Sexual and Gender Minority Curriculum Within Otolaryngology Residency Programs

Purpose: Otolaryngologists are uniquely situated to provide sexual and gender minority (SGM) care, including gender-affirmation (voice/communication, facial surgery) and HIV/AIDS-related conditions. Yet, no research has characterized otolaryngology residency program directors' attitudes toward SGM-related curricula, nor opportunities for supporting training in SGM-related care. Methods: An anonymous cross-sectional e-mail survey was disseminated to 116 otolaryngology residency program directors in July-September 2019. Information collected included current/future curriculum in and attitudes toward SGM care, and program demographics. Data were categorical and analysis utilized chi-square test. Results: The 65 complete responses (56% rate) were nationally representative. Overall, 17% of programs include no SGM-related education. Subjective importance of SGM training ranged from not important at all (3%) to absolutely essential (11%), with mode of average importance (47%); this varied significantly by program geographic setting and population, and program size. The mean percentage of curriculum dedicated to SGM care was 1.0% for didactics and 0.7% for clinical. Curricula include HIV/AIDS-related conditions (58%), facial gender-affirming procedures (50%), culturally informed care (42%), changes with gender-affirming hormones (voice/communication: 48%, facial: 22%), and cancer in SGM patients (42%). Frequently reported barriers were insufficient experienced faculty (52%) and time (42%). Program directors deemed visiting expert lectures (66%), small-group discussion (39%), and online modules (27%) the best ways to incorporate SGM education. Conclusions: More than 80% of otolaryngology residency curricula in a representative national survey include SGM-related education, which represents a limited portion of total curriculum. These results highlight the opportunity for expert lectures and discussion-based and online tool development to facilitate standardized SGM education in otolaryngology residencies.

Assessing the current state of quality improvement training in urology in the UK: Findings from the General Medical Council 2018 trainee survey

Objective:

The General Medical Council (GMC) of the UK has identified the need to support doctors through education in safety and quality improvement (QI) methods. This study reports findings from the GMC annual survey of 2018 from urology trainees regarding the state of QI training and their training needs.

Material and methods:

We designed a set of four questions to assess how QI methods are being taught nationally, and inserted them in the 2018 annual GMC trainee survey for urology. This is a cross-sectional study assessing the current state of QI training and mentoring received by trainees, and their self-assessed ability and confidence in completing a QI project as part of training requirements. Data were statistically analysed in Stata 15 stratified by Local Education Training Boards (LETBs)/Deanery and by specialty trainee level (ST3–7).

Results:

In total, 270 responses were received from urology trainees. Data showed significant variation across the country. Responses from ST3–7 trainees ranged from 5–20% on completing more than three QI projects, while 7–58% replied that they had done none. Across all ST grades, 40% of trainees stated they had not undertaken QI, whereas 0–27% reported they had not received any mentoring on QI to date. There was significant variation across training regions too: 11–74% of trainees answered that they have received training in QI methods, and 58–100% responded that they were confident in undertaking QI projects. Across all LETBs, 1–3% responded that they uploaded projects on national websites for dissemination; finally, a range of 0–18% stated they had completed more than three projects.

Conclusion:

This is the first national snapshot of QI training for the entire urology specialty in the UK. The study demonstrates wide variation in QI training and activity undertaken by trainees, and shows a lack of systematic implementation of QI education across training regions.

Level of evidence:

2c

A Multimodal Quality Improvement Curriculum for Pediatric GME Program Directors

The 2016 Accreditation Council for Graduate Medical Education Clinical Learning Environment Review report identified knowledge gaps for quality in the clinical environment. It suggested quality improvement (QI) training is necessary to develop skills to improve health care quality. However, at the authors' institution, there is limited department-level QI mentorship and engagement, thus limiting QI experiences for residents and fellows. The authors developed pediatric graduate medical education program director (PD) proficiency in QI through a fellowship-focused QI project. PDs underwent an 18-month QI curriculum consisting of focused online QI education, a half-day workshop, additional QI didactic sessions, project presentations, and individual QI coaching. QI knowledge in 9 domains and participants' confidence were assessed. Participants' self-perceived confidence and skills increased by at least 20% in most domains. Overall, PDs felt prepared to help with their fellows' future QI projects. Fellowship-focused QI projects and individual coaching were key to course engagement.

Education Research: A novel resident-driven neurology quality improvement curriculum

OBJECTIVE

To describe and assess the effectiveness of a neurology resident quality improvement curriculum focused on development of practical skills and project experience.

METHODS

We designed and implemented a quality improvement curriculum composed of (1) a workshop series and (2) monthly resident-led Morbidity, Mortality, & Improvement conferences focused on case analysis and project development. Surveys were administered precurriculum and 18 months postcurriculum to assess the effect on self-assessed confidence with quality improvement skills, attitudes, and project participation. Scholarship in the form of posters, presentations, and manuscripts was tracked during the course of the study.

RESULTS

Precurriculum, 83% of neurology residents felt that instruction in quality improvement was important, but most rated their confidence level with various skills as low. Following implementation of the curriculum, residents were significantly more confident in analyzing a patient case (odds ratio, 95% confidence interval) (2.4, 1.9-3.1), proposing system changes (3.1, 2.3-3.9), writing a problem statement (9.9, 6.2-13.5), studying a process (3.1, 2.3-3.8), identifying resources (3.1, 2.3-3.8), identifying appropriate measures (2.5, 1.9-3.0), collaborating with other providers to make improvements (4.9, 3.5-6.4), and making changes in a system (3.1, 2.3-3.8). Project participation increased from the precurriculum baseline (7/18, 39%) to the postcurriculum period (17/22, 77%; p = 0.023). One hundred percent of residents surveyed rated the curriculum positively.

CONCLUSIONS

Our multifaceted curriculum was associated with increased resident confidence with quality improvement skills and increased participation in improvement projects. With adequate faculty mentorship, this curriculum represents a novel template for preparing neurology residents for meeting the expectations of improvement in practice and offers scholarship opportunities.

Trends in Pediatric Otolaryngology Disparities Research

Objectives To describe trends in disparities research within pediatric otolaryngology as evidenced by major meeting presentations and to compare observed trends with those in the realm of patient safety and quality improvement (PSQI). Study Design Retrospective review of presentations at national otolaryngology meetings. Setting Online review of meeting programs. Subjects and Methods Meeting programs from the American Society of Pediatric Otolaryngology, Triological Society, American Academy of Otolaryngology-Head and Neck Surgery Foundation, and Society for Ear, Nose and Throat Advances in Children from 2003 to 2016 were manually searched for pediatric oral and poster presentations addressing disparities and socioeconomic determinants of health, as well as PSQI. Presentation frequency was compared between categories and within each category over time. Results Of 11,311 total presentations, 3078 were related to the pediatric population, and 1945 (63.2%) of those were oral presentations. Disparities-related presentations increased from 0 in 2003 to 17 in 2016. From 2003 to 2009, 9 of 656 (1.4%) presentations involved disparities, as opposed to 70 of 2422 (2.9%) from 2010 to 2016 ( P = .03). The proportion of presentations regarding PSQI also increased: from 42 of 656 (6.4%) in 2003-2009 to 221 of 2422 (9.1%) in 2010-2016 ( P = .01). PSQI presentations remain more common than disparities presentations (9.1% vs 2.9%, P < .001). Conclusion Health care disparities are increasingly addressed in pediatric otolaryngology meeting presentations. Compared with the well-established realm of PSQI, disparities research remains nascent but is gaining attention. Health care reform and quality improvement efforts should recognize the role of socioeconomic factors and include strategies for addressing disparities.

National Multispecialty Survey Results: Comparing Morbidity and Mortality Conference Practices within and outside Otolaryngology

Objective

The objective is to describe variations in the otolaryngology morbidity and mortality (M&M) conference and to compare with other specialties.

Design

Cross-sectional survey.

Setting

The setting included otolaryngology departments across the United States and nonotolaryngology medical and surgical departments at 4 academic medical centers.

Subjects and Methods

Participants were members of a national otolaryngology quality/safety network and nonotolaryngology quality leaders at 4 large academic hospitals. Surveys were administered January 2017. Respondents described M&M conference practices, goals, and educational role.

Results

Twenty-eight of 39 individuals representing 28 institutions completed the otolaryngology survey (72% response rate). Of 197 individuals, 60 (30% response rate) representing 11 surgical and 20 nonsurgical specialties completed the comparison survey. Twenty-seven of 28 otolaryngologists (46 of 60 nonotolaryngologists) worked in academic settings. All otolaryngology programs conducted an M&M conference: 54% discussed all adverse events and errors; 32% used standard case selection processes; 70% used structured discussion, usually root cause analysis (64%); and 32% classified harm level. In comparison with other specialties, otolaryngology programs were more likely to discuss all adverse events and errors ( P = .01). Most conferences led to quality projects and intrainstitutional communication: 22% communicated to patients and families; 73% of respondents thought that M&M conferences should be standardized or use “best practices.” In both surveys, improving patient care was rated the conference’s most important function, followed by trainee education and culture change. Patient care and practice-based learning were rated the most relevant Accreditation Council for Graduate Medical Education Core Competencies in both surveys.

Conclusions

Academic otolaryngology M&M practices generally align with other specialties, but specifics vary widely, making collaborative quality improvement challenging. Educational and administrative priorities cross specialties. Most respondents thought that standardization and best practices are worthwhile. Nonacademic practice data are needed.

The state of academic sleep surgery: A survey of United States residency and fellowship programs

OBJECTIVES/HYPOTHESIS

Our objectives were to describe otolaryngology residency programs' experience in and attitudes toward sleep surgery, and describe current otolaryngology sleep fellowships and their impact on future academic practice.

STUDY DESIGN

E-mail survey.

METHODS

A survey was e-mailed to program directors of 106 Accreditation Council for Graduate Medical Education-accredited otolaryngology residencies assessing resident sleep medicine experience, program satisfaction, and impact of sleep faculty. A separate survey was sent to directors of the seven sleep medicine otolaryngology fellowships. Frequency of graduates pursuing academic careers was examined.

RESULTS

Forty-six (43.4%) residency programs responded. Thirty-one (67.4%) have a faculty member with any time spent practicing sleep medicine or surgery. Nineteen (41.3%) have a faculty member with >50% dedicated sleep practice and/or who is board certified in sleep medicine. These programs were significantly more likely to respond "extremely" or "very" satisfied with resident sleep exposure than those without (P < .001). Most programs (69.6%) "strongly agreed" or "agreed" their program would benefit from a dedicated sleep surgeon; there was no significant difference in response rates between programs already with and those without dedicated sleep faculty. All fellowship directors responded. In the past 5 years these programs have trained 11 total fellows. Ten (90.9%) have remained in academic practice.

CONCLUSIONS

There is significantly increased satisfaction in resident sleep education at otolaryngology programs with dedicated sleep providers. Concurrently, there is strong program interest in sleep surgeons' involvement in resident training. Sleep fellowships are producing surgeons who pursue academic careers. This study provides support to training fellowship-specialized sleep surgeons and encouraging otolaryngology sleep faculty.

LEVEL OF EVIDENCE

NA Laryngoscope, 127:2423-2428, 2017.

From Morbidity and Mortality to Quality Improvement: Effects of a Structured and Interactive Otolaryngology Conference

Objective

Measure the effects of a structured morbidity and mortality conference format on the attitudes of resident and faculty participants.

Study Design

Prospective cohort study.

Setting

Otorhinolaryngology–head and neck surgery residency training program.

Subjects and Methods

Two changes were implemented to the structure of our morbidity and mortality conference: (1) we adopted a recently described presentation framework called situation-background-assessment-recommendation and (2) appointed a faculty moderator to lead the conference. Surveys were distributed to residents and faculty before and after these modifications were implemented to measure changes in attitude of conference attendees.

Results

After implementing the above changes to the morbidity and mortality conference, participant engagement increased from “moderately engaged” to “extremely engaged” (P < .01). Among both faculty and residents, the perceived educational value of conference also improved from “moderately educational” to “extremely educational” (P < .01). Finally in the attending cohort, the impact on future patient care increased from “no change” to “greatly enhanced” (P < .01).

Conclusion

By implementing the situation-background-assessment-recommendation framework and appointing a faculty moderator to morbidity and mortality conference, participants reported significantly enhanced engagement during the conference, increased educational value of the session, and a positive impact on future patient care.

Patient Safety and Quality Improvement Education in Otolaryngology Residency: Preliminary Look at a Module-Based Approach

Since publication of the Institute of Medicine's report To Err Is Human in 1999, patient safety and health care quality have become hot topics in the parlance of modern medical care. The Accreditation Council for Graduate Medical Education now requires integration of these topics into resident education, with evidence of trainee involvement in Patient Safety and Quality Improvement (PSQI) projects. Research in other disciplines indicates that interactive, experiential learning leads to the highest quality PSQI education. Otolaryngology as a field has been slow to adopt these changes into its residency curricula due to competing educational demands and lack of faculty expertise. The author reports preliminary experience with integration of an online module-based curriculum that addresses both of these issues.

Quality Improvement Curriculum for Physical Medicine and Rehabilitation Residents: A Needs Assessment

This needs assessment survey of physical medicine and rehabilitation (PM&R) program directors (PDs) from Accreditation Council for Graduate Medical Education-accredited programs aimed to (1) describe current quality improvement (QI) training, (2) characterize PDs' perceptions of their own and their faculty's QI knowledge and skill, and (3) determine PDs' opinions of optimal QI training to inform the development of a future QI curriculum. Descriptive statistics were used for data analysis. Forty-five percent of PDs (35/78) responded. All programs had QI education and required QI project participation; however, the quantity and types of learning experiences varied greatly. PDs assessed their ability as less than proficient to teach QI (67%) and lead a project (57%), and rated 60% of their faculty as having novice or advanced beginner QI skills. PDs reported 31% of graduating residents had less than competent QI skills. Almost all PDs were interested in a standardized QI curriculum.

Programmatic Assessment of a Comprehensive Quality Improvement Curriculum in an Otolaryngology Residency

To date, there is minimal literature discussing quality improvement curricula in otolaryngology. Herein, we present our program, including didactic, web-based, and experiential learning, developed in the setting of a preexisting institutional quality and safety policy. Nine otolaryngology residents were evaluated with assessments focused on learner satisfaction, learner attitudes, and knowledge acquisition according to the Kirkpatrick framework. Wilcoxon signed-rank test was used to compare results. While the total score increased across all assessments, it was significant for only the Quality Improvement Knowledge Application Tool Revised ( P < .05). We find our initial learning outcomes encouraging and hope that our comprehensive curriculum can serve as a resource to other programs, which can be adapted to fit within the context of variable training environments. Furthermore, it is imperative to consider continuous assessment and refinement of any educational program, using the same quality improvement principles that we endeavor to teach.