Exploring Qualitative Perspectives on Surgical Resident Training, Well-Being, and Patient Care

A qualitative study on the adoption of the new duty hour regulations among medical residents and faculty in Korea

Duty hour regulations (DHRs) were enforced in 2017 in Korea to prevent the detrimental effects of excessively prolonged working hours among medical residents. We investigated the adoption of and implications of the new DHRs among medical residents and faculty members. Semi-structured interviews were conducted with 15 medical residents and 9 faculty members across general surgery, internal medicine, obstetrics-gynecology, and pediatrics departments at Chonnam National University Hospital. Based on the constructivist grounded theory, we developed themes from the data by concurrent coding and analysis with theoretical sampling until data saturation. In addition, respondent validation was used to ensure accuracy, and all authors remained reflexive throughout the study to improve validity. The methods of DHRs adoption among residents and faculty members included the following 4 themes: DHRs improved work schedule, residents have more time to learn on their own, clinical departments have come to distribute work, organization members have strived to improve patient safety. Residents have undertaken initial steps towards creating a balance between personal life and work. Teamwork and shift within the same team are the transitions that minimize discontinuity of patient care considering patient safety. Teaching hospitals, including faculty members, should ensure that residents' work and education are balanced with appropriate clinical experience and competency-based training.

Patient handoffs and multi-specialty trainee perspectives across an institution: informing recommendations for health systems and an expanded conceptual framework for handoffs

BACKGROUND

Safe and effective physician-to-physician patient handoffs are integral to patient safety. Unfortunately, poor handoffs continue to be a major cause of medical errors. Developing a better understanding of challenges faced by health care providers is critical to address this continued patient safety threat. This study addresses the gap in the literature exploring broad, cross-specialty trainee perspectives around handoffs and provides a set of trainee-informed recommendations for both training programs and institutions.

METHODS

Using a constructivist paradigm, the authors conducted a concurrent/embedded mixed method study to investigate trainees' experiences with patient handoffs across Stanford University Hospital, a large academic medical center. The authors designed and administered a survey instrument including Likert-style and open-ended questions to solicit information about trainee experiences from multiple specialties. The authors performed a thematic analysis of open-ended responses.

RESULTS

687/1138 (60.4%) of residents and fellows responded to the survey, representing 46 training programs and over 30 specialties. There was wide variability in handoff content and process, most notably code status not being consistently mentioned a third of the time for patients who were not full code. Supervision and feedback about handoffs were inconsistently provided. Trainees identified multiple health-systems level issues that complicated handoffs and suggested solutions to these threats. Our thematic analysis identified five important aspects of handoffs: (1) handoff elements, (2) health-systems-level factors, (3) impact of the handoff, (4) agency (duty), and (5) blame and shame.

CONCLUSIONS

Health systems, interpersonal, and intrapersonal issues affect handoff communication. The authors propose an expanded theoretical framework for effective patient handoffs and provide a set of trainee-informed recommendations for training programs and sponsoring institutions. Cultural and health-systems issues must be prioritized and addressed, as an undercurrent of blame and shame permeates the clinical environment.

Meditation Using a Mobile App Improves Surgery Trainee Performance: a simulation-based randomized controlled trial

PURPOSE

To primarily investigate: (1) whether a 10 min instant meditation practice using mobile app could enhance arthroscopy performance and (2) whether a 10-day app-based meditation could reduce short-term arthroscopic skills deterioration.

METHODS

Orthopedic residents with no previous experience in arthroscopy and meditation were randomly assigned to Groups A, B, and C. After initial standard competency-based arthroscopy training on the simulator on Day 1, a pretest was performed via simulator by all participants to assess their initial level of performance, then Groups A and B were required to practice app-based mindfulness meditation 10 min/day for 10 consecutive days, while Group C did nothing. On Day 11, all participants came back to perform a posttest. Prior to the posttest, the participants in Group A practiced app-based meditation (10 min) , whereas Groups B and C had no intervention.

RESULTS

43 participants were included and reached similar level of performance after initial training phase in Day1. In Day11, participants in Group A had statistically better instant arthroscopy performance than Group B, with higher total score (Mean Difference, 3.57; P<.001), less completion time (MD, -42.89s; P=.001), shorter camera (MD, -23.38cm; P<.001) and grasper (MD, -15.23cm; P=.002) path length and less cartilage injury (MD, -1.07%; P=.012). Participants in Group B had less skills deterioration than Group C, with better total score (MD, -5.42; P<.001), less completion time (MD, 51.96s; P=.002), camera path length (MD, 28.41cm; P=.007) and cartilage injury (MD, 1.19%; P=.038).

CONCLUSION

Meditation training using mobile app enhanced instant simulation-based arthroscopy performance and reduced short-term skills deterioration of orthopedic residents with no arthroscopy hands-on experience.

CLINICAL RELEVANCE

Meditation using mobile app for clinicians and educators should be incorporated into simulation-based arthroscopy curriculums and perhaps clinical settings to improve arthroscopy performance and mental health of orthopedic residents without any prior arthroscopy experience.

ACGME 2011 Duty Hours Restrictions and Their Effects on Surgical Residency Training and Patients Outcomes: A Systematic Review

OBJECTIVE

The ACGME instituted the 2011 residency duty-hour restrictions (DHR) to increase resident well-being and patient safety. However, its eventual remodeling came after patient care was deemed unaffected. We aimed to identify the effects of the ACGME 2011-DHR on (1) patient outcomes, (2) surgical resident case volume, and (3) surgical resident quality of life.

DESIGN

Literature search using Google Scholar, PubMed, Cochrane, and Embase for publications between 2010 and 2020, on the 2011-DHR effects on resident and patient outcomes. Studies containing the number of cases performed during training, quality of life, and surgical patients' outcomes were included.

RESULTS

Fifteen studies met inclusion criteria. There was no difference in complication rates for surgical patients post 2011-DHR (p = 0.561). 2011-DHR caused surgical caseload shifts from interns to senior residents reflected by decreased operative cases for interns (p = 0.005) with significantly more total cases performed by chief residents (p = 0.0006). Pre-2011-DHR had more work flexibility that led to higher resident well-being (p = 0.01). Only 25% of residents approved of the 2011-DHR while 87% felt these restrictions would have adverse effects.

CONCLUSION

Current literature supports that the 2011-DHR did not improve patient outcomes, decreased surgical experience for junior residents and shifted clinical responsibilities to senior residents. System wide regulations such as the 2011-DHR may unintentionally create professional and personal life imbalance and introduce stress over resident inability to perform clinical responsibilities. Future systemic interventions to address resident well-being should be made with caution and not solely limited to the number of hours they work in a single week or in a single shift.

Public Perceptions of General Surgery Residency Training

OBJECTIVE

Patients are integral to surgical training. Understanding our patients' perceptions of surgical training, resident involvement and autonomy is crucial to optimizing surgical education and thus patient care. In the modern, connected world many factors extrinsic to a patient's experience of healthcare may influence their opinion of our training systems (i.e., social media, television shows, and internet searches). The purpose of this article is to contextualize the literature investigating public perceptions of general surgery training to allow us to effect patient education initiatives to optimize both surgical training and patient safety.

DESIGN

This is a perspective including a literature review summarizing the current knowledge of public perceptions of general surgery training.

CONCLUSIONS

Little is published regarding patient and public perceptions of general surgery residency training and the role of residents within this. Current literature demonstrates that the majority of patients are willing to have residents participate in their care. Patients' attitude toward resident involvement in their operation is improved by utilizing educational materials and by ensuring a supervising attending is present within the operating room. These observations, coupled with future work to delve deeper into factors affecting public perceptions of surgical training and resident involvement within this, can guide strategies to improve surgical education.

A National Mixed-Methods Evaluation of Preparedness for General Surgery Residency and the Association With Resident Burnout

Importance

Differences in medical school experiences may affect how prepared residents feel themselves to be as they enter general surgery residency and may contribute to resident burnout.

Objectives

To assess preparedness for surgical residency, to identify factors associated with preparedness, to examine the association between preparedness and burnout, and to explore resident and faculty perspectives on resident preparedness.

Design, Setting, and Participants

This cross-sectional study used convergent mixed-methods analysis of data from a survey of US general surgery residents delivered at the time of the 2017 American Board of Surgery In-Training Examination (January 26 to 31, 2017) in conjunction with qualitative interviews of residents and program directors conducted as part of the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial. A total of 262 Accreditation Council for Graduate Medical Education-approved US general surgery residency programs participated. Survey data were collected from 3693 postgraduate year (PGY) 1 and PGY2 surgical residents (response rate, 99%) and 98 interviews were conducted with residents and faculty from September 1 to December 15, 2018. Data were analyzed from June 1, 2017, to February 15, 2018.

Main Outcomes and Measures

Hierarchical regression models were developed to examine factors associated with preparedness and to assess the association between preparedness and resident burnout. Qualitative interviews were conducted to identify themes associated with preparation for residency.

Results

Of the 3693 PGY1 and PGY2 residents who participated (2258 male [61.1%]), 1775 (48.1%) reported feeling unprepared for residency. Approximately half of surgery residents took overnight call infrequently (≤2 per month) during their core medical student clerkship (1904 [51.6%]) or their subinternship (1600 [43.3%]); 524 (14.2%) took no call during their core clerkship. In multivariable analysis, residents were more likely to report feeling unprepared for residency if they were female (odds ratio [OR], 1.34; 95% CI, 1.15-1.57) or did not take call as a medical student (OR for 0 vs >4 calls, 2.72; 95% CI, 2.10-3.52). Residents who did not complete a subinternship were less likely to report feeling prepared for residency (OR, 0.68; 95% CI, 0.48-0.96). Feeling adequately prepared for residency was associated with a nearly 2-fold lower risk of experiencing burnout symptoms (OR, 0.57; 95% CI, 0.48-0.68). In interviews, the dominant themes associated with preparedness included the following: (1) various regulations limit the medical school experience, (2) overnight call facilitates preparation and selection of a specialty compatible with their preferences, and (3) adequate perceptions of residency improve expectations, resulting in improved preparedness, lower burnout rates, and lower risk of attrition.

Conclusions and Relevance

In this cross-sectional study, the perception of feeling unprepared was associated with inadequate exposure to resident responsibilities while in medical school. These findings suggest that effective preparation of medical students for residency may result in lower rates of subsequent burnout.

Learner Preference of Schedule Type Improves Engagement of Pediatric Residents: Results of a Mixed-Methods Analysis

OBJECTIVE

Determine whether a call or shift schedule is better for acquiring optimal knowledge and professionalism, while limiting fatigue for pediatric residents during the pediatric intensive care unit (PICU) rotation in a small residency program.

METHODS

This was a prospective, randomized, crossover, mixed-methods study in which pediatric residents were randomized to either a call or shift schedule during their PICU rotation. Attentiveness, bedside care, perceived knowledge, and professionalism were assessed by the resident participants, attending physicians, and nursing staff. Epworth Sleepiness Scale determined the level of resident fatigue. Statistical analysis utilized a t test of unequal variances. Two focus groups were conducted of resident non-participants and participants. Graduated resident participants and non-participants were surveyed via anonymous e-mail responses.

RESULTS

Thirty residents participated in the study and twenty residents were surveyed and participated in a focus group. No major differences were detected between each participating group, whether assigned to a call or shift schedule in regard to perceived knowledge, professionalism, or fatigue. Overall themes from qualitative analysis identified advantages and disadvantages for both work schedules. Participants recognized a learner preference for schedule type depending on level of training, suggesting a shift schedule for junior residents and a call schedule for senior residents.

CONCLUSIONS

There is no difference between the call or shift schedule in regard to residents' perceived knowledge, professionalism, and fatigue. Participants expressed learner preferences for one schedule over the other, recommending the shift schedule during the PGY-2 year and the call schedule during the PGY-3 year.

Association for Academic Surgery Presidential Address-Fanning the Burnout Fire: How Our Misconceptions and Good Intentions Could Fail Tomorrow's Surgeons

The issue of burnout among surgical trainees became evident during our work on the FIRST Trial. In studying the issue, we found that burnout symptoms occurred in a relatively large proportion of surgical trainees, and burnout was associated with significant risks of having thoughts of leaving the residency program or having suicidal thoughts. The SECOND Trial seeks to reduce trainee wellbeing and mistreatment by leveraging approaches used in healthcare quality performance improvement (e.g., comparative reports, toolkits, collaboration). Importantly, the epidemic of surgical trainee wellbeing issues have worsened (i.e., fanning the burnout fire) given our misconceptions about generational differences, our delayed adaptations to shifts in healthcare, and even some of our good intentions. However, there are several things we can do to improve the situation: (1) embrace the change that comes with each generation; (2) appreciate, respect, and enjoy our trainees; (3) teach residents constructively, leaving yelling and bullying behind; (4) embrace the concept of wellness for ourselves and each other; (5) provide meaningful feedback and mentorship; and (6) give each other the benefit of the doubt (e.g., principle of charity). Despite these issues, academic surgery remains the best job in the world, and the strength of our profession, leaders, and colleagues will see us through these challenges. The Association for Academic Surgery will help lead the way on these important issues.

Gender Differences in Utilization of Duty-hour Regulations, Aspects of Burnout, and Psychological Well-being Among General Surgery Residents in the United States

OBJECTIVE

The aim of the study was to (1) assess differences in how male and female general surgery residents utilize duty-hour regulations and experience aspects of burnout and psychological well-being, and (2) to explore reasons why these differing experiences exist.

BACKGROUND

There may be differences in how women and men enter, experience, and leave residency programs.

METHODS

A total of 7395 residents completed a survey (response rate = 99%). Logistic regression models were developed to examine the association between gender and resident outcomes. Semistructured interviews were conducted with 42 faculty and 56 residents. Transcripts were analyzed thematically using a constant comparative approach.

RESULTS

Female residents reported more frequently staying in the hospital >28 hours or working >80 hours in a week (≥3 times in a month, P < 0.001) and more frequently feeling fatigued and burned out from their work (P < 0.001), but less frequently "treating patients as impersonal objects" or "not caring what happens" to them (P < 0.001). Women reported more often having experienced many aspects of poor psychological well-being such as feeling unhappy and depressed or thinking of themselves as worthless (P < 0.01). In adjusted analyses, associations remained significant. Themes identified in the qualitative analysis as possible contributory factors to gender differences include a lack of female mentorship/leadership, dual-role responsibilities, gender blindness, and differing pressures and approaches to patient care.

CONCLUSIONS

Female residents report working more, experiencing certain aspects of burnout more frequently, and having poorer psychological well-being. Qualitative themes provide insights into possible cultural and programmatic shifts to address the concerns for female residents.

Interprofessional Communication Goes Up When the Electronic Health Record Goes Down

OBJECTIVE

The electronic health record (EHR) has been faulted for the erosion of interprofessional communication and the patient-physician relationship. Surgical residents may be susceptible to communication workarounds facilitated by the EHR, but the full extent is not well understood. A recent ransomware attack with the abrupt return to paper charting provided a unique opportunity to investigate the impact of the EHR on surgical residents' interprofessional communication. We sought to explore how surgical residents perceived communications during the 2-month period when the EHR was inaccessible.

DESIGN

General surgery residents who rotated through the regional tertiary referral medical center and level I trauma center were invited to participate in a semistructured interview about communication with one another, faculty, staff, and patients during the downtime. A grounded theory approach was used to analyze the data.

SETTING

Regional tertiary referral medical center and level I trauma center.

PARTICIPANTS

General surgery residents who rotated through the affected site.

RESULTS

Ten general surgery residents were interviewed. Interviews revealed that the abrupt loss of the EHR impacted communication in three major ways: (1) engendered more professional courtesy and collegiality, (2) prioritized bedside patient care over documentation demands, and (3) encouraged more explicit and deliberate communications.

CONCLUSIONS

Our study demonstrates that the loss of the EHR encourages surgery residents interprofessional communication. With healthcare becoming increasingly digital, active efforts should be made to preserve the communication benefits by optimizing existing and emerging technology to facilitate direct face-to-face interactions.

Uncovering Cultural Barriers to Quality Improvement Learning in a Trauma Program: An Ethnographic Study

OBJECTIVE

Quality improvement (QI) training is an essential component of postgraduate surgical education and can occur through formal and informal education programs. Informal QI education requires that faculty take advantage of learning opportunities in the hospital setting. Trauma rotations appear ideal opportunities for informal QI learning given that performance improvement is a mandatory component of care at verified trauma centers. It is unclear, however, whether QI initiatives within trauma programs are well integrated into trainee education. This study explored the QI learning environment in a level 1 academic trauma center.

STUDY DESIGN

An ethnographic study using observation and interviews methods. The theoretical lens of hidden curriculum was used to interpret the data and generate hypotheses around faculty and trainee experiences.

SETTING

University of Toronto and Sunnybrook Health Sciences Center.

PARTICIPANTS

Twenty-seven observations involving more than 50 faculty and trainees; seventeen interviews with faculty and surgical trainees.

RESULTS

All faculty and trainees endorsed QI and informal QI learning. Discrepant experiences were found regarding opportunities to learn and do QI in the clinical setting. Faculty viewed themselves as perpetually doing and teaching QI while trainees perceived little to no QI learning. Trainees identified Morbidity and Mortality rounds as the main opportunity for QI learning; however, traditional teaching style through "pimping" and a largely clinical focus acted as barriers to QI education. Furthermore, trainees chiefly viewed QI as service to the institution, rather than as a form of learning, which contributed to their disinterest in taking up informal QI lessons.

CONCLUSION

Informal QI education is highly valued and desired in academic trauma centers but enduring teaching methods, inconsistencies in the cultural learning environment and a hidden curriculum devaluing QI learning are persistent barriers to change.

Qualitative Analysis of a Cultural Dexterity Program for Surgeons: Feasible, Impactful, and Necessary

OBJECTIVES

Ineffective cross-cultural communication contributes to adverse outcomes for minority patients. To address this, the authors developed a novel curriculum for surgical residents built on the principle of cultural dexterity, emphasizing adaptability to clinical and sociocultural circumstances to tailor care to the needs of the individual patient. This study's objective was to evaluate the feasibility, acceptability, and perception of this program upon conclusion of its first year.

DESIGN, SETTING, AND PARTICIPANTS

The curriculum was implemented at 3 general surgery programs. The flipped classroom model combined independent study via e-learning modules with interactive role-playing sessions. Sessions took place over 1 academic year. Four focus groups were held, each with 6 to 9 participants, to gain feedback on the curriculum. Focus groups were recorded and transcribed, and the data were analyzed using a grounded theory approach.

RESULTS

Five major themes emerged: (1) Role modeling from senior colleagues is integral in developing communication/interpersonal skills and attitudes toward cultural dexterity. (2) Cultural dexterity is relevant to the provision of high-quality surgical care. (3) Barriers to providing culturally dexterous care exist at the system level. (4) "Buy-in" at all levels of the institution is necessary to implement the principles of cultural dexterity. (5) The shared experience of discussing the challenges and triumphs of caring for a diverse population was engaging and impactful.

CONCLUSION

Early implementation of the curriculum revealed that the tension between surgical residents' desire to improve their cultural dexterity and systemic/practical obstacles can be resolved. Combining surgically relevant didactic materials with experiential learning activities can change the paradigm of cross-cultural training.

A 3-Year Study of Resident Reaction to 2011 ACGME Work Hour Rules in a Family Medicine Residency

INTRODUCTION

2011 Accreditation Council for Graduate Medical Education (ACGME) work hour rules prompted concerns regarding potential negative impacts on patient care and resident education. We were interested in resident reaction to call restructuring and night oat (NF) in a family medicine residency over 3 years following implementation of the 2011 rules.

METHODS

We conducted structured interviews of residents from 2011-2012 through 2013-2014. Interviews were recorded, transcribed, and analyzed for themes.

RESULTS

Fifty-eight interviews were conducted, including 18/18 residents in 2011-2012 (100%), 18/20 residents in 2012-2013 (90%), and 22/22 residents in 2013-2014 (100%). Following introduction of the 24-hour work limit, upper year residents reported significantly less fatigue and improved personal lives, patient care, and educational experience. Reactions to NF varied with length and intensity of the NF rotation; most PGY-1 residents reported increased fatigue, more burnout, and worse personal lives on NF. Most residents felt patient care quality on NF did not differ from non-NF rotations because improved inpatient nighttime continuity mitigated effects of fatigue and increased care transitions. Reactions regarding educational experience on NF were initially negative, but improved over time.

CONCLUSIONS

Residents' reactions to 2011 ACGME work hour rules suggest the rules improved resident well-being, except on NF. Negative effects of NF may be minimized by limiting NF rotations to 5 nights/week for 2 consecutive weeks, and 1 month total per academic year.