faculty/research scientist career intention at graduation (vs all other career intentions; AOR: 3.04; 95% CI: 2.16-4.28), and ≥ 1 year of GME research (vs no GME research year[s]; AOR: 2.45; 95% CI: 1.96-3.06) predicted a greater likelihood of research engagement. Among graduates engaged in research, the mean percentage of research time was 49.9% (standard deviation 30.1%). Participation in ≥ 1 year of GME research (beta [β] coefficient: 7.99, P < .001) predicted a higher percentage of research time, whereas a radiation oncology (β: -28.70), diagnostic radiology (β: -32.92), or surgery (β: -29.61) specialty, among others, predicted a lower percentage of research time (each P < .001 vs internal medicine).

CONCLUSIONS

Most MD-PhD graduates were engaged in research, but the extent of their engagement varied substantially among specialties. Across specialties, participation in research during GME may be one factor that sustains MD-PhD graduates' subsequent early- to midcareer research engagement.

Breaking Tradition to Bridge Bench and Bedside: Accelerating the MD-PhD-Residency Pathway

PROBLEM

Physician-scientists are individuals trained in both clinical practice and scientific research. Often, the goal of physician-scientist training is to address pressing questions in biomedical research. The established pathways to formally train such individuals are mainly MD-PhD programs and physician-scientist track residencies. Although graduates of these pathways are well equipped to be physician-scientists, numerous factors, including funding and length of training, discourage application to such programs and impede success rates.

APPROACH

To address some of the pressing challenges in training and retaining burgeoning physician-scientists, New York University Grossman School of Medicine formed the Accelerated MD-PhD-Residency Pathway in 2016. This pathway builds on the previously established accelerated 3-year MD pathway to residency at the same institution. The Accelerated MD-PhD-Residency Pathway conditionally accepts MD-PhD trainees to a residency position at the same institution through the National Resident Matching Program.

OUTCOMES

Since its inception, 2 students have joined the Accelerated MD-PhD-Residency Pathway, which provides protected research time in their chosen residency. The pathway reduces the time to earn an MD and PhD by 1 year and reduces the MD training phase to 3 years, reducing the cost and lowering socioeconomic barriers. Remaining at the same institution for residency allows for the growth of strong research collaborations and mentoring opportunities, which foster success.

NEXT STEPS

The authors and institutional leaders plan to increase the number of trainees who are accepted into the Accelerated MD-PhD-Residency Pathway and track the success of these students through residency and into practice to determine if the pathway is meeting its goal of increasing the number of practicing physician-scientists. The authors hope this model can serve as an example to leaders at other institutions who may wish to adopt this pathway for the training of their MD-PhD students.

GENDER DIFFERENCES IN SELF-REPORTED PROCEDURAL VOLUME AMONG VITREORETINAL FELLOWS

PURPOSE

A prior study revealed discrepancies in self-reported surgical numbers between male and female ophthalmology residents. This study further investigates the gender differences in self-reported procedural volume among vitreoretinal surgery fellows and examines the differences for surgical, medical, and total self-reported procedural volume between male and female vitreoretinal fellows.

METHODS

A retrospective review of case logs submitted to the American Society of Retina Specialists by first-year and second-year vitreoretinal fellows from July 1, 2018, to June 30, 2019, was performed. Fellows who reported fewer than 100 pars plana vitrectomies were excluded. A total of 133 fellows were included.

RESULTS

Overall, 37 of 57 (65%) first-year fellows and 59 of 76 (78%) second-year fellows were male. An average of 1,120 procedures were self-reported among all vitreoretinal fellows. In the group of second-year fellows at the completion of fellowship, men reported more total procedures (1,171 [864-1,600] vs. 1,005 [719-1,257]; P = 0.072). Women reported statistically significant fewer endolaser (P = 0.018), internal limiting membrane peel (P = 0.042), and cryoretinopexy (P = 0.002) procedures compared with men. When splitting the data by total surgical versus medical procedures, men reported more procedures than women both surgically (1,077 [799-1,490] vs. 925 [622-1,208]; P = 0.085) and medically (72 [41-116] vs. 56 [20-94]; P = 0.141), although these differences were not statistically significant.

CONCLUSION

There is a trend for female vitreoretinal fellows to report fewer surgical procedures than their male counterparts, raising concerns for gender gaps in vitreoretinal surgical training. Further research is needed to verify this discrepancy and identify potential barriers that female vitreoretinal surgeons are facing in training.

Learner Handover: Who Is It Really For?

PURPOSE

Learner handover is the sharing of information about learners between faculty supervisors. Learner handover can support longitudinal assessment in rotation-based systems, but there are concerns that the practice could bias future assessments or stigmatize struggling learners. Because successful implementation relies on an understanding of existing practices and beliefs, the purpose of this study was to explore how faculty perceive and enact learner handover in the workplace.

METHOD

Using constructivist grounded theory, 23 semistructured interviews were conducted with faculty from 2 Canadian universities between August and December 2018. Participants were asked to describe their learner handover practices, including learner handover delivered or received about resident and student trainees either within or between clinical rotations. The authors probed to understand why faculty used learner handover and their perceptions of its benefits and risks.

RESULTS

Learner handover occurs both formally and informally and serves multiple purposes for learners and faculty. While participants reported that learner handover was motivated by both learner benefit and patient safety, they primarily described motivations focused on their own needs. Learner handover was used to improve faculty efficiency by focusing teaching and feedback and was perceived as a "self-defense mechanism" when faculty were uncertain about a learner's competence and trustworthiness. Informal learner handover also served social or therapeutic purposes when faculty used these conversations to gossip, vent, or manage insecurities about their assessment of learner performance. Because of its multiple, sometimes unsanctioned purposes, participants recommended being reflective about motivations behind learner handover conversations.

CONCLUSIONS

Learners are not the only potential beneficiaries of learner handover; faculty use learner handover to lessen insecurities surrounding entrustment and assessment of learners and to openly share their frustrations. The latter created tensions for faculty needing to share stresses but wanting to act professionally. Formal education policies regarding learner handover should consider faculty perspectives.

Burnout and engagement among PhD students in medicine: the BEeP study

INTRODUCTION

Using a self-determination theory framework, we investigated burnout and engagement among PhD students in medicine, and their association with motivation, work-life balance and satisfaction or frustration of their basic psychological needs.

METHOD

This cross-sectional study was conducted among PhD students at a university medical centre (n = 990) using an electronic survey on background characteristics and validated burnout, engagement, motivation and basic psychological needs questionnaires. Cluster analysis was performed on the burnout subscale scores to find subgroups within the sample which had similar profiles on burnout. Structural equation modelling was conducted on a hypothesized model of frustration of basic psychological needs and burnout.

RESULTS

The response rate was 47% (n = 464). We found three clusters/subgroups which were composed of PhD students with similar burnout profiles within the cluster and different profiles between the clusters. Cluster 1 (n = 199, 47%) had low scores on burnout. Clusters 2 (n = 168, 40%) and 3 (n = 55, 13%) had moderate and high burnout scores, respectively, and were associated with low engagement scores. Cluster 3, with the highest burnout scores, was associated with the lowest motivational, engagement, needs satisfaction and work-life balance scores. We found a good fit for the "basic psychological needs frustration associated with burnout" model.

DISCUSSION

The most important variables for burnout among PhD students in medicine were lack of sleep and frustration of the basic psychological needs of autonomy, competence and relatedness. These add to the factors found in the literature.

Evaluation of pediatric procedural sedation education in pediatric emergency medicine fellowships

ABSTRACT

Pediatric procedural sedation (PPS) is often performed outside of the operating room, and by various sub-specialty providers. There is no consistency in how pediatric emergency medicine (PEM) fellows are trained in PPS. The objective of this study was to survey PEM program directors (PDs) and PEM fellows about their current sedation teaching practices via a direct survey. While many fellowship programs train PEM fellows in PPS, we hypothesize that there is no consistent method of developing and measuring this skill.A 12-question survey was sent to PEM PDs directly via email. A separate 17-question survey was sent to current PEM fellows via their program coordinators by email. Each survey had multiple choice, yes-no and select-all program questions. Responses were collected in an online (REDCap) database and summarized as frequencies and percentages.Based on identifiable email, 67 programs were contacted, with a PD response rate of 46 (59%). Sixty-two program coordinators were contacted based on identifiable email with 78 fellow responses. We noted that 11/46 PD respondents offer a formal PPS rotation. Thirty programs report using propofol in the emergency department and 93% of PD respondents (28/30) actively train fellows in the use of propofol. Approximately 62% of PEM fellow respondents (48/78) report sedating without any attending oversight. Twenty-eight percent of PEM fellow respondents report using simulation as a component of their sedation training.PPS is a critical skill. However, there is a lack of consistency in both education and evaluation of competency in this area. An organized PPS rotation would improve PPS case exposure and PPS skills.

Postgraduate Assessment Approaches Across Surgical Specialties: A Systematic Review of the Published Evidence

PURPOSE

Ensuring competence for surgical trainees requires holistic assessment of the qualities and competencies necessary to practice safely and effectively. To determine the next steps toward achieving this aim, the authors conducted a systematic review to summarize and appraise the available evidence related to any assessment approach to postgraduate surgical training and to identify the dominant themes for assessment approaches across different specialties or countries.

METHOD

Medline and Embase were searched on January 10, 2019, without language or time restrictions. Any peer-reviewed study that described an assessment framework (in practice or novel) throughout postgraduate surgical training globally was included. An iterative review and thematic analysis were performed on full-text articles to determine assessment themes. Studies were then grouped by assessment themes. A tailored quality assessment of the studies included in the final analysis was conducted. Assessment themes and validity were compared across surgical specialties and countries.

RESULTS

From an initial 7,059 articles, 91 studies (evaluating 6,563 surgical trainees) were included in the final analysis. Ten defined assessment themes were extracted. Ten studies (11.0%) were deemed low risk of bias based on the quality assessment tool used and thus were determined to be high quality. Minor differences in assessment themes were observed between specialties and countries. Assessment themes neglected by individual surgical specialties and assessment themes that need validated assessment tools were identified.

CONCLUSIONS

This review highlights the low quality of evidence and fragmented efforts to develop and optimize surgical assessments. The minor differences observed demonstrate a common approach, globally and across specialties, related to surgical assessments. A paradigm shift in assessment approaches, which will require national and international collaboration, is required to optimize design and validation so that a comprehensive assessment of surgical competence can be implemented.

Evaluation of Factors Associated With Successful Matriculation to Colon and Rectal Surgery Fellowship

BACKGROUND

As an increasing number of general surgery residents apply for fellowship positions, it is important to identify factors associated with successful matriculation. For applicants to colon and rectal surgery, there are currently no objective data available to distinguish which applicant attributes lead to successful matriculation.

OBJECTIVE

The purpose of this study was to identify objective factors that differentiate colon and rectal surgery fellowship applicants who successfully matriculate with those who apply but do not matriculate.

DESIGN

This was a retrospective analysis of colon and rectal surgery applicant characteristics.

SETTINGS

Deidentified applicant data provided by the Association of American Medical Colleges from 2015 to 2017 were included.

MAIN OUTCOME MEASURES

Applicant demographics, medical school and residency factors, number of program applications, number of publications, and journal impact factors were analyzed to determine associations with successful matriculation.

RESULTS

Most applicants (n = 371) and subsequent matriculants (n = 248) were white (61%, 62%), male (65%, 63%), US citizens (80%, 88%) who graduated from US allopathic medical schools (66%, 75%). Statistically significant associations included graduation from US allopathic medical schools (p < 0.0001), US citizenship (p < 0.0001), and number of program applications (p = 0.0004). Other factors analyzed included American Osteopathic Association membership (p = 0.57), university-based residency (p = 0.51), and residency association with a colon and rectal surgery training program (p = 0.89). Number of publications and journal impact factors were not statistically different between cohorts (p = 0.067, p = 0.150).

LIMITATIONS

American Board of Surgery In-Training Examination scores, rank list, and subjective characteristics, such as strength of interview and letters of recommendation, were not available using our data source.

CONCLUSIONS

Successful matriculation to a colon and rectal surgery fellowship program was found to be associated with US citizenship, graduation from a US allopathic medical school, and greater number of program applications. The remaining objective metrics analyzed were not associated with successful matriculation. Subjective and objective factors that were unable to be measured by this study are likely to play a determining role. See Video Abstract at http://links.lww.com/DCR/B415.

EVALUACIN DE FACTORES VINCULADOS EN LA INMATRICULACIN EXITOSA PARA BECAS DE CIRUGA COLORRECTAL

ANTECEDENTES:A medida que un número cada vez mayor de residentes de Cirugía General solicitan una beca, es importante identificar los factores vinculados con una inmatriculación exitosa. Para los candidatos a una beca en Cirugía Colorrectal, hoy en día no existen datos objetivos disponibles para distinguir qué atributos del solicitante conducen a una inmatriculación exitosa.OBJETIVO:Identificar objetivamente los factores que diferencian un candidato a una beca en Cirugía Colorrectal que se inmatricula con éxito de aquel que aplica pero no llega a inmatricularse.DISEÑO:Análisis retrospectivo de las características de los solicitantes de beca para Cirugía Colorrecatl.AJUSTES:Datos de los solicitantes no identificados, proporcionados por la Asociación de Colegios Médicos Estadounidenses de 2015 a 2017.PRINCIPALES MEDIDAS DE RESULTADO:Se analizaron los factores demográficos del solicitante, las facultades de medicina y los factores de la residencia, el número de solicitudes de programas, el número y el factor de impacto de las publicaciones realizadas para determinar la asociación con una inmatriculación exitosa.RESULTADOS:La mayoría de los solicitantes (n = 371) que posteriormente fueron inmatriculados exitosamente (n = 248) eran blancos (61%, 62%, respectivamente), hombres (65%, 63%), ciudadanos estadounidenses (80%, 88%) que se graduaron de Facultades de medicina alopática en los EE. UU. (66%, 75%). Las asociaciones estadísticamente significativas incluyeron la graduación de las escuelas de medicina alopática de los EE. UU. (P <0,0001), la ciudadanía de los EE. UU. (P <0,0001) y el número de solicitudes de programas (p = 0,0004). Otros factores analizados incluyeron: membresía AOA (p = 0,57), la residencia universitaria (p = 0,51) y asociación de la residencia con un programa de formación en Cirugía Colorrectal (p = 0,89). El número de publicaciones y los factores de impacto de las revistas no fueron estadísticamente diferentes entre las cohortes (p = 0,067, p = 0,15, respectivamente).LIMITACIONES:El Score ABSITE, la posición en lista de clasificación y las características subjetivas como el de una buena entrevista y las cartas de recomendación no se encontraban disponibles en la fuente de datos.CONCLUSIONES:Se encontró que la inmatriculación exitosa a un programa de becas de Cirugía Colorreectal estaba asociada con la ciudadanía estadounidense, la graduación en una Facultad de medicina alopática en los EE. UU, y al mayor número de solicitudes de programas. El analisis de las medidas objetivas restantes no se asociaron con una inmatriculación exitosa. Es probable que los factores subjetivos y objetivos que no pudieron ser medidos por este estudio jueguen un papel determinante. Consulte Video Resumen en http://links.lww.com/DCR/B415. (Traducción-Dr Xavier Delgadillo).

Demographics and Career Intentions of Graduates of Combined Baccalaureate-MD Programs, 2010-2017: An Analysis of AAMC Graduation Questionnaire Data

PURPOSE

Combined baccalaureate-MD programs exist to fulfill a variety of educational missions, including to promote the development of physician-scientists, increase workforce diversity, promote primary care careers, and meet the needs of underserved patients. The authors sought to determine the demographics of combined program graduates, as well as their intention to practice in primary care (IPPC) and intention to work with the medically underserved (IWMU), as compared with graduates of traditional MD programs.

METHOD

Data from the 2010-2017 Association of American Medical Colleges Graduation Questionnaire, a national survey of graduating medical students, were recategorized (e.g., as combined program or traditional program) before analysis. Logistic regression models on the 2 primary outcomes (IPPC and IWMU) were conducted to estimate odds ratios for the effects of covariates and predictors (e.g., gender, underrepresented in medicine [URM] group member, type of medical degree program).

RESULTS

Data from a total of 109,028 respondents were included (3,182 from combined and 105,846 from traditional programs). Compared with students in traditional programs, those in combined programs were more likely to be younger (age at graduation ≤ 29: 3,143, 98.8% vs 89,688, 84.7%) and female (1,813, 57.0% vs 52,013, 49.1%) but less likely to identify as a URM group member (276, 8.7% vs 14,757, 13.9%). In an adjusted logistic regression model, graduating from a combined program, identifying as female, and IWMU predicted significantly greater odds of IPPC, while identifying as a URM, identifying as female, and having debt predicted significantly greater odds of IWMU. Graduating medical students who indicated family medicine as a career specialty were more likely to indicate an IWMU.

CONCLUSIONS

Medical students graduating from combined programs were more likely to indicate an IPPC but were no more likely to indicate an IWMU than traditional program graduates.

Early Effects of COVID-19 Pandemic on Neurosurgical Training in the United States: A Case Volume Analysis of 8 Programs

OBJECTIVE

To determine the impact of the 2019 novel coronavirus disease (COVID-19) pandemic on operative case volume in 8 U.S. neurosurgical residency training programs in early 2020 and to survey these programs regarding training activities during this period.

METHODS

A retrospective review was conducted of monthly operative case volumes and types for 8 residency programs for 2019 and January through April 2020. Cases were grouped as elective cranial, elective spine, and nonelective emergent cases. Programs were surveyed regarding residents' perceptions of the impact of COVID-19 on surgical training, didactics, and research participation. Data were analyzed for individual programs and pooled across programs.

RESULTS

Across programs, the 2019 monthly mean ± SD case volume was 211 ± 82; 2020 mean ± SD case volumes for January, February, March, and April were 228 ± 93, 214 ± 84, 180 ± 73, and 107 ± 45. Compared with 2019, March and April 2020 mean cases declined 15% (P = 0.003) and 49% (P = 0.002), respectively. COVID-19 affected surgical case volume for all programs; 75% reported didactics negatively affected, and 90% reported COVID-19 resulted in increased research time. Several neurosurgery residents required COVID-19 testing; however, to our knowledge, only 1 resident from the participating programs tested positive.

CONCLUSIONS

This study documents a significant reduction in operative volume in 8 neurosurgery residency training programs in early 2020. During this time, neurosurgery residents engaged in online didactics and research-related activities, reporting increased research productivity. Residency programs should collect data to determine the educational impact of the COVID-19 pandemic on residents' operative case volumes, identify deficiencies, and develop plans to mitigate any effects.

Identifying Entrustable Professional Activities for Shared Decision Making in Postgraduate Medical Education: A National Delphi Study

PURPOSE

Although shared decision making (SDM) is considered the preferred approach in medical decision making, it is currently not routinely used in clinical practice. To bridge the transfer gap between SDM training and application, the authors aimed to reach consensus on entrustable professional activities (EPAs) for SDM and associated behavioral indicators as a framework to support self-directed learning during postgraduate medical education.

METHOD

Using existing literature on SDM frameworks and competencies; input from an interview study with 17 Dutch experts in SDM, doctor-patient communication, and medical education; and a national SDM expert meeting as a starting point, in 2017, the authors conducted a modified online Delphi study with a multidisciplinary Dutch panel of 32 experts in SDM and medical education.

RESULTS

After 3 Delphi rounds, consensus was reached on 4 EPAs-(1) the resident discusses the desirability of SDM with the patient, (2) the resident discusses the options for management with the patient, (3) the resident explores the patient's preferences and deliberations, and (4) the resident takes a well-argued decision together with the patient. Consensus was also reached on 18 associated behavioral indicators. Of the 32 experts, 30 (94%) agreed on this list of SDM EPAs and behavioral indicators.

CONCLUSIONS

The authors succeeded in developing EPAs and associated behavioral indicators for SDM for postgraduate medical education to improve the quality of SDM training and the application of SDM in clinical practice. These EPAs are characterized as process EPAs for SDM in contrast with content EPAs related to diverse medical complaints. A next step is the implementation of the SDM EPAs in existing competency-based workplace curricula.