Sharps and Needlestick Injuries Among Medical Students, Surgical Residents, Faculty, and Operating Room Staff at a Single Academic Institution

BACKGROUND

The hospital is a place of high risk for sharps and needlestick injuries (SNI) and such injuries are historically underreported.

METHODS

This institutional review board approved study compares the incidence of SNI among all surgical personnel at a single academic institution via an anonymous electronic survey distributed to medical students, surgical residents, general surgery attendings, surgical technicians, and operating room nurses.

RESULTS

The overall survey response rate was 37% (195/528). Among all respondents, 55% (107/195) had a history of a SNI in the workplace. The overall report rate following an initial SNI was 64%. Surgical staff reported SNIs more frequently, with an incidence rate ratio (IRR) of 1.33 (p = 0.085) when compared with attendings. When compared with surgical attendings, medical students (IRR of 2.86, p = 0.008) and residents (IRR of 2.21, p = 0.04) were more likely to cite fear as a reason for not reporting SNIs. Approximately 65% of respondents did not report their exposure either because of the time consuming process or the patient involved was perceived to be low-risk or both.

CONCLUSIONS

The 2 most common reasons for not reporting SNIs at our institution are because of the inability to complete the time consuming reporting process and fear of embarrassment or punitive response because of admitting an injury. Further research is necessary to mitigate these factors.

[Improving the quality of life of residents]

The socially interactive therapeutic robot Paro is presented in the form of a soft toy. It can benefit patients suffering from Alzheimer's as well as nurses.

Racial and Ethnic Diversity of U.S. Plastic Surgery Trainees

BACKGROUND

Increased diversity of U.S. physicians can improve patient communication and mitigate health disparities for racial minorities. This study analyzes trends in racial and ethnic diversity of plastic surgery residents.

METHODS

Demographic data of surgical residents, medical students, and integrated plastic surgery residency applicants were obtained from the Association of American Medical Colleges. Data for college students and the general population were obtained from the U.S. Census for comparison with plastic surgery. Interspecialty differences and temporal trends in racial composition were analyzed with chi-square tests.

RESULTS

From 1995 to 2014, Asian and Hispanic plastic surgery residents increased nearly 3-fold (7.4%-21.7%, p < 0.001) and 2-fold (4.6%-7.9%, p < 0.001), respectively. African American plastic surgery residents did not increase significantly (3.0%-3.5%, p = 0.129). Relative to the U.S. population, Hispanics (range: 0.1-0.5-fold) and African Americans (range: 0.1-0.4-fold) were underrepresented, whereas Asians (range: 2.2-5.3-fold) were overrepresented in plastic surgery. A "bottleneck" existed in the pipeline of African American and Hispanic plastic surgery residents. Significant differences in racial composition existed between plastic surgery and other surgical disciplines, which varied over time. The percentage of Hispanic (10.6% vs 7.0%, p = 0.402) and African American (6.4% vs 2.1%, p < 0.001) plastic surgery residency applicants exceeded those in residency.

CONCLUSIONS

Hispanics and African Americans are underrepresented in plastic surgery residency relative to whites and Asians. This study underscores the need for greater initiatives to increase diversity in plastic surgery residency.

A Comparison of Residents' Knowledge Regarding the Surviving Sepsis Campaign 2012 Guideline

Background:

Recently, Surviving Sepsis Campaign (SSC) guideline was updated. Our objective was to evaluate the knowledge of residents in different departments regarding the SSC 2012.

Methods:

A cross-sectional, descriptive self-questionnaire was distributed to interns and residents in the Departments of Internal Medicine, Surgery, and Emergency Medicine.

Results:

The response rate was 136 (89%) from 153 residents. The residents included 46 (33%) interns, 42 (31%) internal medicine residents, 41 (30%) surgical residents, and 7 (5%) emergency residents. Regarding the definitions of severe sepsis and septic shock, only 44 (32.4%) residents were able to differentiate the severity of sepsis. The surgical residents had a significantly lower rate of correct answers than that of internal medicine residents (12.2% vs. 45.2, P = 0.001), emergency residents (12.2% vs. 57.1%, P = 0.005), and interns (12.2% vs. 34.8%, P = 0.014). Only 77 (51.5%) residents would measure blood lactate in patients with sepsis. In respect to the dose of fluid resuscitation, only 72 (52.9%) residents gave the recommended fluid (30 ml/kg) within the first 3 h. Surgical residents had a significantly lesser percentage of correct answers than that of internal medicine residents (29.3% vs. 69%, P < 0.0001) and interns (29.3% vs. 60.8%, P = 0.003). About 123 (90.4%) and 115 (84.6%) residents knew the appropriate targets for mean arterial pressure and vasopressors, respectively. Most residents could give antimicrobial drugs (73.5%) and steroids (93.4%) appropriately in the treatment of patients with septic shock. However, only half of the residents knew the target range of blood sugar control in patients with sepsis.

Conclusions:

Our residents’ knowledge about the SSC 2012 is not satisfactory. Further instruction concerning sepsis management is required.

Migratory common blackbirds have lower innate immune function during autumn migration than resident conspecifics

Animals need a well-functioning immune system to protect themselves against pathogens. The immune system, however, is costly and resource trade-offs with other demands exist. For migratory animals several (not mutually exclusive) hypotheses exist. First, migrants reduce immune function to be able to allocate resources to migration. Second, migrants boost immune function to cope with more and/or novel pathogens encountered during migration. Third, migrants reallocate resources within the immune system. We tested these hypotheses by comparing baseline immune function in resident and migratory common blackbirds (Turdus merula), both caught during the autumn migration season on the island of Helgoland, Germany. Indices of baseline innate immune function (microbial killing capacity and haptoglobin-like activity) were lower in migrants than in residents. There was no difference between the groups in total immunoglobulins, a measure of baseline acquired immune function. Our study on a short-distance avian migrant supports the hypothesis that innate immune function is compromised during migration.

Elucidating Trainee Effect on Outcomes for General, Gynecologic, and Urologic Oncology Procedures

BACKGROUND AND OBJECTIVES

Surgical complications delay adjuvant therapy in oncology patients. Current literature remains unclear regarding resident effect on postoperative outcomes, with inappropriate coverage possibly endangering patients in spite of attending oversight. We assessed resident postgraduate year (PGY) effect on 30-day overall morbidity in cancer patients undergoing major intra-abdominal and non-abdominal surgery.

METHODS

Patients undergoing non-emergent major intra- and extra-abdominal operations from 2005-2012 were queried using the American College of Surgeons' National Surgical Quality Improvement Program. Attending alone and resident PGY cohorts were compared for demographics, 30-day overall morbidity, mortality, and relevant outcomes.

RESULTS

A total of 156,941 cancer patients undergoing major intra-abdominal (n = 76,385) or major non-abdominal (n = 80,556) procedures were captured. Demographics were clinically similar across attending and PGY levels. Rates of overall morbidity increased significantly with PGY level, along with operative time and length of stay. For major intra-abdominal procedures, all resident levels except PGY2 level adversely affected overall morbidity. Above PGY4 level, resident involvement had a stronger association with adverse outcome than preoperative comorbidities and preoperative chemotherapy. Interestingly, gastric, gall bladder, liver, pancreas, esophageal, and thyroid procedures demonstrated no effect of resident involvement on overall morbidity.

CONCLUSIONS

Resident PGY is independently associated with increased overall morbidity in patients undergoing selected major surgical procedures. Understanding surgical procedures affected by resident involvement will maximize outcomes.

Concussion assessment and management knowledge among chiropractic fourth year interns and residents

OBJECTIVES

To investigate the degree of knowledge chiropractic fourth year interns and post-graduate chiropractic residents have in regard to concussion diagnosis and management.

METHODS

A survey modified from a study conducted by Boggild and Tator (2012), was administered to fourth year chiropractic interns and post-graduate residents via SurveyMonkey.com.

RESULTS

Chiropractic fourth year interns and postgraduate chiropractic specialty college residents scored 5.2 and 5.25 out of 9 respectively, which compares well with Bogglid and Tator's reports on medical students and residents. Several knowledge gaps were identified in the sample population.

CONCLUSION

The results from this survey show that the concussion knowledge among Canadian fourth year chiropractic interns and specialty college residents compares favorably with the knowledge of fourth year medical students and residents in diagnosing and managing concussions. Chiropractors appear to possess the skills and knowledge to diagnose and manage concussion equal to their medical counterparts. However, knowledge gaps regarding concussion diagnosis and management were found among chiropractic students and residents.

Predicting Success of Preliminary Surgical Residents: A Multi-Institutional Study

OBJECTIVE

A nondesignated preliminary surgery (NDPS) position encompasses 1 year of training provided by many general surgery residencies. Our aim was to assess factors predicting success and provide evidence for program directors to support career guidance to preliminary residents.

METHODS

Retrospective cohort study of 221 NDPS residents who entered 5 university-based institutions were identified from 2009 to 2013. Records for trainees were reviewed. We defined primary success as obtaining a categorical position in the specialty of choice and secondary success as obtaining a categorical position in any specialty immediately after finishing their NDPS training. Statistical evaluation was performed using chi-square analysis, independent t-test and logistic regression using α <0.05.

RESULTS

Of the 221 NDPS residents, 217 (98%) completed postgraduate year (PGY)-1 and 65 (29%) completed PGY-2. Totally, 90 (41%) obtained categorical general surgery positions, 89 (40%) obtained categorical positions in other specialties, and 42 (19%) failed to obtain a categorical position immediately after their NDPS years. Ultimately, 139 (63%) of residents achieved primary success and 40 (18%) additional residents obtained categorical positions in specialties other than their first choice, resulting in a total of 179 (81%) of residents obtaining categorical positions. Mean United States Medical Licensing Examination step 1 and step 2 scores for those who obtained secondary success were 227 and 234 vs. 214 and 219, respectively, for those who failed to secure a categorical position (p < 0.01). United States Medical Licensing Examination step 2 score was a significant predictor of primary (p < 0.03) and secondary success (p < 0.02). Of 65 PGY-2 NDPS residents, 32 (49%) achieved primary success, and 11 (17%) others achieved secondary success for a total of 43 (66%). For PGY-2 NDPS, American Board of Surgery In-Training Examination was the only significant predictor of primary and secondary success (p < 0.02 and p < 0.05).

CONCLUSIONS

NDPS training provides a viable and successful opportunity for at least 81% of young physicians to pursue their career goals even after an unsuccessful first match.

Burnout Syndrome During Residency

OBJECTIVE

The aim of this study is identified the degree of Burnout Syndrome (BOS) and find out its correlation with years of recidency and sociodemograpfic chareacteristics, training, sleeping habits, such as smoking and alcohol consumption.

METHODS

After approval from the Hospital Ethics Committee and obtaining informed consent, First, second, third, fourth and fifth year of recidency staff (n=127) working in our hospital were involved in this study. The standardized Maslach Burnout Inventory (MBI) was used in this study.

RESULTS

Fifty six male (44.1%) and seventy one female (55.9%) residents were enroled in this study (Coranbach Alfa(α)=0.873). 57% of the first year residents smokes cigaret and 54% of them use alcohol. 2% of them gets one day off after hospital night shift, 61% of them suffers from disturbed sleep. 60% of them had been stated that they willingly selected their profession. 61% of them prefers talking to friends and 32% of them prefers shopping to overcome stress. There were statistical difference acording to years of recidency in MBI, Emotional Burnout (EB) and desensitisation scale (DS) points. EB scale points of the second year of residency group was statisticaly higher than fourth year of residency group. DS points of second year of residency group was also statisticaly higher than the third and fourth year of residency group. There was no statistical difference between any groups in Personal Success.

CONCLUSION

BOS is a frequent problem during residency in anaesthesia. Appropriate definition and awareness are the first important steps to prevent this syndrome. Further administrative approaches should be evaluated with regard to their effects.

Validating a standardized laparoscopy curriculum for gynecology residents: a randomized controlled trial

BACKGROUND

Residency programs struggle with integrating simulation training into curricula, despite evidence that simulation leads to improved operating room performance and patient outcomes. Currently, there is no standardized laparoscopic training program available for gynecology residents.

OBJECTIVE

The purpose of this study was to develop and validate a comprehensive ex vivo training curriculum for gynecologic laparoscopy.

STUDY DESIGN

In a prospective, single-blinded randomized controlled trial (Canadian Task Force Classification I) postgraduate year 1 and 2 gynecology residents were allocated randomly to receive either conventional residency training or an evidence-based laparoscopy curriculum. The 7-week curriculum consisted of cognitive didactic and interactive sessions, low-fidelity box trainer and high-fidelity virtual reality simulator technical skills, and high-fidelity team simulation. The primary outcome measure was the technical procedure score at laparoscopic salpingectomy with the use of the objective structured assessment of laparoscopic salpingectomy tool. Secondary outcome measures related to performance in multiple-choice questions and technical performance at box trainer and virtual reality simulator tasks. A sample size of 10 residents per group was planned (n = 20). Results are reported as medians (interquartile ranges), and data were compared between groups with the Mann-Whitney U, chi-square, and Fisher's exact tests (P ≤ .05).

RESULTS

In July 2013, 27 residents were assigned randomly (14 curriculum, 13 conventional). Both groups were similar at baseline. Twenty-one residents (10 curriculum, 11 conventional) completed the surgical procedure-based assessment in the operating room (September to December 2013). Our primary outcome indicated that curriculum-trained residents displayed superior performance at laparoscopic salpingectomy (P = .043). Secondary outcomes demonstrated that curriculum-trained residents had higher performance scores on the cognitive multiple-choice questions (P < .001), the nontechnical skills multiple-choice questions (P = .016), box trainer task time (P < .001), and all virtual reality simulator parameters.

CONCLUSION

Participation in a comprehensive simulation-based training curriculum for gynecologic laparoscopy leads to a superior improvement in knowledge and technical performance in the operating room compared with conventional residency training.

Postpartum Depression in a General Pediatric Practice: Practical Methods for Improving Screening and Referrals

Postpartum depression (PPD) is a common problem in new mothers. Untreated PPD is associated with behavioral and developmental problems in children. We examined the effects of an educational session about PPD and modification of the electronic medical record (EMR) on providers' screening for PPD. An education session was given to the physicians and pre and post surveys compared comfort and self-reported screening. Following the EMR change, a retrospective chart review was conducted from three time periods: group 1-before the conference, group 2-after the conference but before EMR change, and group 3-after screening in the EMR. Documented screening increased from 0% in group 1, to 2% in group 2, to 74% in group 3 (P < .001). Ten percent screened positive, but only 14% had documented referrals to a provider for treatment. The combination of provider education and screening questions integrated into the EMR enhanced PPD screening rates among physicians in a busy practice.

[Internal and external assessment of nursing home residents' satisfaction]

Quality improvement procedures and measuring the satisfaction of nursing home residents is a major priority. A study assessed the differences between the results of a survey conducted by internal staff and of one carried out by an external service provider to evaluate the satisfaction of the residents of a nursing home.

[Reinforced accommodation units and the management of patients with dementia]

Dementia is frequently associated with behavioural disorders that can be difficult to manage. In regards to these symptoms, psychoactive drugs are not very effective and have many potential side effects. In order to take care of patients with such severe disorders, specific units called "reinforced hosting units" ("UHR; Unités d'Hébergement Renforcées" in French) have been developed within long term care units. Specifically trained teams take care of these patients in specially designed settings. A French national inquiry has studied the development, the characteristics and the activity of these units in 2013 and 2012.

Effectiveness of a Core-Competency-based Program on Residents' Learning and Experience

Background

The Care of the Elderly (COE) Diploma Program is a six-to-twelve-month enhanced skills program taken after two years of core residency training in Family Medicine. In 2010, we developed and implemented a core-competency–based COE Diploma program (CC), in lieu of one based on learning objectives (LO). This study assessed the effectiveness of the core-competency–based program on residents’ learning and their training experience as compared to residents trained using learning objectives.

Methods

The data from the 2007–2013 COE residents were used in the study, with nine and eight residents trained in the LO and CC programs, respectively. Residents’ learning was measured using preceptors’ evaluations of residents’ skills/abilities throughout the program (118 evaluations in total). Residents’ rating of training experience was measured using the Graduate’s Questionnaire which residents completed after graduation.

Results

For residents’ learning, overall, there was no significant difference between the two programs. However, when examined as a function of the four CanMEDS roles, there were significant increases in the CC residents’ scores for two of the CanMEDS roles: Communicator/Collaborator/Manager and Scholar compared to residents in the LO program. With respect to residents’ training experience, seven out of ten program components were rated by the CC residents higher than by the LO residents.

Conclusion

The implementation of a COE CC program appears to facilitate resident learning and training experience.

A national survey of Canadian emergency medicine residents' comfort with geriatric emergency medicine

BACKGROUND

Geriatric patients represent a large and complex subgroup seen in emergency departments (EDs). Competencies in geriatric emergency medicine (EM) training have been established. Our objectives were to examine Canadian postgraduate year (PGY)-5 EM residents' comfort with the geriatric EM competency domains, assess whether Canadian EM residents become more comfortable through residency, and determine whether geriatric educational exposures are correlated with resident comfort with geriatric EM.

METHODS

A national, cross-sectional study of PGY-1 and PGY-5 Royal College EM residents was conducted to determine their comfort in geriatric EM clinical competency domains. Residents reported their level of comfort in satisfying each competency domain using a seven-point Likert scale. Residents were also asked about the location of their medical education as well as the type and number of different geriatric exposures that they had received to date.

RESULTS

Of the 141 eligible residents from across Canada, 77% (109) consented to participate. None of the PGY-1 EM residents and 34% (14) of PGY-5 EM residents reported that they were comfortable with all eight geriatric EM competency domains. PGY-5 EM residents were significantly more comfortable than PGY-1 EM residents. Residents reported a highly variable range of geriatric educational exposures obtained during training. No relationship was found between resident-reported comfort and the nature or number of geriatric exposures that they had received.

CONCLUSION

Current Royal College EM residency training in Canada may not be adequately preparing graduates to be comfortable with defined competencies for the care of older ED patients.

Perceptions of pathology informatics by non-informaticist pathologists and trainees

Background:

Although pathology informatics (PI) is essential to modern pathology practice, the field is often poorly understood. Pathologists who have received little to no exposure to informatics, either in training or in practice, may not recognize the roles that informatics serves in pathology. The purpose of this study was to characterize perceptions of PI by noninformatics-oriented pathologists and to do so at two large centers with differing informatics environments.

Methods:

Pathology trainees and staff at Cleveland Clinic (CC) and Massachusetts General Hospital (MGH) were surveyed. At MGH, pathology department leadership has promoted a pervasive informatics presence through practice, training, and research. At CC, PI efforts focus on production systems that serve a multi-site integrated health system and a reference laboratory, and on the development of applications oriented to department operations. The survey assessed perceived definition of PI, interest in PI, and perceived utility of PI.

Results:

The survey was completed by 107 noninformatics-oriented pathologists and trainees. A majority viewed informatics positively. Except among MGH trainees, confusion of PI with information technology (IT) and help desk services was prominent, even in those who indicated they understood informatics. Attendings and trainees indicated desire to learn more about PI. While most acknowledged that having some level of PI knowledge would be professionally useful and advantageous, only a minority plan to utilize it.

Conclusions:

Informatics is viewed positively by the majority of noninformatics pathologists at two large centers with differing informatics orientations. Differences in departmental informatics culture can be attributed to the varying perceptions of PI by different individuals. Incorrect perceptions exist, such as conflating PI with IT and help desk services, even among those who claim to understand PI. Further efforts by the PI community could address such misperceptions, which could help enable a better understanding of what PI is and is not, and potentially lead to increased acceptance by non-informaticist pathologists.

Geographic Trends in the Plastic Surgery Match

BACKGROUND

The integrated plastic surgery match is among the most competitive residency matches in recent years. Although previous studies have correlated applicant characteristics with successful match outcomes, none have comprehensively investigated the role of geography in the match. This study elucidates regional biases in the match.

METHODS

Plastic surgery residents who matched during 2011-2015 were eligible for study inclusion. Names of residents were obtained from official residency program websites and cross-referenced with data obtained from the Student Doctor Network. For each resident, region of residency program and medical school were compared.

RESULTS

From 67 programs, 622 residents were identified. Most graduated from US medical schools (97.9%). A total of 94 residents matched at a home institution (15.1%). Half of the residents matched in the same region as their medical school (48.9%). Programs in the South matched the greatest number of residents from the same region (60.8%), whereas West programs matched the least (30.8%, p < 0.001). No regional differences existed regarding residents matching at their home institution (p = 0.268). More women matched at West programs (43.1%) versus East programs (30.6%, p < 0.05).

CONCLUSIONS

A significant number of residents matched at their home institution. Roughly, half matched at a program in the same region as their medical school. Whether this regional phenomenon stems from applicant or program factors remains unknown. Yet, given the limited number of interviews and the high costs of interviewing, applicants and programs can use these data to help optimize the match process.

Literature review of teaching skills programs for junior medical officers

OBJECTIVE

The aim of this review was to assess the current evidence regarding the efficacy of teaching skills programs for junior medical officers. We aimed to compare and contrast these results with findings from previous literature reviews, the last of which were published in 2009.

METHODS

In order to capture studies since the last published literature reviews, five databases and grey literature were searched for publications from January 2008 to January 2015. A search for literature reviews without using the timeframe limitation was also performed.

RESULTS

The search from January 2008 to January 2015 resulted in the inclusion of 12 studies. Five systematic reviews of the topic were found which included 39 individual studies that were also analysed. Nearly all studies reported positive effects. Twenty nine studies reported change in attitudes, 28 reported modification in knowledge, 28 reported change in behaviour, 6 reported change in the organisation and two reported change in program participant's students. There were substantial threats of bias present.

CONCLUSIONS

The literature reviewed demonstrated many positive effects of teaching skills programs, which supports their utilization. However, high level outcomes need to be evaluated over longer periods of time to establish their true impact. An organisation specific approach to these programs needs to occur using sound course design principles, and they need to be reported in evaluation trials that are designed with robust methodology.

Resident training in single-incision laparoscopic colectomy

Single-incision laparoscopic colectomy (SLC) is touted as an improved approach to minimally invasive surgery, although no data currently exist regarding the acquisition of this technique. The aim of this study was to evaluate resident performance and outcomes in patients undergoing SLC performed by residents vs. staff colorectal surgeons. A retrospective case-control study was conducted, including 220 patients who underwent elective surgical intervention with multiport laparoscopic colectomy (MLC, n=141) or SLC (n=79) for colon cancer over a 24-month period at Yao Municipal Hospital (Yao, Japan). Data on patient demographics, operative data, oncological outcomes and short-term outcomes were evaluated for statistical significance. To investigate issues regarding the surgical procedures, the entire operation was recorded on video for all patients and was divided into 6 procedures, with each procedure measured in seconds. Senior-level residents were able to safely perform MLC under appropriate experienced supervision. For SLC, 1 case required conversion to an open procedure. No case required additional trocar placement. The mean operative times were similar for the staff and resident groups for total colon cancer (192.5 and 217.5 min, respectively; P=0.88), whereas the operative times of the staff group for right-sided colon cancer were significantly longer, and the operative times of the resident group for left-sided colon cancer were significantly longer. In addition, the overall perioperative outcomes, including blood loss, number of harvested lymph nodes, length of the surgical margin and complications, were similar between the two groups. When video recordings were evaluated by dividing the surgical process for the right colon into 4 procedures and that for the left colon into 6 procedures, the results demonstrated that the residents required more time to close the mesenteric margin for the left colon compared with the staff performing the same procedure (3,470.1±1,258.5 vs. 5,218.6±2,341.2 sec; P=0.01). Therefore, senior-level residents were able to safely perform SLC under appropriate experienced supervision. For the left colon, the main challenge for the residents appeared to be the closure of the mesenteric margin. Our data support that it is possible to train senior residents to complete a SLC safely and with the same efficacy as staff surgeons.

High level of patient satisfaction and comfort during diagnostic urological procedures performed by urologists and residents

OBJECTIVE

The aim of this study was to investigate how patients experience diagnostic urological procedures performed by urologists, junior residents and senior residents, and to assess the influence of procedure-related factors on patient experiences.

METHODS

Data were collected during 222 procedures: 84 transrectal ultrasound-guided prostate biopsies (TRUSP; urologists n = 39, residents n = 45) and 138 urethrocystoscopies (UCS; urologists n = 44, residents n = 94) in six hospitals. Patient experiences were assessed using a questionnaire focusing on pain, comfort and satisfaction (visual analogue scale, 0-10) and communication aspects on a four-point Likert scale. Clinical observations were made to identify influencing factors.

RESULTS

Median values for patient experiences across procedures were 10 (range 5-10) for patient satisfaction, 2 (0-9) for pain and 8 (0-10) for comfort. Generalized estimating equations revealed no significant differences between urologists, senior residents and junior residents in terms of experienced patient comfort, satisfaction or pain. Procedural time was longer for residents, but this did not correlate significantly with patient-experienced comfort (p = 0.3). In UCS, patient comfort and satisfaction were higher in the supine position for male and female patients, respectively (p < 0.01). In TRUSP, local anaesthesia resulted in a significant decrease in pain (p = 0.002) and an increase in comfort (p = 0.03). Finally, older patients experienced less pain and gave higher comfort and satisfaction responses than younger patients.

CONCLUSIONS

Patients expressed high levels of satisfaction and comfort during diagnostic urological procedures. Experiences were not affected by the level of training, suggesting highly developed interpersonal and communication skills for residents in an early stage of residency training. Patients demonstrated significant preferences for local anaesthesia in TRUSP and performance of UCS in the supine position over the lithotomy position.

Characteristics That Define a Successful Pharmacy Resident as Perceived by Residency Programs

PURPOSE

To identify the subjective and objective characteristics that pharmacy residency programs use to define a successful resident and to determine what percentage of their 2009-2010 residency class they felt were successful.

METHODS

An electronic survey was sent via e-mail to all residency program directors (RPDs) of postgraduate year 1 (PGY1) and postgraduate year 2 (PGY2) pharmacy residency programs in the United States. A 3-part survey instrument was developed following validation of questions for clarity and reliability using a pilot survey. Respondents were asked to rank the importance of 20 subjective characteristics for a resident to possess in order to be considered successful and the importance of different objective measurements of accomplishment in the definition of a "successful" resident using a Likert scale where 1 = not at all important, 2 = some importance, 3 = very important, and 4 = critical.

RESULTS

Of the 1,081 surveys sent to RPDs, 473 respondents answered at least one question, yielding a response rate of 43.8%. The most critically important subjective characteristics in defining a successful resident as ranked among PGY1 residency programs are dependability, professionalism, self-motivation/initiative, and work ethic. PGY2 programs ranked clinical knowledge and skills, critical thinking, and dependability as the most important. The most critically important objective characteristic in defining a successful resident as ranked among both PGY1 and PGY2 programs is obtaining a clinical position. The majority of PGY1 and PGY2 respondents felt that 76% to 100% of their 2009-2010 residency class was successful based on the characteristics they rated most important.

CONCLUSION

Identification of the characteristics that pharmacy residency programs use to define success will allow them to identify predictors of success and optimal methods of selecting residents who possess these characteristics.

Graduating Students' and Surgery Program Directors' Views of the Association of American Medical Colleges Core Entrustable Professional Activities for Entering Residency: Where are the Gaps?

OBJECTIVE

Residency program directors have increasingly expressed concern about the preparedness of some medical school graduates for residency training. The Association of American Medical Colleges recently defined 13 core entrustable professional activities (EPAs) for entering residency that residents should be able to perform without direct supervision on the first day of training. It is not known how students' perception of their competency with these activities compares with that of surgery program directors'.

DESIGN

Cross-sectional survey.

SETTING

All surgery training programs in the United States.

PARTICIPANTS

All program directors (PDs) in the Association of Program Directors in Surgery (APDS) database (n = 222) were invited to participate in an electronic survey, and 119 complete responses were received (53.6%). Among the respondents, 83% were men and 35.2% represented community hospital programs. PDs' responses were compared with questions asking students to rate their confidence in performance of each EPA from the Association of American Medical Colleges Graduation Questionnaire (95% response).

RESULTS

PDs rated their confidence in residents' performance without direct supervision for every EPA significantly lower when compared with the rating by graduating students. Although PDs' ratings continued to be lower than students' ratings, PDs from academic programs (those associated with a medical school) gave higher ratings than those from community programs. PDs generally ranked all 13 EPAs as important to being a trustworthy physician. PDs from programs without preliminary residents gave higher ratings for confidence with EPA performance as compared with PDs with preliminary residents. Among PDs with preliminary residents, there were equal numbers of those who agreed and those who disagreed that there are no identifiable differences between categorical and preliminary residents (42.7% and 41.8%, respectively).

CONCLUSIONS

A large gap exists between confidence in performance of the 13 core EPAs for entering residency without direct supervision for graduating medical students and surgery program directors. Both the groups identified several key areas for improvement that may be addressed by medical school curricular interventions or expanding surgical boot camps in hopes to improve resident performance and patient safety.

Surgical Specialty Residents More Likely to Receive the Arnold P. Gold Humanism and Excellence in Teaching Award

OBJECTIVE

The Arnold P. Gold Humanism and Excellence in Teaching Awards are given by medical students to residents. The aim of this study is to evaluate the distribution of this award based on residency specialty. The hypothesis is that surgical residents more commonly receive this award.

METHODS

This was a retrospective study from 2004 to 2013. All award recipients were obtained from the Arnold P. Gold Foundation website. The specialties of award recipients were tabulated. The number of award winners per thousand specialty residents was estimated using the Accreditation Council for Graduate Medical Education Data Resource Book, adjusting for the number of awarding schools and resident specialties. All statistics used an α = 0.05.

RESULTS

There were 2489 awards given during the study period, with 52.6% in medical specialties and 47.4% in surgical specialties (p = 0.45). The specialties most commonly awarded were General Surgery (22.3%), Internal Medicine (20.9%), and Obstetrics/Gynecology (20.4%). Adjusting for the number of eligible residents, there were 59.9 awards/1000 Obstetrics/Gynecology residents, 43.1 awards/1000 General Surgery residents, and 20.2 awards/1000 Internal Medicine residents (p < 0.001).

CONCLUSION

Controlling for the number of eligible residents, the Arnold P. Gold Humanism and Excellence in Teaching Awards are more commonly given to surgical specialty residents.

Residents' Experience in Breast Cancer Care

OBJECTIVE

General surgeons commonly treat breast cancer (BC), hence necessitating adequate training during residency. We examined surgery residents' exposure to these conditions across postgraduate years (PGYs) to assess the proximity of involvement to commencement.

STUDY DESIGN

We examined the BC operative profile by PGY using the American College of Surgeons National Surgical Quality Improvement Program Participant Use File (ACS NSQIP PUF, 2008-2011). Operations were classified using the Surgical Council on Resident Education curriculum complexity categories. Univariate analysis was performed using chi-square, Fisher exact, analysis of variance, and Kruskal-Wallis tests, as appropriate.

RESULTS

Of 58,413 BC operations, 23,996 involved PGY1 to PGY5 residents. A Surgical Council on Resident Education complexity was assigned to 97.7% of operations studied (n = 23,432). PGY was inversely proportional to the number of operations performed. PGY1 to PGY3 residents covered most essential-common operations (PGY1-3, 72% vs PGY4-5, 28%; p < 0.001). PGY1 and PGY2 residents covered more than half of the complex operations (PGY1-2, 55% [n = 359] vs PGY3-5, 45% [n = 288]; p = 0.033).

CONCLUSIONS

Although junior residents perform most of the BC cases in surgical residency, residents do participate in operations for BC across the continuum of the training years. Program directors should consider trainees' career aspirations to ensure adequate exposure to the operative and nonoperative management of this common disease before the transition to independent practice.

Caring for Children With Medical Complexity: Challenges and Educational Opportunities Identified by Pediatric Residents

OBJECTIVE

High-quality care for children with medical complexity (CMC) is in its infancy. Residents have the opportunity to view care for CMC with a fresh perspective that is informed by their work across diverse health care settings and significant time spent at the bedside. This study aimed to identify the challenges and potential solutions for complex care delivery and education from their perspectives.

METHODS

We conducted three 60-minute focus groups with a purposeful sample of residents and recent graduates at a US tertiary-care medical center. Data were transcribed verbatim, and themes were identified using an iterative approach and modified grounded theory.

RESULTS

Sixteen participants identified 4 major challenges to caring for CMC: 1) lack of care coordination; 2) complex technology management; 3) patients' pervasive psychosocial needs; and 4) lack of effective health care provider training. Participants identified 3 solutions: 1) greater integration of primary care providers; 2) attention to psychosocial needs through shared decision making; and 3) integration of longitudinal patient relationships into provider training. We found that residents who experienced longitudinal relationships with CMC felt more efficacious and better equipped to handle challenges of caring for CMC as a result of their broader understanding of patients' priorities and of their role as providers.

CONCLUSIONS

Residents recognize important challenges and offer thoughtful solutions to caring for CMC. Although multiple solutions exist, formal integration of longitudinal patient experiences into residency training may better prepare residents to understand patient priorities and identify when their own attitudinal changes can guide them into more efficacious roles as providers.

Impact of inpatient caseload, emergency department duties, and online learning resource on General Medicine In-Training Examination scores in Japan

Background

Both clinical workload and access to learning resource are important components of educational environment and may have effects on clinical knowledge of residents.

Methods

We conducted a survey with a clinical knowledge evaluation involving postgraduate year (PGY)-1 and -2 resident physicians at teaching hospitals offering 2-year postgraduate training programs required for residents in Japan, using the General Medicine In-Training Examination (GM-ITE). An individual-level analysis was conducted to examine the impact of the number of assigned patients and emergency department (ED) duty on the residents’ GM-ITE scores by fitting a multivariable generalized estimating equations. In hospital-level analysis, we evaluated the relationship between for the number of UpToDate reviews for each hospital and for the hospitals’ mean GM-ITE score.

Results

A total of 431 PGY-1 and 618 PGY-2 residents participated. Residents with four or five times per month of the ED duties exhibited the highest mean scores compared to those with greater or fewer ED duties. Those with largest number of inpatients in charge exhibited the highest mean scores compared to the residents with fewer inpatients in charge. Hospitals with the greater UpToDate topic viewing showed significantly greater mean score.

Conclusion

Appropriate ED workload and inpatient caseload, as well as use of evidence-based electronic resources, were associated with greater clinical knowledge of residents.

Role-Modeling Cost-Conscious Care--A National Evaluation of Perceptions of Faculty at Teaching Hospitals in the United States

BACKGROUND

Little is known about how well faculty at teaching hospitals role-model behaviors consistent with cost-conscious care.

OBJECTIVE

We aimed to evaluate whether residents and program directors report that faculty at their program consistently role-model cost-conscious care, and whether the presence of a formal residency curriculum in cost-conscious care impacted responses.

DESIGN

Cost-conscious care surveys were administered to internal medicine residents during the 2012 Internal Medicine In-Training Examination and to program directors during the 2012 Association of Program Directors in Internal Medicine Annual Survey. Respondents stated whether or not they agreed that faculty in their program consistently role-model cost-conscious care. To evaluate a more comprehensive assessment of faculty behaviors, resident responses were matched with those of the director of their residency program. A multivariate logistic regression model was fit to the outcome variable, to identify predictors of responses that faculty do consistently role-model cost-conscious care from residency program, resident, and program director characteristics.

PARTICIPANTS

Responses from 12,623 residents (58.4 % of total sample) and 253 program directors (68.4 %) from internal medicine residency programs in the United States were included.

MAIN MEASURES

The primary outcome measure was responses to questionnaires on faculty role-modeling cost-conscious care.

KEY RESULTS

Among all responses in the final sample, 6,816 (54.0 %) residents and 121 (47.8 %) program directors reported that faculty in their program consistently role-model cost-conscious care. Among paired responses of residents and their program director, the proportion that both reported that faculty do consistently role-modeled cost-conscious care was 23.0 % for programs with a formal residency curriculum in cost-conscious care, 26.3 % for programs working on a curriculum, and 23.7 % for programs without a curriculum. In the adjusted model, the presence of a formal curriculum in cost-conscious care did not have a significant impact on survey responses (odds ratio [OR], 1.04; 95 % Confidence Interval [CI], 0.52-2.06; p value [p] = 0.91).

CONCLUSIONS

Responses from residents and program directors indicate that faculty at US teaching hospitals were not consistently role-modeling cost-conscious care. The presence of a formal residency curriculum in cost-conscious care did not impact responses. Future efforts should focus on placing more emphasis on faculty development and on combining curricular improvements with institutional interventions to adapt the training environment.

Opinions of Otorhinolaryngology Residents about Their Education Process

Objective

Our study was planned to get the views of residents about the Otorhinolaryngology (ORL) education process and to enlighten the studies to make this process more effective.

Methods

A questionnaire was sent to the residents who were still in the residency program in all education clinics via "Google Drive". Seventy-four of 354 residents responded and the answers were evaluated electronically.

Results

Fifty residents (67.56%) gave an affirmative answer to the question about the use of "Resident Log Book" and no difference was seen among the clinics. While 9 residents (12.16%) were reporting that they did not read any scientific papers, 43 (58.1%) reported they read less than three per month. Forty-one residents thougt that they were having a good and sufficient education. Seventeen residents (51.51%) who thought they were not having a sufficient education reported that the education period should be longer. When they were wanted to evaluate the education process, while 66 of them (89.18%) said "Exhausting", 52 (70.27%) said "Stressful", it was seen that the ones who said "Instructive" and "Rewarding" were 26 (35.13%) and 17 (22.97%) respectively. Further, 43 of 48 residents (89.58%) who were over the third year of their residency program indicated that they were unable to perform at least one procedure listed in the questionnaire after finishing their education.

Conclusion

This study is important because it is the first study about the opinion of ORL residents and will help determine the current status in Turkey. This study will be useful for the preparation of educational programs and guides in the future.

Patient Safety Risks of Basic Urological Procedures Performed by Junior and Senior Residents

OBJECTIVE

To investigate the current performance of urological residents regarding basic urological procedures in relation to patient safety issues and the identification of specific training needs.

DESIGN

Observational data of 146 urethrocystoscopies (UCSs), 27 transrectal ultrasounds of the prostate (TRUSs), 38 transrectal ultrasound-guided prostatic biopsies (TRUSPs), and 30 transurethral resections of bladder tumor (TURBTs) were collected. Performance was evaluated using scoring lists including details on completeness of procedural steps, level of independence, time, and the incidence of unintended events. The causal factors contributing to the unintended events were identified by 2 expert urologists and classified according to the recognized PRISMA method.

SETTING

This study was performed in 5 teaching hospitals in the Netherlands.

PARTICIPANTS

We included 11 junior residents and 5 senior residents in urology in the final study cohort.

RESULTS

Senior residents showed a lower degree of completeness in material usage than junior residents did during UCS (p < 0.01) and in preparation, material usage, and procedure during TRUSP (all p < 0.05). In UCS and TURBT, senior residents received significantly less feedback than junior residents did (both p < 0.01). Incidence of unintended events for junior vs senior residents was 11% and 4% in UCS, 0% and 7% in transrectal ultrasound of the prostate, 36% and 62% in TRUSP, and 41% and 23% in TURBT, respectively. Overall, unintended events were mainly caused by human factors, in particular, verification and skills-based issues.

CONCLUSION

Present performance of basic urological procedures involves a high percentage of unintended events, especially in TRUSP and TURBT, which are mainly caused by human factors and are a potential threat for patient safety. Junior residents are less independent but more thorough in the performance of UCS and TRUSP than senior residents are. Targeted skills training including assessment should be implemented before privileges for independent practice are granted to reduce the incidence of unintended events and optimize patient safety.

Improving resident handoffs for children transitioning from the intensive care unit

BACKGROUND AND OBJECTIVE

Handoffs ensure patient safety during patient care transitions in the hospital setting. At our institution, verbal handoffs communicated by resident physicians are suggested practice for patients transferring from the PICU to the hospital medicine (HM) service. Despite their importance, these verbal handoffs occurred only 76% of the time before patient arrival on HM units. Our goal was to increase the completion rate of verbal handoffs to 100% within 5 months.

METHODS

Baseline data were collected in a daily survey of HM residents. Interventions were developed and tested on small, incremental change cycles. Key interventions included education about the importance of handoffs, standardization of the handoff process, standardization of handoff documentation, and identification and mitigation of handoff documentation failures. We tracked handoff completion rates by using statistical control charts. After success with improving the completion rate of patient handoffs to the HM service, we applied our process to handoffs from the PICU to all inpatient services.

RESULTS

Median completion of verbal patient handoff increased from 76% to 100% within 6 weeks, with improvement sustained for 15 months. Physician compliance with electronic medical record documentation increased from 58% to 94% within 8 months. After spreading to all patients transferring out of the PICU, documentation of patient handoffs increased from 76% to 94% in 5 months.

CONCLUSIONS

A system using improvement science methods was successful in increasing the reliability of resident verbal patient handoffs. Consistent documentation and internal redundancy with checklists were associated with sustained improvement.

The Pathology Resident Wiki: A Valuable Resource for Residents to Use on Call

Situations encountered on-call often bring some of the most unique and educationally rich questions to a pathology resident's attention which can be difficult to incorporate into institutional memory. A searchable online site (wiki) provides an easily accessible platform by which to do this and could serve as a valuable after-hour resident resource. Therefore, we evaluated a wiki's usefulness by creating a wiki using Campuspack for residents to catalog uncommon questions/situations encountered on call or rotations. After 41 months in use, analytic software embedded in the site was queried for usage statistics and one year's cohort of residents was surveyed to assess the wiki's value. Since the sites inception, over 7200 individual interactions with the site were recorded, with June through August being the most active period each year. Of the 15 residents surveyed, 60% utilized the site to answer a clinical question at least monthly and the majority (93%) considered the wiki a valuable on call resource. These findings suggest that an on-call wiki is a convenient tool for capturing the unique situations that pathology residents encounter. The majority of residents find the site a valuable resource and utilize it to answer clinical questions.

Experience of morning reports in the emergency department

Morning report in the emergency medicine departments is an emerging teaching modality in the medicine curriculum. Our institution, Hotel-Dieu de France hospital, a multidisciplinary tertiary care university hospital affiliated to the Saint Joseph University of Medical Sciences, is the only hospital in Middle East to hold morning reports in the emergency department (ED). We evaluate the usefulness of the morning report as a pedagogic tool as it assesses the content, quality of the discussions, professionalism, leadership, participation and duration of the morning report. The particularity of this paper is that it takes into consideration the interns' input often under-recognised in the studies. An anonymous questionnaire was diffused to the residents and interns that rotated in the ED during the previous year. It consisted of seven multiple-choice questions to evaluate the quality of the presentations, targeted discussions, ethics and professionalism, evidence-based medicine, clinical reasoning, relation of cases to discussions and implication of the ED physician. Overall, of the 63 patients who answered the survey, 65.1% were satisfied by the content. The majority considered the quality of the discussions acceptable and the leadership and participation satisfactory, professionalism was judged poor. Both residents and interns were satisfied of the teaching point of the morning reports. The only fail back observed was professionalism and pathophysiological discussions that require to be added to the sessions, whereas clinical management, teaching points, leadership and time management were completely satisfactory.

Resident Self-Assessment and Learning Goal Development: Evaluation of Resident-Reported Competence and Future Goals

OBJECTIVE

To determine incidence of learning goals by competency area and to assess which goals fall into competency areas with lower self-assessment scores.

METHODS

Cross-sectional analysis of existing deidentified American Academy of Pediatrics' PediaLink individualized learning plan data for the academic year 2009-2010. Residents self-assessed competencies in the 6 Accreditation Council for Graduate Medical Education (ACGME) competency areas and wrote learning goals. Textual responses for goals were mapped to 6 ACGME competency areas, future practice, or personal attributes. Adjusted mean differences and associations were estimated using multiple linear and logistic regression.

RESULTS

A total of 2254 residents reported 6078 goals. Residents self-assessed their systems-based practice (51.8) and medical knowledge (53.0) competencies lowest and professionalism (68.9) and interpersonal and communication skills (62.2) highest. Residents were most likely to identify goals involving medical knowledge (70.5%) and patient care (50.5%) and least likely to write goals on systems-based practice (11.0%) and professionalism (6.9%). In logistic regression analysis adjusting for postgraduate year (PGY), gender, and degree type (MD/DO), resident-reported goal area showed no association with the learner's relative self-assessment score for that competency area. In the conditional logistic regression analysis, with each learner serving as his or her own control, senior residents (PGY2/3+s) who rated themselves relatively lower in a competency area were more likely to write a learning goal in that area than were PGY1s.

CONCLUSIONS

Senior residents appear to develop better skills and/or motivation to explicitly turn self-assessed learning gaps into learning goals, suggesting that individualized learning plans may help improve self-regulated learning during residency.

The effect of an evidence-based medicine curriculum on breast cancer knowledge and satisfaction of surgical residents

OBJECTIVE

The current study was performed to determine if evidence-based medicine (EBM) curriculum would affect education of surgical residents.

DESIGN

A 5-year prospective study was designed to determine if EBM curriculum could improve residents' satisfaction and understanding of breast cancer management during a breast surgical oncology rotation. During the first 2 years, 45 journal articles were used. During the subsequent 3 years, journal articles were not used. The proportion of patients seen in clinic was collected as an objective measure of the "effort" made by the resident. The final assessment was a 120-question examination.

SETTING

Maricopa Medical Center, Phoenix, AZ. Safety net institution with General Surgery residency program.

PARTICIPANTS

Postgraduate year 2 general surgery residents.

RESULTS

Over 5 years, 30 postgraduate year 2 residents were involved. Univariate analysis showed that female sex (p = 0.04), residents with peer-reviewed publications (p = 0.03), younger age (p = 0.04), American Board of Surgery in-service training examination score (p = 0.01), and clinical effort (p < 0.01) were associated with higher scores. Although residents taught using the journal articles scored 7 points higher on the final examination, this was not significant (p = 0.10). Multivariate analysis showed that American Board of Surgery in-service training examination score and clinic efficiency remained statistically significant. Residents who were taught using the EBM curriculum had significantly higher satisfaction (4.4 vs 3.5, p = 0.001) compared with those who did not go through the EBM curriculum.

CONCLUSIONS

The current study demonstrates that an EBM curriculum significantly improved resident satisfaction with the rotation. The EBM curriculum may improve residents' breast cancer knowledge. The most important predictor of resident performance was the effort of resident.

Does nature make provision for backups in the modification of bacterial community structures?

Self-balancing is an inherent character in nature in response to community structure modification pressure and modern biotechnology has revolutionized the way such detections are made. Presented here is an overview of the forces and process interactions between released bacteria and indigenous microflora which encompass soil bacterial diversity, community structure, indigenous endorhizosphere micro-organisms, molecular detection methodologies, and transgenic plants and microbes. Issues of soil bacterial diversity and community structure as well as the interpretation of results from various findings are highlighted and discussed as inferred from research articles. An understanding of the factors influencing bio-inoculant modification of bacterial community structure in the colonization of the rhizosphere is essential for improved establishment of biocontrol agents, and is critically reviewed.

Outcomes of a randomized controlled educational intervention to train pediatric residents on caring for children with special health care needs

OBJECTIVE

To evaluate an innovative curriculum meeting new pediatric residency education guidelines, Special Care Optimization for Patients and Education (SCOPE).

METHODS

Residents were randomized to intervention (n = 23) or control (n = 25) groups. Intervention residents participated in SCOPE, pairing them with a child with special health care needs (CSHCN) and faculty mentor to make a home visit, complete care coordination toolkits, and participate in case discussions. The primary outcome was resident self-efficacy in nine skills in caring for CSHCN. Secondary outcomes included curriculum feasibility/acceptance, resident attitudes, and family satisfaction.

RESULTS

Response rates were ≥65%. Intervention residents improved in their self-efficacy for setting patient-centered goals compared with controls (mean change on 4-point Likert-type scale, 1.36 vs 0.56, P < .05). SCOPE was feasible/acceptable, residents had improved attitudes toward CSHCN, and families reported high satisfaction.

CONCLUSION

SCOPE may serve as a model for efforts to increase residents' self-efficacy in their care of patients with chronic disease.

Globalization of Craniofacial Plastic Surgery: Foreign Mission Programs for Cleft Lip and Palate

International Humanitarian Interchanges are a bona fide component of surgery and medicine. Additionally, these programs also provide substantial benefit both to the doers and the recipients.The foreign mission program is potentially a weapon of foreign policy which is underutilized and underestimated.Physician job dissatisfaction is increasing. However, the happiness and satisfaction of the participants in the short-term multidisciplinary trips, repeated, well-organized and respectful, with rather complete integration of the surgical system of the sister countries ("Plan B"), approaches 100%.The theory of the International Humanitarian Interchanges is based on substance, on medical theory. These trips are particularly successful in interchanges with medium-resourced countries.Furthermore, the academic visiting professor ("Plan A": hi-resource place to hi-resource place), the One Man Can Save the World model ("Plan C": to the low-resource place), and the intriguing Horton Peace Plan have possibilities for long-term benefit to the doer, recipient, the field of surgery, and the body of knowledge. In all of these, our country and the family of nations advance.The theoretical basis is not always religious nor the grand strategy plan; both have either proselytizing or political dominance as primary motives, and are mentioned as historically helpful.

Nature and extent of external-cause deaths of nursing home residents in Victoria, Australia

OBJECTIVES

To describe the nature and extent of external-cause deaths of residents of nursing homes in Victoria, Australia.

DESIGN

A retrospective cohort study of all decedents using routinely collected data contained within the National Coronial Information System.

SETTING

Accredited nursing homes in Victoria.

PARTICIPANTS

Nursing home residents who had died from external causes and whose deaths were reported to the Coroners Court between July 1, 2000, and December 31, 2012.

MEASUREMENTS

Basic descriptive analysis was conducted to measure frequencies and proportion of exposures within each outcome group, and rates were calculated using population data.

RESULTS

One thousand two hundred ninety-six external cause deaths of nursing home residents were identified. Deaths were due to falls (n=1,155, 89.1%), choking (n=89, 6.9%), suicide (n=17, 1.3%), complications of clinical care (n=8, 0.6%) and resident-on-resident assault (n=7, 0.5%). Deaths occurred more frequently in women (n=814, 62.8%), in keeping with the sex distribution in nursing homes, and residents aged 85 and older (n=923, 71.2%). The number of inquests held to investigate a death as a matter of public interest was small (n=24, 1.9%).

CONCLUSION

A significant proportion of nursing home resident deaths are from external causes and are potentially preventable. A shift in community attitudes is required toward an understanding that premature death of a resident from injury is not a natural part of life.

Patient attitudes toward resident participation in cosmetic vs reconstructive outpatient consultations

OBJECTIVES

The goal of residency programs is to provide trainees with exposure to all aspects of their chosen field so that they exit the program ready to be independent practitioners. However, it is common in some plastic surgery residency training programs to exclude residents from participation in consultations with patients who are seeking cosmetic surgery. The purpose of this study was to determine whether cosmetic surgery patients had a different view about resident involvement than reconstructive surgery patients and to evaluate what factors might be linked to patient attitudes on this topic.

PARTICIPANTS

All new patients older than 18 years presenting to either academic or nonacademic locations were asked to complete the voluntary survey at their initial consultation.

SETTING

The study was conducted at both the Ohio State University (academic) and Advanced Aesthetic and Laser Surgery (private practice) in Columbus, Ohio.

DESIGN

The survey asked patients to identify their surgical concern as either cosmetic or reconstructive and to indicate the location on their body where they were having surgery. Additionally, a series of statements regarding resident involvement was presented with a 5-point Likert-type rating system to assess each patient's attitudes about a range of factors, such as resident sex and seniority.

RESULTS

In total, 119 patients participated in the study by completing the survey. Of this population, 59.7% (n = 71) were classified as reconstructive surgery patients and 40.3% (n = 48) were classified as cosmetic surgery patients. Based on responses, it was determined that reconstructive surgery patients were more approving of resident involvement in their care than cosmetic surgery patients were. When other factors were analyzed, the patients seeking breast surgery were found to be more apprehensive about resident participation than non-breast surgery patients were.

CONCLUSION

Although there were some differences in the way resident participation was perceived by cosmetic and reconstructive surgery patient populations, neither group strongly believed that resident participation decreased the quality of patient care. Based on these findings, plastic surgery training programs should begin to allow residents to become more involved in the care of cosmetic surgery patients.

Optimizing inter-professional communications in surgery: protocol for a mixed-methods exploratory study

Background

Effective nurse-physician communication is critical to delivering high quality patient care. Interprofessional communication between surgical nurses and surgeons, often through the use of pagers, is currently characterized by information gaps and interprofessional tensions, both sources of workflow interruption, potential medical error, impaired educational experience, and job satisfaction.

Objective

This study aims to define current patterns of, and understand enablers and barriers to interprofessional communication in general surgery, in order to optimize the use of communication technologies, teamwork, provider satisfaction, and quality and safety of patient care.

Methods

We will use a mixed-methods multiphasic approach. In phase 1, a quantitative and content analysis of alpha-numeric pages (ANP) received by general surgery residents will be conducted to develop a paging taxonomy. Frequency, timing (on-call vs regular duty hours), and interval between pages will be described using a 4-week sample of pages. Results will be compared between pages sent to junior and senior residents. Finally, using an inductive analysis, two independent assessors will classify ANP thematically. In Phase 2, a qualitative constructivist approach will explore stakeholders’ experiences with interprofessional communication, including paging, through interviews and shadowing of 40 residents and 40 nurses at two institutions. Finally, a survey will be developed, tested, and administered to all general surgery nurses and residents at the same two institutions, to evaluate their attitudes about the effectiveness and quality of interprofessional communication, and assess their satisfaction.

Results

Describing the profile of current pages is the first step towards identifying areas and root causes of IPC inefficiency. This study will identify key contextual barriers to surgical nurse-house staff communication, and existing interprofessional knowledge and practice gaps.

Conclusions

Our findings will inform the design of a guideline and tailored intervention to improve IPC in order to ensure high quality patient care, optimal educational experience, and provider satisfaction.

Outcomes registries: an untapped resource for use in surgical education

OBJECTIVE

To examine the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) for use in profiling the aggregated resident operative experience by postgraduate training year and to demonstrate the extent to which a surgical registry could be used to examine resident exposure to adverse events.

BACKGROUND

Independent data regarding the operative experience and clinical effectiveness across residency programs remain elusive. In the absence of reliable data, the ability to standardize surgical education and reduce variation in practice remains an unachievable goal.

METHODS

We identified general surgery cases using the ACS NSQIP Participant Use File 2011. Resident participation was defined according to postgraduate year (PGY). Descriptive statistical analyses were performed regarding procedure type and clinical outcomes.

RESULTS

Of the total general surgery cases, a PGY 1 to 5 resident participated in 87% (45,423), and 28% (n = 14,559) were performed with PGY 5 residents. Interns were involved with 10% (n = 5448) of the cases. The type of procedures performed varied by PGY, but cholecystectomy was the most common. Overall, 11% (4773) of cases were associated with an adverse event or mortality or both, with a mortality rate of 0.8% (374). The most common adverse event was bleeding (5%).

CONCLUSIONS

The ACS NSQIP captures the breadth of the resident experience in operative case mix and exposure to adverse events. Although the program was originally designed to uncover areas for quality improvement, the findings of our study demonstrate the utility of an outcomes registry as a guide for the development of future educational content in the resident curriculum.

Residency Program Directors' View on the Value of Teaching

PURPOSE

There is no standardization for teaching activities or a requirement for residency programs to offer specific teaching programs to pharmacy residents. This study will determine the perceived value of providing teaching opportunities to postgraduate year 1 (PGY-1) pharmacy residents in the perspective of the residency program director. The study will also identify the features, depth, and breadth of the teaching experiences afforded to PGY-1 pharmacy residents.

METHODS

A 20-question survey was distributed electronically to 868 American Society of Health-System Pharmacists-accredited PGY-1 residency program directors.

RESULTS

The survey was completed by 322 program directors. Developing pharmacy educators was found to be highly valued by 57% of the program directors. Advertisement of teaching opportunities was found to be statistically significant when comparing program directors with a high perceived value for providing teaching opportunities to program demographics. Statistically significant differences were identified associating development of a teaching portfolio, evaluation of Advanced Pharmacy Practice Experiences students, and delivery of didactic lectures with program directors who highly value developing pharmacy educators.

CONCLUSIONS

Future residency candidates interested in teaching or a career in academia may utilize these findings to identify programs that are more likely to value developing pharmacy educators. The implementation of a standardized teaching experience among all programs may be difficult.

Communication between nurses and physicians: strategies to surviving in the emergency department trenches

The emergency department (ED) is a challenging and stressful work environment where communication lapses can lead to negative health outcomes. This article offers strategies to Emergency Medicine residents, nurses and staff physicians on how to improve communication to optimize patient care.

Factors influencing escalation of care by junior medical officers

Patients can acutely deteriorate unexpectedly. Junior medical officers (JMOs) are often first to review patients who become unwell. Opportunities to escalate care to a senior colleague may exist prior to the need for a rapid response team review. Little is known about the factors that influence JMO decisions to escalate care. In this study, our objective was to investigate the self-reported factors that influence escalation of care by JMOs in a university-affiliated, tertiary level hospital. We designed a face-to-face questionnaire of JMOs using standardised introduction to minimise interviewer bias. Fifty JMOs participated in the study (a 100% response rate). Most (63.3%) felt that they would be able to identify a clinically deteriorating patient. They would be more likely to escalate care if they were not familiar with the patient's clinical problem. If handover plans were seen to be adequate, JMOs felt it was less necessary to escalate care. Few JMOs (12%) agreed that they limited escalation due to fear of criticism or fear of conflict with senior medical staff. Although 36% agreed that they were concerned about waking seniors overnight, only 6% feared that escalating care overnight would affect their future career prospects. Escalation of care appears to be mostly influenced by the confidence and familiarity of the JMO with the cause of deterioration. JMOs identified clear handover with documented goals of treatment and suggested actions in event of clinical deterioration as the best means by which to improve the process of escalation of care for clinically deteriorating patients.

An accelerated, practice-based model for fostering precepting skills in pharmacy residents

Sound precepting skills are vitally important for all pharmacists and for the future of our profession. Residency training provides a fertile environment for the resident to learn and foster new skills. This article outlines an accelerated model for developing precepting skills in residents and provides helpful advice for residents seeking to gain experience as a preceptor.

Low-fidelity hybrid sexual assault simulation training's effect on the comfort and competency of resident physicians

BACKGROUND

Alternative training methods are needed for resident physicians to ensure that care is not compromised should they practice in settings without well-established Sexual Assault Nurse Examiner (SANE) programs.

OBJECTIVE

The purpose of this study is to determine the effectiveness of a simulation-based sexual assault response course for resident physicians at an institution without an on-site SANE program.

METHODS

Educational intervention study of 12 emergency medicine residents using a low-fidelity hybrid simulation model. The study was comprised of eight male and four female physicians at a military medical center in San Diego, CA. Assessment occurred using three separate metrics. The first was a written knowledge test. The second was a simulated interview and evidentiary examination. These metrics were given 1 month before and 3 months after an 8-h training course. The final metric was Likert-scale questionnaires surveying pre- and post-course feelings of competency and comfort.

RESULTS

The emergency medicine residents showed a 13% improvement (95% confidence interval [CI] 7-20%) in written examination scores pre and post intervention. Post-course interview and examinations reflected a 44% improvement (95% CI 24-64%) in critical action completion. Pre-course comfort and competency questionnaires were a median of 2 (interquartile range [IQR] 1-3) on a Likert Scale. Post-course survey responses were a median of 4 (IQR 2-5).

CONCLUSIONS

Low-fidelity hybrid simulation is a useful tool to train inexperienced physicians to perform evidentiary examinations and interviews without sacrificing the privacy and direct care of sexual assault victims.

A resident preceptor model improves the clerkship experience on general surgery

BACKGROUND

The frenetic pace of inpatient care on surgical services can create barriers to resident teaching of students. Students are often concerned that busy surgical residents will not be able to adequately evaluate their performance at the end of a clerkship.

OBJECTIVE

To determine whether the addition of a resident preceptor would increase the satisfaction of students rotating through the general surgery portion of the required third-year surgery clerkship.

STUDY DESIGN

Before implementing a resident preceptor model, third-year students rotating on general surgery were administered a 24-item web-based survey regarding their experience on the general surgery portion of the surgery clerkship. General surgery residents were similarly surveyed. A resident preceptor model was then introduced. Subsequent students and residents were surveyed. Presurveys and postsurveys were compared and mean responses analyzed.

RESULTS

The addition of a resident preceptor made students more comfortable with asking residents questions (p = 0.02), increased the time students felt was available for developing relationships with residents (p = 0.03), and improved the feeling that residents would be able to accurately evaluate the student's effectiveness as a team member (p = 0.05). The students felt resident teaching on afternoon rounds was increased with the resident preceptor model (p = 0.05). Residents reported spending more time teaching students on morning rounds (p = 0.03).

CONCLUSIONS

Implementation of a resident preceptor model resulted in significant improvement in medical students' perceptions of resident teaching effectiveness and ability to accurately evaluate a student's performance.

Implementation of a low-cost laparoscopic skills curriculum in a third-world setting

BACKGROUND

Training outside the operating room has become a mainstay of surgical education. Laparoscopic training often takes place in a simulation setting. Advanced laparoscopic procedures are now commonplace, even in third-world countries with minimal hospital resources. We sought to implement a low-cost laparoscopic skills curriculum in a general surgery residency program in East Africa.

STUDY DESIGN

The laparoscopic skills curriculum created and validated at the University of Kentucky was presented to the 10 general surgery residents at Tenwek Hospital. The curriculum and all materials were purchased for approximately $50 (USD). The residents in Kenya had access to laparoscopic trainer boxes and personal laptops to perform the simulations. Residents were timed on their performance at the initiation of the project and after 3 weeks of practice.

RESULTS

Residents were tested on 3 separate tasks (cannulation drill, peg board, and rope pass). At the initiation of the project, residents were unable to complete the 3 tasks chosen for timing without a critical error (i.e., dropping a peg out of view). After 3 weeks of independent practice, residents were able to successfully complete the tasks, nearing the time limits established in the curriculum manual. Additional practice and testing sessions are scheduled for the remainder of the year.

CONCLUSIONS

Implementation of a low-cost laparoscopic skills curriculum in a third-world setting is feasible. This approach offers much-needed exposure and opportunities for residents with extremely limited resources and promises to be a vital aspect of the growing surgical residency training in third-world settings.