1
|
Jurgens V, Librizzi J, Shah N, Bhansali P, Balmer DF, Beck J. Pediatric Hospital Medicine Fellows' Perspectives on Autonomy Through Time. Hosp Pediatr 2024; 14:682-689. [PMID: 39049744 DOI: 10.1542/hpeds.2024-007855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 04/30/2024] [Accepted: 05/13/2024] [Indexed: 07/27/2024]
Abstract
OBJECTIVE Promoting autonomy is at the core of fellowship education. Pediatric hospital medicine (PHM) fellowship programs are relatively new, and many supervising physicians are not trained on how to promote fellow autonomy. Moreover, no studies have explored fellows' perception of autonomy throughout training. To fill this gap, we explored PHM fellows' perceptions of autonomy throughout training. METHODS PHM fellows starting fellowship in July 2021 were recruited to participate in a longitudinal qualitative study. Using self-determination theory as a sensitizing framework, the authors conducted semistructured interviews with 14 fellows throughout fellowship. Incoming data were iteratively analyzed, and codes were created from patterns in the data. Coded data were clustered into themes. RESULTS Four themes developed: (1) at the beginning of fellowship, fellows valued direct observation and close supervision from their attending. (2) Initially, fellows felt pressured to make the identical clinical decision as their attending, but over the course of training, they realized their autonomous decisions could coexist with different decisions from their attending physicians. (3) At first, fellows desired attending presence to support and guide their decision making. Over time, fellows desired a coach who could provide valuable formative feedback. (4) Because of the hierarchical nature of medicine, conversations between fellows and attending physicians about autonomy were challenging to initiate. CONCLUSIONS Fellows' perceptions of autonomy change throughout fellowship, which should be taken into consideration as provisions of autonomy evolve through training. Our findings can inform PHM fellowship curricula and professional development around the promotion of autonomy in fellowship.
Collapse
Affiliation(s)
- Valerie Jurgens
- Children's National Hospital, Washington, District of Columbia
- George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | | | - Neha Shah
- Children's National Hospital, Washington, District of Columbia
- George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Priti Bhansali
- Children's National Hospital, Washington, District of Columbia
- George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Dorene F Balmer
- The Perelman School of MedicineUniversity of Pennsylvania, Philadelphia, Pennsylvania
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jimmy Beck
- Seattle Children's Hospital, Seattle, Washington
- The University of Washington School of Medicine, Seattle, Washington
| |
Collapse
|
2
|
Yu Y, Oliver JB, Kunac A, Sehat AJ, Anjaria DJ. Declining Surgical Resident Operative Autonomy-All Trainees Are Not Created Equal. J Surg Res 2023; 292:330-338. [PMID: 37117092 DOI: 10.1016/j.jss.2023.02.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 02/07/2023] [Accepted: 02/18/2023] [Indexed: 04/30/2023]
Abstract
INTRODUCTION We have previously shown that resident autonomy has decreased over time overall for all surgery residents. The purpose of this study is to examine changes in operative autonomy in general surgery residency within each postgraduate year (PGY) level. MATERIALS AND METHODS This is a retrospective analysis of the Veterans Association Surgical Quality Improvement Program database from July 1, 2004 to September 30, 2019. All general surgery, vascular surgery, and thoracic surgery procedures were analyzed and categorized by level of resident supervision as attending primary, attending operating with resident, or resident primary without attending scrubbed. Procedure work portion of relative value unit was used to capture procedure complexity. Changes in resident autonomy over time, procedure complexity, and outcomes were compared among PGY levels 1 to 5. RESULTS A total of 385,482 cases were analyzed. At each PGY level from 2014 to 2018, the relative decrease in resident primary cases ranged from -37.3% (PGY 4) to -75.5% (PGY 3). Mean work portion of relative value unit saw steady increase with PGY level (8.4 ± 3.5 in PGY 1 to 10.8 ± 5.7 in PGY 5, P < 0.001) and did not show a trend over time. CONCLUSIONS Surgical resident operative autonomy has markedly decreased over time across all PGY levels. This effect is most profound at the PGY 3 level, while more senior residents are affected to a lesser degree. Case complexity show PGY level-appropriate increase in resident autonomous cases. Decrease in resident autonomy over time is not associated with changes in case complexity.
Collapse
Affiliation(s)
- Yasong Yu
- Department of Surgery, VA New Jersey Healthcare System, East Orange, New Jersey; Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Joseph B Oliver
- Department of Surgery, VA New Jersey Healthcare System, East Orange, New Jersey; Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Anastasia Kunac
- Department of Surgery, VA New Jersey Healthcare System, East Orange, New Jersey; Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Alvand J Sehat
- Department of Surgery, VA New Jersey Healthcare System, East Orange, New Jersey
| | - Devashish J Anjaria
- Department of Surgery, VA New Jersey Healthcare System, East Orange, New Jersey; Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey.
| |
Collapse
|
3
|
Beaulieu-Jones BR, de Geus SWL, Rasic G, Woods AP, Papageorge MV, Sachs TE. A propensity score matching analysis: Impact of senior resident versus fellow participation on outcomes of complex surgical oncology. Surg Oncol 2023; 48:101925. [PMID: 36913848 PMCID: PMC10200751 DOI: 10.1016/j.suronc.2023.101925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 02/12/2023] [Accepted: 03/05/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND Teaching hospitals that train both general surgery residents and fellows in complex general surgical oncology have become more common. This study investigates whether participation of a senior resident versus a fellow has an impact on outcomes of patients undergoing complex cancer surgery. METHODS Patients who underwent esophagectomy, gastrectomy, hepatectomy, or pancreatectomy between 2007 and 2012 with assistance from a senior resident (post-graduate years 4-5) or a fellow (post-graduate years 6-8) were identified from the ACS NSQIP. Based on age, sex, body mass index, ASA classification, diagnosis of diabetes mellitus, and smoking status, propensity-scores were created for odds of undergoing the operation assisted by a fellow. Patients were matched 1:1 based on propensity score. Postoperative outcomes including risk of major complication were compared after matching. RESULTS In total, 6934 esophagectomies, 13,152 gastrectomies, 4927 hepatectomies, and 8040 pancreatectomies were performed with assistance of a senior resident or fellow. After matching, overall rates of major complications were equivalent across all four anatomic locations between cases performed with the participation of a senior resident versus a surgical fellow: esophagectomy (37.0%% vs 31.6%, p = 0.10), gastrectomy (22.6% vs 22.3%, p = 0.93), hepatectomy (15.8% v 16.0%, p = 0.91), and pancreatectomy (23.9% vs 25.2%, p = 0.48). Operative time was shorter for gastrectomy (212 vs. 232 min; p = 0.004) involving a resident compared to a fellow, but comparable for esophagectomy (330 vs. 336 min; p = 0.41), hepatectomy (217 vs. 219 min; p = 0.85), and pancreatectomy (320 vs. 330 min; p = 0.43). CONCLUSIONS Senior resident participation in complex cancer operations does not appear to negatively impact operative time or postoperative outcomes. Future research is needed to further assess this domain of surgical practice and education, particularly with regard to case selection and operative complexity.
Collapse
Affiliation(s)
- Brendin R Beaulieu-Jones
- Department of Surgery, Boston Medical Center, Boston, MA, USA; Boston University School of Medicine, Boston, MA, USA
| | | | - Gordana Rasic
- Department of Surgery, Boston Medical Center, Boston, MA, USA; Boston University School of Medicine, Boston, MA, USA
| | - Alison P Woods
- Department of Surgery, Boston Medical Center, Boston, MA, USA; Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Teviah E Sachs
- Department of Surgery, Boston Medical Center, Boston, MA, USA; Boston University School of Medicine, Boston, MA, USA.
| |
Collapse
|
4
|
Golubkova A, Liebe H, Leiva T, Lees J, Reinschmidt KM, Hunter CJ. Ethics of Resident Involvement in Surgical Training. THE JOURNAL OF CLINICAL ETHICS 2023; 34:175-189. [PMID: 37229744 DOI: 10.1086/725083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
AbstractBackground: Attending surgeons must maintain balance between promoting education and assuring safe, transparent patient care. This investigation aimed to define ethics that guide surgical training. We hypothesized that resident autonomy in the operating room is influenced by attending approach to patients, specifically patients considered to be vulnerable. MATERIALS AND METHODS After IRB approval, surgeons from three institutions were invited to participate in a pilot, survey, exploring how principles of patient autonomy, physician beneficence, nonmaleficence, and justice apply to participant opinions. Responses were transcribed and coded for quantitative and qualitative analysis. RESULTS 51 attendings and 55 residents completed the survey. We identified that patient autonomy is upheld through transparent consent practices. Intraoperative supervision is a key practice that maintains the principles of physician beneficence and nonmaleficence and mitigates the risk of resident participation. Vulnerable patients were defined by respondents as those unable to participate in their own consent and those limited by social determinants of health and barriers to medical literacy. In contrast, resident participation is not limited in the care of vulnerable patients but is restricted in cases of higher complexity and those procedures deemed to have lower error margins. CONCLUSIONS Although residents measure the success of their training based on their level of intraoperative independence, autonomy afforded to the resident does not only depend on objective skill. There are ethical considerations that the attending must navigate as they decide on effective teaching and safe surgical management, which is especially relevant in the care of complex cases.
Collapse
|
5
|
Yu Y, Kunac A, Oliver JB, Sehat AJ, Anjaria DJ. General Surgery Resident Complement and Operative Autonomy - Size Matters. JOURNAL OF SURGICAL EDUCATION 2022; 79:e76-e84. [PMID: 36253329 DOI: 10.1016/j.jsurg.2022.09.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 06/21/2022] [Accepted: 09/11/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE Operative autonomy has progressively decreased for surgery residents. This study investigates the effect of general surgery resident complement size at Veterans Affairs (VA) hospitals on operative autonomy for the residents. We hypothesize that smaller complements of residents would result in fewer opportunities for operative autonomy. DESIGN Retrospective analysis of the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. SETTING Operative cases within the VASQIP database from July 1, 2004 to September 30, 2019 were analyzed. PARTICIPANTS All general surgery procedures performed at teaching VA hospitals from January 2004 to September 2019 were included. The level of resident operative autonomy is defined as follows: attending primary surgeon with or without a resident (AP), resident primary surgeon with attending scrubbed (AR), and resident primary without attending scrubbed (RP). Resident complement is based on funded resident positions at each VA hospital during the academic year 2017-2018 and stratified into 3 groups: small (≤4), medium (>4-<7), and large (≥7). The primary outcome was the proportion of operative autonomy for each resident complement group. Secondary outcomes were level of autonomy over time, and mortality and morbidity for RP procedures. Categorical data were compared with Chi-squared test. RESULTS Four hundred sixty-one thousand seven hundred thirty-four procedures across 92 VA hospitals with general surgery residents were included in the analysis. There were 126,062 cases performed at 29 small resident complement hospitals, 135,539 at 28 medium resident complement hospitals, and 200,133 at 35 large resident complement hospitals. The percentage of RP procedures was higher with increasing resident complement (2.1% vs 6.8% vs 9.9%, p < 0.001). RP procedures have decreased over time in all groups, but the relative decrease was less pronounced as resident complement increased (79.5% vs 73.3% vs 64.7%, p < 0.001). There was no significant difference in adjusted 30-day all-cause mortality between groups. CONCLUSIONS Increased resident complement at VA hospitals is associated with increased resident autonomy in resident primary procedures. Resident autonomy has decreased over time regardless of complement size, but it is less dramatic at sites with more residents. Increasing resident complement at a site may improve operative autonomy, leading to an improved educational experience for surgical residents.
Collapse
Affiliation(s)
- Yasong Yu
- Department of Surgery, VA New Jersey Healthcare System, East Orange, New Jersey; Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Anastasia Kunac
- Department of Surgery, VA New Jersey Healthcare System, East Orange, New Jersey; Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Joseph B Oliver
- Department of Surgery, VA New Jersey Healthcare System, East Orange, New Jersey; Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Alvand J Sehat
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Devashish J Anjaria
- Department of Surgery, VA New Jersey Healthcare System, East Orange, New Jersey; Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey.
| |
Collapse
|
6
|
Cadaveric Wet Lab Training for Nasolacrimal Procedures in Ophthalmology Residency. Ophthalmic Plast Reconstr Surg 2022; 38:409-410. [DOI: 10.1097/iop.0000000000002245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
7
|
The Influence of Chronic Pain and Catastrophizing on Patient Outcomes in an Athletic Therapy Setting. J Sport Rehabil 2022; 31:60-68. [PMID: 34824164 DOI: 10.1123/jsr.2020-0450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 07/05/2021] [Accepted: 07/08/2021] [Indexed: 12/16/2022]
Abstract
CONTEXT Chronic pain is a challenge for Athletic Trainers and Athletic Therapists working in a clinical or university setting. The fear avoidance model, including catastrophizing, is well established in other health professions but is not established in Athletic Training and Athletic Therapy and may affect rehabilitation outcomes. OBJECTIVE To measure the influence of catastrophizing on rehabilitation outcomes of patients being treated in an Athletic Therapy setting. DESIGN Prospective single group pre-post design. SETTING Student Athletic Therapy clinic. PATIENTS A total of 92 patients were evaluated at initial assessment, and 49 were evaluated at follow-up. INTERVENTION All participants completed self-reported function questionnaires to assess level of injury and then received individualized treatments for a variety of musculoskeletal injuries. All measures were completed at initial assessment and at follow-up approximately 6 weeks later. MAIN OUTCOME MEASURES The authors measured function using a variety of patient self-reported functional questionnaires: the Disability of the Arm, Shoulder, and Hand; Lower Extremity Functional Scale; the Neck Disability Index; and the Oswestry Disability Index depending on injury site. Catastrophizing was measured using the Pain Catastrophizing Scale. RESULTS Function significantly improved from the initial assessment to the follow-up (P > .001). Patients with acute pain experienced a significantly greater improvement in function between the initial assessment and follow-up compared with participants with chronic pain (P = .050). Those with high catastrophizing presented with lower levels of function at initial assessment (66.8%) and follow-up (72.1%) compared with those with low catastrophizing (80.8% and 87.0%, respectively). CONCLUSION Similar to other studies in other professions, the function of patients with chronic pain does not improve as much compared with patients recovering from acute pain in an Athletic Therapy setting. It is important to measure patient-reported outcomes to evaluate patient rehabilitation progress. Rehabilitating patients with chronic pain is a challenge, and pain catastrophizing should be evaluated at the initial assessment since catastrophizing is associated with worse function.
Collapse
|
8
|
Yeung C, Shih JG, Knox ADC, Zhygan N, Courtemanche DJ, Fish JS, Brown MH. Variable Experience in Microsurgery and Flap-Based Procedures Among Canadian Plastic Surgery Residents. JOURNAL OF SURGICAL EDUCATION 2020; 77:1623-1631. [PMID: 32532696 DOI: 10.1016/j.jsurg.2020.04.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 04/04/2020] [Accepted: 04/18/2020] [Indexed: 06/11/2023]
Abstract
TITLE Variable experience in microsurgery and flap-based procedures among Canadian plastic surgery residents. OBJECTIVE Plastic surgery residencies are transitioning toward a competency-based education model. It is not known whether trainees can realistically achieve proficiency in microsurgical techniques during their training. This study aims to define the operative experience in the core microsurgical flap procedures among Canadian plastic surgery residents. DESIGN Microsurgical core procedural competencies (CPCs) have been described. A retrospective review was conducted, evaluating case logs recorded by graduating plastic surgery residents at 10 Canadian English-speaking training programs between 2004 and 2014. Perceived role and competence scores were also collected and analyzed. SETTING University of Toronto, Toronto, ON, Canada; University of British Columbia, Vancouver, BC, Canada. RESULTS Among 27 microsurgical CPCs, 2082 procedures were logged and each resident performed an average of 37.9 (±21.7) procedures. Anterolateral thigh flaps, radial forearm-based flaps, and digit replants were the most common; however, 10.9% to 14.5% of residents did not have any operative experience with these flaps. Most residents reported zero operative experience with many of the CPCs (10.9%-100%). Co-Surgeon (50%) and First Assistant (30%) were the most common roles. None of the graduating residents reported feeling competent enough to independently perform 50% of the microsurgery CPCs. There was no difference in perceived roles when programs with ≥5 residents were compared against programs with fewer trainees. There were weak to moderate correlations between role and self-perceived competence, and between Post Graduate Year and self-perceived competence. CONCLUSIONS There is wide variation in resident operative experience in microsurgical CPCs. Many residents graduate with little to no experience in many of the core procedures. Identifying areas of deficiency may help guide curriculum development in the new competency-based education model.
Collapse
Affiliation(s)
- Celine Yeung
- Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jessica G Shih
- Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Aaron D C Knox
- Division of Plastic Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nick Zhygan
- Division of Plastic Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Douglas J Courtemanche
- Division of Plastic Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Joel S Fish
- Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Mitchell H Brown
- Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto, Ontario, Canada.
| |
Collapse
|
9
|
Shin TH, Naples R, French JC, Khandelwal CM, Rose W, Alaedeen D, Dai J, Lipman J, Rosen MJ, Petro C. Effect modification of resident autonomy and seniority on perioperative outcomes in laparoscopic cholecystectomy. Surg Endosc 2020; 35:3387-3397. [PMID: 32642848 DOI: 10.1007/s00464-020-07780-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 07/01/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Resident operative involvement is an integral aspect of general surgery residency training. However, current data examining the effect of resident autonomy on perioperative outcomes remain limited. METHODS Patient and operator-specific data were collected from 344 adult laparoscopic cholecystectomies at a tertiary academic institution and its regional affiliates between 2018 and 2019. Multivariate modeling compared postoperative outcomes between cases completed with or without resident involvement and its effect modification by resident seniority and autonomy per Zwisch scale. Outcomes include 30-day postoperative complications, hospital readmission rate, and operative time. RESULTS Multivariate analysis revealed resident involvement in laparoscopic cholecystectomy did not significantly change odds of 30-day postoperative complications (OR 2.52, p = 0.185, 95% CI 0.64-9.92) or hospital readmission (OR 1.61, p = 0.538, 95% CI 0.36-7.23). Operative time is significantly increased compared to faculty-only cases (IRR 1.37, p < 0.001, 95% CI 1.26-1.48). While accounting for case difficulty and resident performance evaluated by SIMPL criteria, stratification by resident autonomy measured by Zwisch scale or seniority reveal no effect modification on 30-day postoperative complications, readmissions, or operative time. The effect of resident involvement on longer relative rates of operative time loses its significance in supervision-only cases (IRR 1.18, p = 0.069, 95% CI 0.99-1.41). CONCLUSION While resident involvement and autonomy are associated with significantly longer operative times in laparoscopic cholecystectomy, their lack of significant effect on postoperative outcomes argues strongly for continued resident involvement and supervised operative independence.
Collapse
Affiliation(s)
- Thomas H Shin
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA. .,Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A-100, Cleveland, OH, 44195, USA.
| | - Robert Naples
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Judith C French
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | | | - Warren Rose
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Diya Alaedeen
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jie Dai
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jeremy Lipman
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Michael J Rosen
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Clayton Petro
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| |
Collapse
|