The Enneagram as a Tool for Resident Wellness and Correlation With Accreditation Council for Graduate Medical Education Milestone Achievements

INTRODUCTION

The Enneagram is an ancient personality typing system developed to improve self-knowledge. Broken down into nine personality types, each is driven by a core motivating factor. Other personality assessments have been used to study the personality profile of surgeons. The purpose of this study is to evaluate the variability in Enneagram type among a single institution's general surgery residents.

METHODS

All categorical general surgery residents at a single institution completed an online Enneagram assessment as part of a wellness initiative. Accreditation Council for Graduate Medical Education milestone levels for professionalism (PRO) and interpersonal and communication skills were collected for each resident's intern year. Milestone levels were compared between the nine Enneagram types.

RESULTS

All nine Enneagram types were represented among surveyed residents. The most frequent Enneagram type was type 3 (20.69%). There was no significant difference between PRO (P = 0.322) and interpersonal and communication skills (P = 0.645) scores among residents distributed by Enneagram type.

CONCLUSIONS

Regardless of core Enneagram type, general surgery residents in this study all achieved appropriate Accreditation Council for Graduate Medical Education milestone levels for entry level of training. The Enneagram can provide self-awareness and understanding of resident differences but does not impact initial assessment of competency in PRO and interpersonal communication skills.

Early Emergency Medicine Milestone Assessment for Predicting First-Year Resident Performance

Introduction

The Accreditation Council for Graduate Medical Education (ACGME) requires emergency medicine (EM) residency training programs to monitor residents' progress using standardized milestones. The first assessment of PGY 1 resident milestones occurs midway through the first year and could miss initial deficiencies. Early assessment of PGY 1 EM resident milestones has potential to identify at-risk residents prior to standard midyear evaluations. We developed an orientation syllabus for PGY 1 residents followed by a milestone assessment. Assessment scores helped predict future milestone scores and American Board of Emergency Medicine (ABEM) In-Training Examination (ITE) scores for PGY 1 residents.

Methods

From 2013 to 2020, we developed and implemented Milestone Evaluation Day (MED), a simulation-based day and written exam assessing PGY 1 EM residents during their first month on the 23 ACGME 1.0 milestones. MED stations included a history and physical with verbal presentation, patient simulation, vascular access, wound management, and airway management. MED, Clinical Competency Committee-generated (CCC-generated) milestone, and ABEM ITE scores were averaged and compared utilizing Pearson's correlation coefficient.

Results

Of 112 PGY 1 EM residents, 110 (98%) were analyzed over an 8-year period. We observed a moderate positive correlation of MED and CCC-generated milestone scores (r = .34, p < .001). There was a nonstatistically significant weak positive correlation of MED and ABEM ITE scores (r = .13, p = .17).

Discussion

An early assessment of EM milestones in the PGY 1 year can assist in the prediction of CCC-generated milestone scores for PGY 1 residents.

Correlation between maternal and infant vitamin B12 levels in severe malnutrition in infants under 6 months

BACKGROUND

Malnutrition poses a significant global health challenge, affecting various age groups, with infants under 6 months being particularly vulnerable. Vitamin B12, an essential micronutrient critical for neurological development, has been identified as a key player in the overall health of both mothers and infants.

AIM

To find the correlation between serum vitamin B12 levels in infants, 1-6 months of age with severe malnutrition and maternal levels at tertiary care hospitals in western Rajasthan.

METHODS

The cross-sectional study was conducted in the UNICEF Regional Center of Excellence-supported Nutrition Rehabilitation Center in Rajasthan, India, through simple random sampling. One hundred ten infants with their mothers were enrolled after consent and approval from the Institutional Ethics Committee.

RESULTS

Severe malnutrition predominantly affected infants aged 1-2 months, with 77% born small for gestational age and 66.4% belonging to the multiple birth order group. Serum vitamin B12 levels showed a significant positive correlation between mothers and infants (p < 0.001), while exclusive breastfeeding correlated positively with age-appropriate milestones (p = 0.033).

CONCLUSION

The findings emphasize the importance of targeted interventions addressing maternal and infant nutrition, with a focus on ensuring adequate vitamin B12 levels.

Pediatric Pulmonary Milestones 2.0: Development, Lessons Learned, and Future Directions

Pediatric pulmonology fellowship training programs are required by the Accreditation Council for Graduate Medical Education to report Pediatric Subspecialty Milestones biannually to track fellow progress. However, several issues, such as lack of subspecialty-specific context and ambiguous language, have raised concerns about their validity and applicability to use for fellow assessment and curriculum development. In this Perspective, we briefly share the process of the Pediatric Pulmonology Milestones 2.0 Work Group in creating new specialty-specific Milestones and tailoring information on the Harmonized Milestones to pediatric pulmonologists, with the goal of improving the Milestones' utility for stakeholders, including pulmonology fellows, faculty, program directors, and accrediting bodies. In addition, we created a supplemental guide to better link the Milestones to pulmonary-specific scenarios to create a shared mental model between stakeholders and remove a potential detriment to validity. Through the process, a number of guiding principles were clarified, including: 1) every Milestone should be able to be assessed independently, without overlap with other Milestones; 2) there should be clear developmental progression from one Milestone to the next; 3) Milestones should be based on the unique skills expected of pediatric pulmonologists; and 4) health equity should be a core component to highlight as a top priority to all stakeholders. In this Perspective, we describe these principles that guided formulation of the Pediatric Pulmonary Milestones to help familiarize the pediatric pulmonary community with the new Milestones. In addition, we share lessons learned and challenges in our process to inform other specialties that may soon participate in this process.

Long-term follow-up of subthalamic nucleus deep brain stimulation in patients with Parkinson's disease: An analysis of survival and disability milestones

BACKGROUND

Data on the long-term survival and incidence of disability milestones after subthalamic nucleus deep brain stimulation (STN-DBS) in Parkinson's disease (PD) is limited.

OBJECTIVES

To estimate mortality and assess the frequency/time-to-development of disability milestones (falls, freezing, hallucinations, dementia, and institutionalization) among PD patients post STN-DBS.

METHODS

A longitudinal retrospective study of patients undergoing STN-DBS. For mortality, Cox proportional hazards regression analysis was performed. For disease milestones, competing risk analyses were performed and cumulative incidence functions reported. The strength of association between baselines features and event occurrence was calculated based on adjusted hazard ratios.

RESULTS

The overall mortality for the 109 patients was 16 % (62.1 ± 21.3 months after surgery). Falls (73 %) and freezing (47 %) were both the earliest (40.4 ± 25.4 and 39.6 ± 28.4 months, respectively) and most frequent milestones. Dementia (34 %) and hallucinations (32 %) soon followed (56.2 ± 21.2 and mean 60.0 ± 20.7 months after surgery, respectively). Higher ADL scores in the OFF state and higher age at surgery were associated with falls, freezing, dementia and institutionalization.

CONCLUSIONS

Long-term mortality rate is low after STN-DBS. Disease milestones occur later during the disease course, with motor milestones appearing first and at a higher frequency than cognitive ones.

Pediatric Endocrinology Milestones 2.0-guide to their implementation

The Milestones were initiated by the Accreditation Council for Graduate Medical Education (ACGME) to provide a framework for monitoring a trainee's progression throughout residency/fellowship. The Milestones describe stepwise skill progression through six core domains of clinical competency: Patient Care, Medical Knowledge, Interpersonal and Communication Skills, Practice-based Learning and Improvement, Professionalism, and Systems-based Practice. Since their introduction in 2013, several barriers to implementation have emerged. Thus, the ACGME launched the Milestones 2.0 project to develop updated specialty-specific milestones. The Pediatric Endocrinology Milestones 2.0 project aimed to improve upon Milestones 1.0 by addressing common limitations, providing resources for faculty to easily incorporate milestones into their assessment of trainees, and adding sub-competencies in health disparities, patient safety, and physician well-being.This paper reviews the development of the Pediatric Endocrinology Milestones 2.0 including the major changes from Milestones 1.0, development of the Supplemental Guide, and how Milestones 2.0 can be applied at the program level. Although use of the Milestones are required only for ACGME programs, the tools provided in Milestones 2.0 are applicable to fellowship programs worldwide.

Preventive effects of resveratrol against early-life impairments in the animal model of autism induced by valproic acid

Background

Autism Spectrum Disorder (ASD) is a neurodevelopmental condition characterized by social interaction deficits and repetitive/stereotyped behaviors. Its prevalence is increasing, affecting one in 36 children in the United States. The valproic acid (VPA) induced animal model of ASD is a reliable method for investigating cellular, molecular, and behavioral aspects related to the disorder. Trans-Resveratrol (RSV), a polyphenol with anti-inflammatory and antioxidant effects studied in various diseases, has recently demonstrated the ability to prevent cellular, molecular, sensory, and social deficits in the VPA model. In this study, we examined the effects of prenatal exposure to VPA and the potential preventive effects of RSV on the offspring.

Method

We monitored gestational weight from embryonic day 6.5 until 18.5 and assessed the onset of developmental milestones and morphometric parameters in litters. The generalized estimating equations (GEE) were used to analyze longitudinal data.

Results

Exposure to VPA during rat pregnancy resulted in abnormal weight gain fold-changes on embryonic days 13.5 and 18.5, followed by fewer animals per litter. Additionally, we discovered a positive correlation between weight variation during E15.5-E18.5 and the number of rat pups in the VPA group.

Conclusion

VPA exposure led to slight length deficiencies and delays in the onset of developmental milestones. Interestingly, the prenatal RSV treatment not only prevented most of these delays but also led to the early onset of certain milestones and improved morphometric characteristics in the offspring. In summary, our findings suggest that RSV may have potential as a therapeutic intervention to protect against the negative effects of prenatal VPA exposure, highlighting its importance in future studies of prenatal neurodevelopmental disorders.

Screening and determinant of suspected developmental delays among Egyptian preschool-aged children: a cross-sectional national community-based study

BACKGROUND

Early childhood life is critical for optimal development and is the foundation of future well-being. Genetic, sociocultural, and environmental factors are important determinants of child development.

AIM

The objectives were to screen for suspected developmental delays (DDs) among Egyptian preschool children, and to explore the determinants of these delays based on sociodemographic, epidemiological, maternal, and child perinatal risk factors.

METHODS

A national Egyptian cross-sectional developmental screening of a representative sample of preschool children (21,316 children) aged 12 to 71 months. The Revised Denver Prescreening Developmental Questionnaire (R-PDQ) followed by the Denver Developmental Screening Test, 2nd edition (DDST) was used.

RESULTS

Each screened child manifested at least one of six developmental categories. Either typical development, gross motor delay (GM), fine motor adaptive delay (FMA), Language delay (L), Personal-social delay (PS), or multiple DDs. The prevalence of preschool children with at least one DD was 6.4%, while 4.5% had multiple DDs. Developmental language delay was the most prevalent, affecting 4.2% of children. The least affected domain was GM (1.9% of children). Boys were more likely to have DD than girls. Children in urban communities were more likely to have at least one DD than those in rural areas (OR = 1.28, 95%CI: 1.14-1.42), and children of middle social class than of low or high social class (OR = 1.49, 95%CI: 1.30-1.70 & OR = 1.40, 95%CI: 1.23-1.59 respectively). The strong perinatal predictors for at least one DD were children with a history of postnatal convulsions (OR = 2.68, 95%CI: 1.97-3.64), low birth weight (OR = 2.06, 95%CI: 1.69-2.52), or history of postnatal cyanosis (OR = 1.77, 95%CI: 1.26-2.49) and mothers had any health problem during pregnancy (OR = 1.73, 95%CI: 1.44-2.07). Higher paternal and maternal education decreased the odds of having any DD by 43% (OR = 0.57, 95% CI: 0.47-0.68) and 31% (OR = 0.69, 95%CI: 0.58-0.82) respectively.

CONCLUSION

This study demonstrates a considerable attempt to assess the types and the prevalence of DD among preschool children in Egypt. Perinatal factors are among the most common determinants of DD in preschool children and the majority could be preventable risk factors.

Relationship between epa level of supervision with their associated subcompetency milestone levels in pediatric fellow assessment

BACKGROUND

Entrustable Professional Activities (EPA) and competencies represent components of a competency-based education framework. EPAs are assessed based on the level of supervision (LOS) necessary to perform the activity safely and effectively. The broad competencies, broken down into narrower subcompetencies, are assessed using milestones, observable behaviors of one's abilities along a developmental spectrum. Integration of the two methods, accomplished by mapping the most relevant subcompetencies to each EPA, may provide a cross check between the two forms of assessment and uncover those subcompetencies that have the greatest influence on the EPA assessment.

OBJECTIVES

We hypothesized that 1) there would be a strong correlation between EPA LOS ratings with the milestone levels for the subcompetencies mapped to the EPA; 2) some subcompetencies would be more critical in determining entrustment decisions than others, and 3) the correlation would be weaker if the analysis included only milestones reported to the Accreditation Council for Graduate Medical Education (ACGME).

METHODS

In fall 2014 and spring 2015, the Subspecialty Pediatrics Investigator Network asked Clinical Competency Committees to assign milestone levels to each trainee enrolled in a pediatric fellowship for all subcompetencies mapped to 6 Common Pediatric Subspecialty EPAs as well as provide a rating for each EPA based upon a 5-point LOS scale.

RESULTS

One-thousand forty fellows were assessed in fall and 1048 in spring, representing about 27% of all fellows. For each EPA and in both periods, the average milestone level was highly correlated with LOS (rho range 0.59-0.74; p < 0.001). Correlations were similar when using a weighted versus unweighted milestone score or using only the ACGME reported milestones (p > 0.05).

CONCLUSIONS

We found a strong relationship between milestone level and EPA LOS rating but no difference if the subcompetencies were weighted, or if only milestones reported to the ACGME were used. Our results suggest that representative behaviors needed to effectively perform the EPA, such as key subcompetencies and milestones, allow for future language adaptations while still supporting the current model of assessment. In addition, these data provide additional validity evidence for using these complementary tools in building a program of assessment.

Nutritional rickets presenting with developmental regression: a rare presentation of rickets

Rickets is a disorder of defective mineralisation of the growth plate. Vitamin D deficiency remains the leading cause of nutritional rickets worldwide.We present the case of a 3.5-year-old breastfed boy who presented with dental abscess when a history of developmental regression was noted. Clinical assessment revealed hypotonia, poor growth and stunting. Biochemistry identified hypocalcaemia (1.63mmol/L, [normal range (NR) 2.2-2.7mmol/L]), severe vitamin D deficiency (25hydroxyvitamin D 5.3nmol/L, [NR > 50nmol/L]) with secondary hyperparathyroidism (Parathormone 159pmol/L, [NR 1.6-7.5pmol/L]) and rickets on radiographs. Growth failure screening suggested hypopituitarism with central hypothyroidism and low IGF1 at baseline, however, dynamic tests confirmed normal axis. Management included nasogastric nutritional rehabilitation, cholecalciferol and calcium supplementation and physiotherapy. A good biochemical response in all parameters was observed within 3 weeks and reversal of developmental regression by 3 months from treatment. Developmental regression as a presentation of nutritional rickets is rare and requires a high index of suspicion.

Charting infants' motor development at home using a wearable system: validation and comparison to physical growth charts

BACKGROUND

Early neurodevelopmental care and research are in urgent need of practical methods for quantitative assessment of early motor development. Here, performance of a wearable system in early motor assessment was validated and compared to developmental tracking of physical growth charts.

METHODS

Altogether 1358 h of spontaneous movement during 226 recording sessions in 116 infants (age 4-19 months) were analysed using a multisensor wearable system. A deep learning-based automatic pipeline quantified categories of infants' postures and movements at a time scale of seconds. Results from an archived cohort (dataset 1, N = 55 infants) recorded under partial supervision were compared to a validation cohort (dataset 2, N = 61) recorded at infants' homes by the parents. Aggregated recording-level measures including developmental age prediction (DAP) were used for comparison between cohorts. The motor growth was also compared with respective DAP estimates based on physical growth data (length, weight, and head circumference) obtained from a large cohort (N = 17,838 infants; age 4-18 months).

FINDINGS

Age-specific distributions of posture and movement categories were highly similar between infant cohorts. The DAP scores correlated tightly with age, explaining 97-99% (94-99% CI 95) of the variance at the group average level, and 80-82% (72-88%) of the variance in the individual recordings. Both the average motor and the physical growth measures showed a very strong fit to their respective developmental models (R² = 0.99). However, single measurements showed more modality-dependent variation that was lowest for motor (σ = 1.4 [1.3-1.5 CI 95] months), length (σ = 1.5 months), and combined physical (σ = 1.5 months) measurements, and it was clearly higher for the weight (σ = 1.9 months) and head circumference (σ = 1.9 months) measurements. Longitudinal tracking showed clear individual trajectories, and its accuracy was comparable between motor and physical measures with longer measurement intervals.

INTERPRETATION

A quantified, transparent and explainable assessment of infants' motor performance is possible with a fully automated analysis pipeline, and the results replicate across independent cohorts from out-of-hospital recordings. A holistic assessment of motor development provides an accuracy that is comparable with the conventional physical growth measures. A quantitative measure of infants' motor development may directly support individual diagnostics and care, as well as facilitate clinical research as an outcome measure in early intervention trials.

FUNDING

This work was supported by the Finnish Academy (314602, 335788, 335872, 332017, 343498), Finnish Pediatric Foundation (Lastentautiensäätiö), Aivosäätiö, Sigrid Jusélius Foundation, and HUS Children's Hospital/HUS diagnostic center research funds.

Enhancing motor screening efficiency: Toward an empirically derived abridged version of the Alberta Infant Motor Scale

Use of machine learning (ML) in the early detection of developmental delay is possible through the analysis of infant motor skills, though the large number of potential indicators limits the speed at which the system can be trained. Body joint obstructions, the inability to infer aspects of movement such as muscle tone and volition, and the complexities of the home environment - confound machine learning's ability to distinguish between some motor items. To train the system efficiently requires using an excerpted list of validated items, a salient set, which uses only those motor items that are the 'easiest' to see and identify, while being the most highly correlated to a low/qualifying score. This work describes the examination of motor items, selection of 15 items that comprise the salient set, and the ability of the set to reliably screen for motor delay in the first-year infant.

Pain Medicine Milestones 2.0: A Step into the Future

OBJECTIVE

To describe the process of revising the Pain Medicine Milestones 1.0 and implementing changes into the Pain Medicine Milestones 2.0 along with implications for pain medicine trainees.

BACKGROUND

Competency-based medical education has been implemented in graduate medical education, including pain medicine. Milestones 1.0, introduced by the Accreditation Council for Graduate Medical Education (ACGME), has been used to assess learners in six competencies and respective sub-competencies. Recognizing areas for improvement in Milestones 1.0, the ACGME initiated the process of Milestones 2.0 and a working group was created to execute this task for pain medicine. The working group discussed revisions; consensus was sought when changes were introduced. Final milestones were agreed upon and made available for public comment prior to publication.

RESULTS

Redundant sub-competencies were either merged or eliminated, reducing the number of sub-competencies. A maximum of three rows representing skill, knowledge, behavior and attitude were included for each sub-competency. Harmonized Milestones, aligning with other specialties in a predetermined ACGME framework, were adopted and modified to meet the needs of pain medicine. A supplemental guide was developed to assist educators in implementation of Milestones 2.0 and assessment of trainees.

CONCLUSIONS

The intent of the Milestones 2.0 was to create an improved tool that is comprehensive, easier to utilize, and of increased value for pain medicine training programs. It is expected that implementation of Milestones 2.0 will streamline pain medicine trainee assessments by educators and prepare trainees for the future practice of pain medicine while serving to be the foundation of an iterative process to match the evolution of the specialty.

Looking back, moving forward: A practical guide to implementing the updated ACGME geriatric medicine Milestones 2.0

The Accreditation Council for Graduate Medical Education (ACGME) developed the Milestones as a tool to aid trainee assessment based on the framework of the six core competencies of practice. Variability in the interpretation and application of the original Milestones prompted the ACGME to convene work groups within the different specialties and subspecialties to update the Milestones. The Geriatric Medicine work group was convened in 2019 with the goal of clarifying and simplifying the language of the Milestones, revising content to be specific to geriatrics, and developing supplemental resources to aid in implementation and use. We suggest using a practical, four-step process to implement the updated Milestones, called the Milestones 2.0, in fellowship programs by: (1) training faculty in the use of the Milestones 2.0, including an overview of the background and updates, (2) mapping the Milestones 2.0 to existing assessments, (3) educating fellows about the Milestones 2.0 and (4) presenting and discussing the Milestones 2.0 at Clinical Competency Committee meetings. This systematic approach promotes the development of a shared mental model for trainee assessments.

Mechanisms to expedite pediatric clinical trial site activation: The DOSE trial experience

BACKGROUND

Timely trial start-up is a key determinant of trial success; however, delays during start-up are common and costly. Moreover, data on start-up metrics in pediatric clinical trials are sparse. To expedite trial start-up, the Trial Innovation Network piloted three novel mechanisms in the trial titled Dexmedetomidine Opioid Sparing Effect in Mechanically Ventilated Children (DOSE), a multi-site, randomized, double-blind, placebo-controlled trial in the pediatric intensive care setting.

METHODS

The three novel start-up mechanisms included: 1) competitive activation; 2) use of trial start-up experts, called site navigators; and 3) supplemental funds earned for achieving pre-determined milestones. After sites were activated, they received a web-based survey to report perceptions of the DOSE start-up process. In addition to perceptions, metrics analyzed included milestones met, time to start-up, and subsequent enrollment of subjects.

RESULTS

Twenty sites were selected for participation, with 19 sites being fully activated. Across activated sites, the median (quartile 1, quartile 3) time from receipt of regulatory documents to site activation was 82 days (68, 113). Sites reported that of the three novel mechanisms, the most motivating factor for expeditious activation was additional funding available for achieving start-up milestones, followed by site navigator assistance and then competitive site activation.

CONCLUSION

Study start-up is a critical time for the success of clinical trials, and innovative methods to minimize delays during start-up are needed. Milestone-based funds and site navigators were preferred mechanisms by sites participating in the DOSE study and may have contributed to the expeditious start-up timeline achieved.

CLINICALTRIALS

gov #: NCT03938857.

The dilemma between milestones of progression versus clinical scales in Parkinson's disease

There are significant challenges in accurately documenting the progression of Parkinson's disease (PD). The disease course is highly heterogeneous, there are no validated biomarkers, and we are reliant on repeated clinical measures to assess disease state over time. Yet, the ability to chart disease progression accurately is vital in both observational and interventional study designs, where reliable measures are critical to determine whether an outcome has been met. In this chapter, we first discuss the natural history of PD, including the spectrum of clinical presentation and expected developments through the course of the disease. We then explore in detail the current strategies for measuring disease progression, which can be broadly divided into: (i) the use of quantitative clinical scales; and (ii) determination of the onset time of key milestones. We discuss the strengths and limitations of these approaches for use in clinical trials, with a particular focus on disease modification trials. The selection of outcome measures for a particular study will depend on multiple factors, but trial duration is an important determinant. Milestones are reached over a course of years rather than months, and hence clinical scales with sensitivity to change are needed for short-term studies. However, milestones represent important markers of disease stage which are not confounded by symptomatic therapies and are of critical relevance to the patient. Prolonged but low intensity follow-up beyond a limited period of treatment with a putative disease-modifying agent may allow milestones to be incorporated into evaluation of efficacy in a practical and cost-effective way.

Accreditation Council for Graduate Medical Education Milestone Scores in Pediatrics: Pilot Study Exploring the Relationship Between Residency and Early Fellowship Scores

BACKGROUND

The Accreditation Council for Graduate Medical Education requires Milestone-based assessments of residents and fellows. In pediatrics, 11 subcompetencies are common to both residency and subspecialty fellowship training. It is unknown whether Milestone scores achieved during residency are related to Milestone scores achieved in early fellowship.

OBJECTIVE

To assess the relationship between final residency Milestones scores and first-year fellowship Milestones scores in the 11 common subcompetencies (CSCs) across pediatric subspecialties.

METHODS

This was a retrospective single-institution cohort study of pediatric fellows beginning fellowship training between July 2016 and July 2019. De-identified Milestone score sets for final residency scores (R), mid-year first-year fellowship scores (F1), and final first-year fellowship scores (F2) were collected. Spearman correlation and regression analyses were used to assess score relationships.

RESULTS

Data for 85 of 98 eligible fellows were collected. Consistently, the F1 scores were lowest, and the R scores were highest. There was a weak positive correlation between the composite R scores and the composite F1 scores. There was a weak positive correlation between residency and fellowship scores for 6 CSCs and no significant correlation for the remaining 5.

CONCLUSION

For the 11 pediatric CSCs, the final residency Milestone scores are consistently higher than and only weakly associated with early fellowship Milestone scores. There may be limitations to the use of residency scores for fellowship program directors in guiding individualized education for early fellows. This study provides groundwork for additional study of Milestone relationships and may help inform the next iteration of pediatric subspecialty Milestones.

First Adolescent Romantic and Sexual Experiences in Individuals With Differences of Sex Development/Intersex Conditions

PURPOSE

Adolescence is an important period for sexual development, including sexual debut. The purpose of this study was to assess first romantic and sexual experiences and debut age in individuals with differences of sex development (DSD/intersex) and compare these with age-matched and gender-matched population control values.

METHODS

Questionnaire data on sociodemographic characteristics, romantic and sexual milestones (e.g., masturbation, dating), satisfaction with sexual life and sexual activity at follow-up, self-esteem, and feelings of femininity or masculinity were collected from 976 participants in Europe with a DSD condition. Participants were divided into six diagnostic subgroups based on their diagnostic classification: women with Turner syndrome, congenital adrenal hyperplasia, 46XY-DSD nonvirilized, and 46XY-DSD female partially virilized conditions and men with 46XY-DSD male or Klinefelter syndrome. Age-specific and gender-specific reference values were retrieved from a Dutch population sample.

RESULTS

Individuals with DSD were less likely to reach each of the romantic and sexual milestones compared to their peers without these conditions and they were significantly older when reaching these milestones. Between clinical subgroups, individuals with Klinefelter were significantly older when reaching milestones and in the female groups and individuals with Turner were the least likely to reach milestones. Furthermore, a higher age when reaching several romantic and sexual milestones was correlated with lower self-esteem, lower satisfaction with sexual life, and lower sexual frequency at follow-up.

DISCUSSION

Due to a difference in biopsychosocial context, individuals with DSD often experience a different and/or delayed sexual development during adolescence. Healthcare providers should be aware of these differences in adolescents with DSD and their sexual development to optimize affirmative counseling.

Pediatric surgery milestones 2.0: A primer

More than twenty years ago, the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties began the conversion of graduate medical education from a structure- and process-based model to a competency-based framework. The educational outcomes assessment tool, known as the Milestones, was introduced in 2013 for seven specialties and by 2015 for the remaining specialties, including pediatric surgery. Designed to be an iterative process with improvements over time based on feedback and evidence-based literature, the Milestones started the evolution from 1.0 to 2.0 in 2016. The formation of Pediatric Surgery Milestones 2.0 began in 2019 and was finalized in 2021 for implementation in the 2022-2023 academic year. Milestones 2.0 are fewer in number and are stated in more straightforward language. It incorporated the harmonized milestones, subcompetencies for non-patient care and non-medical knowledge that are consistent across all medical and surgical specialties. There is a new Supplemental Guide that lists examples, references and links to other assessment tools and resources for each subcompetency. Milestones 2.0 represents a continuous process of feedback, literature review and revision with goals of improving patient care and maintaining public trust in graduate medical education's ability to self-regulate. LEVEL OF EVIDENCE: V.

Residency Education in Oral and Maxillofacial Surgery: A New Curriculum Framework

Residency education in oral and maxillofacial surgery (OMS) exists in an environment of transformation unlike anything seen in the past. Changes in American society accelerated by the COVID-19 pandemic are impacting all of health-care education and demand a comprehensive response by OMS programs and in standards for education. The oral health in America report of the National Institutes of Health and actions of the American Council on Graduate Medical Education provides a new framework for structuring and adapting OMS programs. These include incorporating the Quadruple Aims and ACGME core competencies into OMS education. The evolution of clinical education is being adapted to changes in technology and the American higher education environment. A changing workforce and practice model combined with today's technology revolution are being incorporated into OMS residency education.

Reimagining the Clinical Competency Committee to Enhance Education and Prepare for Competency-Based Time-Variable Advancement

Assessing residents and clinical fellows is a high-stakes activity. Effective assessment is important throughout training so that identified areas of strength and weakness can guide educational planning to optimize outcomes. Assessment has historically been underemphasized although medical education oversight organizations have strengthened requirements in recent years. Growing acceptance of competency-based medical education and its logical extension to competency-based time-variable (CB-TV) graduate medical education (GME) further highlights the importance of implementing effective evidence-based approaches to assessment. The Clinical Competency Committee (CCC) has emerged as a key programmatic structure in graduate medical education. In the context of launching a multi-specialty pilot of CB-TV GME in our health system, we have examined several program's CCC processes and reviewed the relevant literature to propose enhancements to CCCs. We recommend that all CCCs fulfill three core goals, regularly applied to every GME trainee: (1) discern and describe the resident's developmental status to individualize education, (2) determine readiness for unsupervised practice, and (3) foster self-assessment ability. We integrate the literature and observations from GME program CCCs in our institutions to evaluate how current CCC processes support or undermine these goals. Obstacles and key enablers are identified. Finally, we recommend ways to achieve the stated goals, including the following: (1) assess and promote the development of competency in all trainees, not just outliers, through a shared model of assessment and competency-based advancement; (2) strengthen CCC assessment processes to determine trainee readiness for independent practice; and (3) promote trainee reflection and informed self-assessment. The importance of coaching for competency, robust workplace-based assessments, feedback, and co-production of individualized learning plans are emphasized. Individual programs and their CCCs must strengthen assessment tools and frameworks to realize the potential of competency-oriented education.

A Not So Perfect Score: Factors Associated with the Rate of Straight Line Scoring in Oncology Training Programs

Straight line scoring (SLS), defined as trainee assessments with the same score for all evaluation items, is statistically improbable and potentially indicates inaccurate assessment. Factors contributing to higher SLS rates are unknown, and knowledge of SLS prevalence within oncologic training is lacking. SLS frequency was measured for evaluations from all Accreditation Council for Graduate Medical Education (ACGME)-accredited programs at a single cancer care institution between 2014 and 2018. SLS prevalence was estimated using hierarchical linear models (HLM) that considered characteristics of evaluator, trainee, and evaluation potentially related to SLS. Results were compared with national SLS rates. Six thousand one hundred sixty evaluations were included from 476 evaluators. Overall prevalence of SLS was 12.1% (95% CI 4.5-28.8). Residents (vs fellows) were less likely to have SLS evaluations (OR 0.5, 95% CI 0.4-0.8), though for all trainees increasing training year corresponded with increasing SLS frequency (OR 1.5, 95% CI 1.3-1.7). SLS was more common in procedural specialties compared with medical specialties (OR 2.1, 95% CI 1.1-3.8). Formative evaluations had lower SLS rates (OR 0.6, 95% CI 0.5-0.9) than summative evaluations, while milestone-based evaluations had higher rates than those that were not milestone-based (OR 1.5, 95% CI 1.03-2.2). Features of evaluators, such as subspecialty within oncology, and of trainees, such as seniority or trainee type, were related to SLS. Summative intent and milestone-based evaluations were more likely to be straight line scored. Specific evaluation scenarios at higher risk of SLS should be further examined.

Breast Imaging Boot Camp Meets Milestones 2.0: A Match Made in Clinic

RATIONALE AND OBJECTIVES

Designed to provide broad-based training in all aspects of imaging, the diagnostic radiology residency program must provide educational experiences that not only provide technical training, but also meet accreditation standards. With the breadth of material to cover during training, carefully orchestrated educational experiences must be planned. This manuscript reports a breast imaging boot camp curriculum with longitudinal outcomes, highlighting the boot camp's pedagogy and adaptability for residencies to meet the challenges of the Accreditation Council for Graduate Medical Education (ACGME) Diagnostic Radiology Milestones Second Revision.

MATERIALS AND METHODS

Breast block curriculum analysis, faculty leader preparation, and evaluation of all objective external benchmarks were undertaken commencing in 2012 and continuing through 2019. Specific curriculum changes include fundamental didactic lectures and self-study education modules, hands-on simulation activities, and team-building time. Upon publication of The Diagnostic Radiology Milestones Second Revision December 2019, all competencies were assessed in the context of the boot camp resident educational experiences.

RESULTS

Following curriculum implementation, resident anonymous evaluation scores of the breast block, resident in-training examination scores, American Board of Radiology Core examination scores, and radiology residency educational website analytics all increased immediately and significantly. The curriculum meets twenty-four Diagnostic Milestones per participating resident when mapped against the newly implemented ACGME requirements.

CONCLUSIONS

Breast imaging boot camp is a successful innovative curriculum, readily meeting our learners' needs in all objective benchmarks. Further, the adaptable model has the potential to play important roles in assisting residencies to meet the challenges of the ACGME Diagnostic Radiology Milestones Second Revision July 1, 2020 implementation date.

How Do Programs Measure Resident Performance? A Multi-Institutional Inventory of General Surgery Assessments

OBJECTIVE

To perform an inventory of assessment tools in use at surgical residency programs and their alignment with the Milestone Competencies.

DESIGN

We conducted an inventory of all assessment tools from a sample of general surgery training programs participating in a multi-center study of resident operative development in the United States. Each instrument was categorized using a data extraction tool designed to identify criteria for effective assessment in competency based education and according to which Milestone Competency was being evaluated. Tabulations of each category were then analyzed using descriptive statistics. Interviews with program directors and assessment coordinators were conducted to understand each instrument's intended use within each program.

SETTING

Multi-institutional review of general surgery assessment programs.

PARTICIPANTS

We identified assessment tools used by 10 general surgery programs during the 2019 to 2020 academic year. Programs were selected from a cohort already participating in a separate research study of resident operative development in the United States.

RESULTS

We identified 42 unique assessment tools used. Each program used an average of 7.2 (range 4-13) unique assessment instruments to measure performance, of which only 5 (11.9%) were used by at least 1 other program in our sample. Of all assessments, 59.5% were used monthly or less frequently. The majority (66.7%) of instruments were retrospective global assessments, rather than discrete observed performances. There were 4 (9.5%) instruments with established reliability or validity evidence. Across programs there was also significant variation in the volume of assessment used to evaluate residents, with the median total number of evaluations/trainee across all Milestone Competencies being 217 (IQR 78) per year. Patient care was the most frequently evaluated Milestone Competency.

CONCLUSIONS

General surgical assessment systems predominantly employ non-standardized global assessment tools that lack reliability or validity evidence. This variability makes it challenging to interpret and compare competency standards across programs. A standardized assessment toolkit with established reliability and validity evidence would allow training programs to measure the competence of their trainees more uniformly and understand where improvements in our training system can be made.

Standardization of Neuroanesthesia Education: Need of the Hour and the Way Forward

Purpose of Review

This review illustrates the evolution and progress with standardization of fellowship education in neuroanesthesiology. It provides a structured discussion around the need for curricula and framework which individual training programs in neuroanesthesiology can use to meet defined educational standards thus meeting criteria for accreditation.

Recent Findings

Neuroanesthesiology training has traditionally been heterogenous around the world but international efforts from the community of neuroanesthesiology have culminated in the development of an international council for perioperative training in neuroscience in anesthesiology(ICPNT). This serves not only as an accrediting body but also creates a platform through their neuroanesthesia program relations committee for collaboration and engagement between various training programs internationally, increasing the educational standards of the individual programs and collectively increasing the overall level of standards for neuroanesthesia training. Standardized curriculum and competency-based assessments and milestones would help with narrowing the focus to quality education in neuroanesthesiology.

Summary

Structured training around the three pillars of neuroanesthesiology with concomitant accreditation is expected to lead to higher education standards with better patient care. The SNACC created milestones for neuroanesthesiology training during residency and the ICPNT can now use this as a foundation for fellowship training. Having a council to accredit and standardize will likely become indispensable in creating a set path for training in neuroanesthesiology. Additionally, the flexibility built in due to the international nature would allow modified and variable pathways depending upon individual capabilities and interests. The path forward will include widespread adoption of standardization supporting the overarching goal of excellent patient outcomes around the world.

Can ACGME Milestones predict surgical specialty board passage: an example in Obstetrics and Gynecology

Background:

Multiple tools including Accreditation Council for Graduate Medical Education (ACGME) standardized milestones can be utilized to assess trainee and residency program performance. However, little is known regarding the objective validation of these tools in predicting written board passage.

Methods:

In this retrospective study, data was gathered on n = 45 Wayne State University Obstetrics and Gynecology program graduates over the five-year period ending July 2018. United States Medical Licensing Examination (USMLE) scores, Council on Resident Education in Obstetrics and Gynecology (CREOG) in-training scores and ACGME milestones were used to predict American Board of Obstetrics and Gynecology (ABOG) board passage success on first attempt. Significance was set at p < 0.05.

Results:

Written board passage was associated with average CREOGs (p = 0.01) and milestones (p = 0.008) while USMLE1 was not significantly associated (p = 0.055). USMLE1 <217 (Positive predictive value (PPV) = 96%). CREOGs <197 (PPV = 100%) and milestones <3.25 (PPV = 100%), particularly practice-based learning and systems-based practice milestones were most strongly correlated with board failure. Using a combination of these two milestones, it is possible to correctly predict board passage using our model (PPV = 86%).

Discussion:

This study is the first validating the utility of milestones in a surgical specialty by demonstrating their ability to predict board passage. Residents with CREOGs or milestones below thresholds are at risk for board failure and may warrant early intervention.

Building a doctor, one skill at a time: Rethinking clinical training through a new skills-based feedback modality

The Accreditation Council for Graduate Medical Education milestones and entrustable professional activities (EPAs) are important assessment approaches but may lack specificity for learners seeking improvement through daily feedback. As in other professions, clinicians grow best when they engage in deliberate practice of well-defined skills in familiar contexts. This growth is augmented by specific, actionable coaching from supervisors. This article proposes a new feedback modality called microskills, which are derived from the psychology, negotiation, and business literature, and are unique in their ability to elicit targeted feedback for trainee development. These microskills are grounded in both clinical and situational contexts, thereby mirroring learners' cognitive schemas and allowing for more natural skill selection and adoption. When taken as a whole, microskills are granular actions that map to larger milestones, competencies, and EPAs. This article outlines the theoretical justification for this new skills-based feedback modality, the methodology behind the creation of clinical microskills, and provides a worked example of microskills for a pediatric resident on a hospital medicine rotation. Ultimately, microskills have the potential to complement milestones and EPAs and inform feedback that is specific, actionable, and relevant to medical learners.

Milestones 2.0: Otolaryngology Resident Competency in the Postpandemic Era

The Accreditation Council for Graduate Medical Education and the American Board of Otolaryngology-Head and Neck Surgery Milestones Project grew out of a continued need to document objective outcomes within resident education. Milestones 2.0 began its work in 2016, with an intent to resolve inconsistencies in the original milestones based on an iterative process. Milestones 2.0 retains the original 5 levels of achievement but includes a "not yet assessable" option as well. In addition, Milestones 2.0 has added harmonized milestones across all specialties. Each specialty has incorporated a supplemental guide with examples and resources to improve facility with the tool. There will be further refinement of the Milestones as new research emerges with the ultimate goal of providing programs and trainees with a reliable roadmap that can be used to direct and assess learning.

Milestone Approach to Designing a Point-of-Care Ultrasound Curriculum for Transition-to-Residency Programs in the United States

Phenomenon: Point-of-care ultrasound is fast becoming standard clinical bedside practice for diverse specialties. Medical schools are responding by adding ultrasound education, though the majority use it to supplement the learning of basic sciences. Point-of-care ultrasound practice-based clinical skills education is rare. There also is a lack of standardization across curricula, leading to much variability in the ultrasound skills that medical students from different schools bring to residency. To best inform a point-of-care ultrasound curriculum for our Transition-to Residency program, we investigated literature on 1) how medical students are being prepared for use of point-of-care ultrasound in clinical practice, 2) what skills are being taught, 3) what point-of-care ultrasound skills residency programs expect from incoming residents. Approach: We reviewed literature to identify curricula in U.S. medical schools that teach the concepts, knowledge, and skills related to point-of-care ultrasound. We also mapped point-of-care ultrasound expectations set forth by the Entrustable Professional Activities for undergraduate medical education to the specialty-specific milestones identified by the Accreditation Council for Graduate Medical Education. Additionally, we reviewed specialty-specific professional organizations for position statements and guidelines describing the point-of-care ultrasound skills expected for practicing physicians in their respective specialties. The goal was to identify any needs and gaps in education regarding point-of-care ultrasound across the undergraduate to graduate medical education continuum to practice. Findings: We found seven published point-of-care ultrasound curricula for medical students. There was wide variability in these curricula regarding what point-of-care ultrasound content is being taught, as well as when and how this skill is taught. No Entrustable Professional Activity listed point-of-care ultrasound as a skill requirement for graduating medical students. For graduate medical education, there was wide variability across specialties in residency milestones related to point-of-care ultrasound; some (e.g., emergency medicine) listed extensive milestones while others (e.g., internal medicine) listed none. However, we found that many specialty-specific professional organizations do list detailed point-of-care ultrasound expectations for their practicing physicians. Insights: As point-of-care ultrasound is fast becoming common practice across many specialties, standardization of education and related competencies-similar to other clinical skills training-is necessary across medical schools. Mapping point-of-care ultrasound expectations to current teaching across the continuum from undergraduate to graduate medical education may allow schools to tailor point-of-care ultrasound training for Transition-to-Residency programs. We provide a sample pilot point-of-care ultrasound curriculum that we designed for our Transition-to-Residency course.

ACGME Milestones 2.0: why and what's new for cytopathology?

BACKGROUND

Primary stakeholders in the Accreditation Council for Graduate Medical Education (ACGME) Milestones Project are: ACGME, Residency Programs, Residents, Fellowship Programs, Fellows, and Certification Boards. The intent of the Milestones is to describe the educational and professional developmental trajectory of a trainee from the first stages of their postgraduate education through the completion of their clinical training. The Milestones 2.0 project includes changes made based on experience with Milestones 1.0.

METHODS

The ACGME solicited volunteers to participate in the development of subspecialty Milestones 2.0. The workgroup was charged with reviewing/making any additions to the four "Harmonized Milestones", developing subspecialty specific milestones for the Patient Care and Medical Knowledge competencies, and creating a supplemental guide. The Milestones were finalized following review of input from an open comment period.

RESULTS

The Cytopathology Milestones 2.0 will go into effect July 2021. They include additional subcompetencies in the 4 harmonized competency areas and cytopathology-specific edits to the patient care and medical knowledge subcompetencies. Although the number of subcompetencies has increased from 18 to 21, within each subcompetency, the number of milestone trajectories has decreased. Additionally, within each subcompetency, the wording has been streamlined. A supplemental guide was created and Milestones 1.0 were compared to 2.0; however, curriculum mapping has been left to programs to develop.

CONCLUSIONS

The ultimate goal of the Cytopathology Milestones 2.0 is to provide better real-time documentation of the progress of cytopathology fellows. The expected outcome is to produce highly competent cytopathologists, improving the care they provide, regardless of the program at which they trained.

Post-Clerkship Curricular Reform: Specialty-Specific Tracks and Entrustable Professional Activities to Guide the Transition to Residency

The development of core entrustable professional activities (EPA) for entering residency and Accreditation Council for Graduate Medical Education's milestones have spurred thinking about the fourth year of medical school as a transition to residency. In this monograph, we lay out our specialty focused post-clerkship curriculum and report learner and residency director perceptions over the first three years of implementation. Ongoing curricular monitoring has reinforced core principles but has also informed actionable quality improvement efforts. EPA-focused learning experiences, integration of specialty-specific milestones, addition of the feedforward process, and accessible mentorships have been key curricular elements to guide the transition to residency.

Competency-based anesthesiology teaching: comparison of programs in Brazil, Canada and the United States

In 2017, the Brazilian Society of Anesthesiology (SBA) and the National Medical Residency Committee (CNRM) presented a joint competence matrix to train and evaluate physicians specializing in Anesthesiology, which was enforced in 2019. The competency-based curriculum aims to train residents in relation to certain results, in that residents are considered capable when they are able to act in an appropriate and effective manner within certain standards of performance. Canada and the United States (US) also use competency-based curriculum to train their professionals. In Canada, the format is the basis for using an evaluation method known as Entrustable Professional Activities (EPA), in which the mentor assesses residents’ capacity to perform certain tasks, classified in 5 levels. The US, in turn, uses Milestones as evaluation, in which competencies and sub-competencies are assessed according to residents’ progress during training. The present article aims to describe and compare the different competency-based curriculum and the evaluation methods used in the three countries, and proposes a reflection on future paths for medical education in Anesthesiology in Brazil.

The OSPE

OBJECTIVES

Resident assessment tends to consist of multiple-choice examinations, even in nuanced areas, such as quality assurance. Internal medicine and many other specialties use objective structured clinical examinations, or OSCEs, to evaluate residents. We adapted the OSCE for pathology, termed the Objective Structured Pathology Examination (OSPE).

METHODS

The OSPE was used to evaluate first- and second-year residents over 2 years. The simulation included an anatomic pathology sign-out session, where the resident could be evaluated on diagnostic skills and knowledge of key information for cancer staging reports, as well as simulated frozen-section analysis, where the resident could be evaluated on communication skills with a "surgeon." The OSPE also included smaller cases with challenging quality issues, such as mismatched slides or gross description irregularities. All cases were scored based on the Pathology Milestones created by the Accreditation Council for Graduate Medical Education.

RESULTS

Using this OSPE, we were able to demonstrate that simulated experiences can be an appropriate tool for standardized evaluation of pathology residents.

CONCLUSIONS

Yearly evaluation using the OSPE could be used to track the progress of both individual residents and the residency program as a whole, identifying problem areas for which further educational content can be developed.

Entrustable Professional Activities (EPAs) and milestones for MD sports medicine: A proposed portfolio

BACKGROUND

Sports Medicine is an upcoming postgraduate speciality in India. A MD Sports Medicine specialist is expected to contribute in the prevention of sports injuries, sportsmen training and enhancement of performance apart from being involved in planning of conduct of sports events amongst many other roles and responsibilities. This requires hands-on training and acquisition of skill sets required to perform these roles. The National Medical Council of India highlights the need for a competency based curriculum and has laid down guidelines for the course. There was a felt need to develop Entrustable Professional Activities (EPAs) and milestones based on the prescribed curricula and develop a portfolio for continuous monitoring of the achievement of these EPAs.

METHODS

A five step model was done by experts in the field to prepare the EPAs, milestones and portfolio. This consisted of faculty development, identification of the EPAs and milestones and portfolio preparation.

RESULTS

114 EPAs and 961 milestones were identified by the subject experts. The portfolio was developed with the help of specialists and faculty of the field of sports medicine, and medical educationists.

CONCLUSION

Post graduate medical education is mandated to be competency based. A portfolio has been developed in the current exercise for use in a competency based post-graduate curriculum in sports medicine. This will help in the better implementation of CBME in the country.

Understanding Assessment Systems for Clinical Competency Committee Decisions: Evidence from a Multisite Study of Psychiatry Residency Training Programs

OBJECTIVE

This multisite study examines how clinical competency committees in Psychiatry synthesize resident assessments to inform milestones decisions to provide guidelines that support their use.

METHODS

The study convened training directors and associate training directors from three psychiatry residency programs to examine decision-making processes of clinical competency committees. Annual resident assessments for one second year and one third year resident were used in a mock clinical competency committee format to assign milestones for two consecutive reporting periods. The committees reflected on the process and rated how the assessment tools impacted the assessment of milestones and evaluated the overall process. The authors compared reliability of assessment between the mock committees and examined both reliability of end of rotation assessments and their composite scores when combined with clinical skills evaluations.

RESULTS

End of rotation evaluations were the most informative tool for assigning milestones and clarifying discrepancies in performance. In particular, the patient care and medical knowledge competencies were the easiest to rate, while the systems-based practice and practice-based learning and improvement were the most difficult. Reliability between committees was low although higher number of available evaluations improved reliability in decision-making.

CONCLUSIONS

The results indicate that the medical knowledge and patient care competencies are the easiest to rate and informed most by end of rotation evaluations and clinical skills examinations. Other evaluation tools may better capture performance on specific sub-competencies beyond workplace-based assessment, or it may be helpful to reconsider the utility of how individual sub-competencies are evaluated.

Association Between Entrustable Professional Activities and Milestones Evaluations: Real-time Assessments Correlate With Semiannual Reviews

OBJECTIVE

Entrustable professional activities (EPAs) have been developed to refine competency-based education. The American Board of Surgery has initiated a 2-year pilot study to evaluate the impact of EPAs on the evaluation and feedback of surgical residents. The ACGME Milestones in Surgery is a semiannual competency-based evaluation program to measure resident progression through 16 professional attributes across 8 practice domains. The correlation between these 2 evaluation tools remains unclear. The purpose of this study is to evaluate this correlation through comparison of an EPA with the corresponding elements of the ACGME Milestones.

DESIGN

From July, 2018 to October, 2019, all residents submitting EPA evaluations for gall bladder disease were evaluated for preoperative, intraoperative, and/or postoperative entrustability. The ratings were converted to a numerical rank from 0 to 4. Milestones scores from May 2019 and November 2019 were obtained for each resident, with scores ranging from 0 to 4. The gall bladder EPA incorporates the operative PC3 and MK2 and nonoperative PC1, PC2, and ICS3 components. Spearman rank correlation was conducted to evaluate the association between each resident's median EPA ranking and his/her milestones scores.

SETTING

SUNY Upstate Medical University, Syracuse, NY, a university-based hospital.

PARTICIPANTS

General surgery residents.

RESULTS

Among 24 residents, 106 intraoperative EPA evaluations were. For both the May and November milestones, significant positive correlations were noted for PC3 (correlation coefficient ρ = 0.690, p < 0.001; ρ = 0.876, p < 0.001). Similarly, for MK2, a significant positive correlation was noted (ρ = 0.882, p < 0.001; ρ = 0.759, p < 0.001). Interestingly, significant positive correlations were also identified between the 3 nonoperative milestones and the intraoperative entrustability ranking.

CONCLUSIONS

We observed significant correlations between EPAs for cholecystectomy and associated milestones evaluation scores. These findings indicate that EPAs may provide more timely and specific feedback than existing tools and, on aggregate, may improve upon existing formative feedback practices provided through the biannual evaluation of surgical residents.

Implementation and Initial Construct Validity Evidence of a Tool, myTIPreport, for Interactive Workplace Feedback on ACGME Milestones

OBJECTIVE

To describe implementation of myTIPreport for milestone feedback and to initiate construct validity testing of myTIPreport for milestones.

DESIGN

myTIPreport was used to provide workplace feedback on Accreditation Council for Graduate Medical Education required milestone sets. Performance of senior learners (postgraduate year [PGY]-4s) was compared to that of junior learners (PGY-1s) to begin the process of construct validity testing for myTIPreport.

SETTING

A convenience-based site selection of Obstetrics and Gynecology (OBGYN) residency programs.

PARTICIPANTS

OBGYN residents and faculty.

RESULTS

Amongst the 12 participating OBGYN residency programs, there were 444 unique learners and 343 unique faculty teachers. A total of 5293 milestone feedback encounters were recorded. Mean PGY-4 performance was rated higher than mean PGY-1 performance on all 25 of the compared milestone sets, with statistically significant differences seen for 19 (76%) of these 25 milestone sets and nonsignificant differences in the predicted direction observed for the other 6 milestone sets.

CONCLUSIONS

myTIPreport detected differences between senior and junior learners for the majority of compared feedback encounters for OBGYN residents. Findings support the emerging construct validity of myTIPreport for milestone feedback.

Charting a professional course for academic gynecologic oncology mentors

OBJECTIVES

To describe the transition from a mentee to mentor role in a cohort of academic gynecologic oncologists by studying the evolution of authorship placement in peer reviewed publications by current gynecologic oncology (GO) fellowship directors.

METHODS

Current GO fellowship directors were identified from the ACGME website. A Pubmed search identified all publications by all listed fellowship directors. Number of publications, and order of authorship were counted by years since medical school graduation. Milestones representing likely career transition points were developed and tracked. Descriptive statistics were used to characterize the individuals and associated institutions. Time to event curves were compared using the Kaplan Meier method.

RESULTS

The study cohort comprised 58 GO fellowship program directors. The median time since medical school graduation was 22 years. Eight unique milestones reflecting the relative frequencies of authorship placement were studied. The median time to accomplishing these milestones ranged from 6 to 18 years. The timing of milestone attainment suggests a stepwise progression of events and was associated with both individual and institutional factors.

CONCLUSIONS

In this cohort of 58 fellowship directors, a roadmap to mentorship was identified, that includes several measurable milestones, and representative times to attain each. Further analyses identified a set of factors associated with the rate of progression. We hope these findings can inform the evolution of mentorship in gynecologic oncology. It is possible that initiatives focused on mentorship training might include milestone tracking to facilitate development.

Professionalism and inter-communication skills (ICS): a multi-site validity study assessing proficiency in core competencies and milestones in medical learners

BACKGROUND

Interpersonal and Communication Skills (ICS) and Professionalism milestones are challenging to evaluate during medical training. Paucity in proficiency, direction and validity evidence of assessment tools of these milestones warrants further research. We validated the reliability of the previously-piloted Instrument for Communication skills and Professionalism Assessment (InCoPrA) in medical learners.

METHODS

This validity approach was guided by the rigorous Kane's Framework. Faculty-raters and standardized patients (SPs) used their respective InCoPrA sub-component to assess distinctive domains pertinent to ICS and Professionalism through multiple expert-built simulated-scenarios comparable to usual care. Evaluations included; inter-rater reliability of the faculty total score; the correlation between the total score by the SPs; and the average of the total score by two-faculty members. Participants were surveyed regarding acceptability, realism, and applicability of this experience.

RESULTS

Eighty trainees and 25 faculty-raters from five medical residency training sites participated. ICC of the total score between faculty-raters was generally moderate (ICC range 0.44-0.58). There was on average a moderate linear relationship between the SPs and faculty total scores (Pearson correlations range 0.23-0.44). Majority of participants ascertained receiving a meaningful, immediate, and comprehensive patient-faculty feedback.

CONCLUSIONS

This work substantiated that InCoPrA was a reliable, standardized, evidence-based, and user-friendly assessment tool for ICS and Professionalism milestones. Validating InCoPrA showed generally-moderate agreeability and high acceptability. Using InCoPrA also promoted engaging all stakeholders in medical education and training-faculty, learners, and SPs-using simulation-media as pathway for comprehensive feedback of milestones growth.

Longitudinal neuroanatomical and behavioral analyses show phenotypic drift and variability in the Ts65Dn mouse model of Down syndrome

Mouse models of Down syndrome (DS) have been invaluable tools for advancing knowledge of the underlying mechanisms of intellectual disability in people with DS. The Ts(1716)65Dn (Ts65Dn) mouse is one of the most commonly used models as it recapitulates many of the phenotypes seen in individuals with DS, including neuroanatomical changes and impaired learning and memory. In this study, we use rigorous metrics to evaluate multiple cohorts of Ts65Dn ranging from 2014 to the present, including a stock of animals recovered from embryos frozen within ten generations after the colony was first created in 2010. Through quantification of prenatal and postnatal brain development and several behavioral tasks, our results provide a comprehensive comparison of Ts65Dn across time and show a significant amount of variability both across cohorts as well as within cohorts. The inconsistent phenotypes in Ts65Dn mice highlight specific cautions and caveats for use of this model. We outline important steps for ensuring responsible use of Ts65Dn in future research.This article has an associated First Person interview with the first author of the paper.

High-Fidelity Simulation Scenario: Pediatric Sulfonylurea Overdose and Treatment

INTRODUCTION

Oral antidiabetic medications are becoming increasingly popular as the incidence of type II diabetes mellitus increases. Overdoses of these medications, either intentional or accidental, can be detrimental if not quickly recognized and treated. One of the most common classes of hypoglycemic oral antidiabetics, sulfonylureas, was discussed in this case.

METHODS

We designed this high-fidelity simulation to help increase the learner's knowledge of sulfonylurea overdoses, including recognizing signs/symptoms, management, and disposition. This simulation was designed to be used with fourth-year medical students, emergency medicine residents, and pediatric residents. The case involves a previously healthy 3-year-old male presenting with altered mental status and seizures secondary to glyburide ingestion. A standard pediatric simulation mannequin was required. The patient presented with altered mental status and began seizing upon arrival. After a thorough history, glyburide ingestion was identified. Critical actions included obtaining a fingerstick glucose measurement, determining an appropriate concentration of dextrose, starting a dextrose drip, and admission for further management.

RESULTS

This simulation case was performed at the simulation lab at SUNY Upstate Medical University by a combination of 83 fourth-year medical students, and emergency medicine and pediatric residents. Feedback and evaluations for the case showed it improved medical education and clinical skills.

DISCUSSION

This simulation was well received and helped participants develop a better understanding of sulfonylurea overdose identification. It also improved participants' ability to manage refractory hypoglycemia and compile a more comprehensive list of differential diagnoses.

Teaching Diagnostic Reasoning to Faculty Using an Assessment for Learning Tool: Training the Trainer

INTRODUCTION

There is a need for a standardized approach to understand and assess clinical reasoning in medical learners. The Assessment of Reasoning Tool was developed based on prevalent theories and frameworks using a multidisciplinary expert panel. As the tool provides a standardized rubric for assessing clinical reasoning, we designed an interactive train-the-trainer workshop for clinical educators and education leaders interested in improving their teaching skills and/or introducing curricula surrounding diagnostic reasoning.

METHODS

In this workshop, participants were exposed to the major domains of diagnostic reasoning and how to apply it to the assessment of a learner's skills. Kolb's experiential learning was the underlying model, which we showcased by using multiple interactive techniques, including small-group discussion, peer sharing, and case practice. We presented the workshop at a national conference of pediatric educators and as a faculty development workshop at a single institution. Participants were asked to complete a survey after the workshop to gauge their reactions and look for areas of improvement.

RESULTS

A total of 34 participants attended the two workshops. Participants rated the workshop favorably, with most planning to make a change to their practice. Comments were largely positive, emphasizing the benefits of the interactive approach.

DISCUSSION

The workshop and teaching materials represent an important early step in the workplace-based assessment of diagnostic reasoning in medical learners. Grounded in the clinical reasoning literature, the workshop offers one approach to assessing these skills in learners with or without direct observation of clinical skills.

Subtle skills: Using objective structured clinical examinations to assess gastroenterology fellow performance in system based practice milestones

BACKGROUND

System based practice (SBP) milestones require trainees to effectively navigate the larger health care system for optimal patient care. In gastroenterology training programs, the assessment of SBP is difficult due to high volume, high acuity inpatient care, as well as inconsistent direct supervision. Nevertheless, structured assessment is required for training programs. We hypothesized that objective structured clinical examination (OSCE) would be an effective tool for assessment of SBP.

AIM

To develop a novel method for SBP milestone assessment of gastroenterology fellows using the OSCE.

METHODS

For this observational study, we created 4 OSCE stations: Counseling an impaired colleague, handoff after overnight call, a feeding tube placement discussion, and giving feedback to a medical student on a progress note. Twenty-six first year fellows from 7 programs participated. All fellows encountered identical case presentations. Checklists were completed by trained standardized patients who interacted with each fellow participant. A report with individual and composite scores was generated and forwarded to program directors to utilize in formative assessment. Fellows also received immediate feedback from a faculty observer and completed a post-session program evaluation survey.

RESULTS

Survey response rate was 100%. The average composite score across SBP milestones for all cases were 6.22 (SBP1), 4.34 (SBP2), 3.35 (SBP3), and 6.42 (SBP4) out of 9. The lowest composite score was in SBP 3, which asks fellows to advocate for cost effective care. This highest score was in patient care 2, which asks fellows to develop comprehensive management plans. Discrepancies were identified between the fellows’ perceived performance in their self-assessments and Standardized Patient checklist evaluations for each case. Eighty-seven percent of fellows agreed that OSCEs are an important component of their clinical training, and 83% stated that the cases were similar to actual clinical encounters. All participating fellows stated that the immediate feedback was “very useful.” One hundred percent of the fellows stated they would incorporate OSCE learning into their clinical practice.

CONCLUSION

OSCEs may be used for standardized evaluation of SBP milestones. Trainees scored lower on SBP milestones than other more concrete milestones. Training programs should consider OSCEs for assessment of SBP.

Tuberculous meningitis manifesting with neuroregression in a eleven month child

Tuberculosis (TB) is a disease of diverse manifestations. In children, neurotuberculosis is the severest form, which when left untreated can have deleterious consequences. There has been reports on pediatric TB meningitis manifesting with fever and seizures, altered sensorium or focal deficits. There are reports on TB meningitis presenting with cognitive decline in adults. We are reporting a eleven month old girl child who presented with acute regression of attained developmental milestones of one month duration as the only presenting complaint and MRI brain revealed basal exudates with hydrocephalus which nailed the diagnosis of tuberculous meningitis. CSF (Cerebro Spinal Fluid) tested by CBNAAT (Cartridge Based Nucleic Acid Amplification Testing) for TB was negative, but gastric aspirate tested for the same, came positive. Tuberculin skin testing was also positive. Chest X-ray was normal. The child had not received BCG (Bacillus Calmette Guerin)vaccine, thereby increasing her risk of complicated TB. The contact couldn't be traced. The child was started on ATT (Anti Tubercular Treatment) as soon as the diagnosis was made and she improved, thus signifying the better outcome with early initiation of ATT. This case reporting is intended to highlight the unusual presentation of TB meningitis in children, which when clinicians are aware of will lead to early treatment and better prognosis.

Mid-Year Medical Knowledge Milestones and ABSITE Scores in First-Year Surgery Residents

OBJECTIVE

Accreditation Council for Graduate Medical Education (ACGME) Surgery milestone ratings in the "Knowledge of Diseases and Conditions" (MK1) sub competency have been shown to correlate with American Board of Surgery In Training Examination (ABSITE) scores, and hypothesized to predict them. To better assess the predictive value of the MK1 milestone and avoid the potential bias caused by previous years' ABSITE scores, we designed a study including only first-year (PGY-1) residents and analyzed the correlation between their mid-year MK1 ratings and their scores in the ABSITE they took approximately a month later.

METHODS

De-identified United States Medical Licensing Examination (USMLE) Step 1 and Step 2 scores, mid-year MK1 milestone ratings and the subsequent ABSITE standard scores for the five academic years from 2014-2015 to 2018-2019 were collected and tabulated for 247 PGY-1 preliminary- and categorical-track residents from ten ACGME-accredited surgery residency programs.

RESULTS

The mid-year rating of PGY-1 residents' MK1 was predictive of their subsequent first ABSITE score for the entire cohort and for the categorical residents' subset. Notably, controlling for all other independent predictors, each half-point increase in MK1 rating was associated with a 25-point increase in ABSITE score. Preliminary residents performed significantly worse on the ABSITE, and their scores did not correlate significantly with their MK1 ratings.

CONCLUSIONS

The mid-year rating of PGY-1 residents' MK1 was predictive of their subsequent first ABSITE score for the entire cohort and for the categorical but not the preliminary residents. This finding suggests that evaluators correctly rated MK1 higher in the categorical residents who did perform better on the subsequent ABSITE.

Multi-Specialty Boot Camp: Enhancing Student Confidence in Residency Preparation

BACKGROUND

A "boot camp" or senior preparatory course can help to bridge the gap between knowledge and skills attained in required clerkships and residency expectations. An under-researched area is in interventions across specialties and with student confidence as the outcome.

OBJECTIVE

A multi-specialty school-wide boot camp for 4th year medical students was evaluated with a curriculum that focused on specialty milestones and entrustable professional activities and the importance of student confidence as an outcome.

METHODS

A school-wide "boot camp" was developed to help 4th year students become ready for their matched specialty. Faculty resources were pooled to teach students from multiple specialties' common milestone topics. Surveys were collected from 3 academic years (2014-2015 to 2016-2017): pre-boot camp (Pre), immediately post-boot camp (Post 1), and 3 months after starting residency (Post 2). Dependent t-tests were employed to determine pre-post differences.

RESULTS

Over the 3-year study period, 185 students participated in boot camp, 162 (87.6%) completed the first 2 surveys, and 75 (40.5%) students provided data at all 3 points in time. With more robust findings between Pre and Post 1, students improved their confidence level in communicating with families and most specialty skills, and students felt more prepared to be an intern as a result of the boot camp.

CONCLUSIONS

The robust increase in student confidence suggested that a multi-specialty, school-wide approach to a capstone curriculum should be considered by medical schools, which will not only benefit students but faculty as well. Future research should examine student competence in achieving specialty skills.

Competency-based medical education for the clinician-educator: the coming of Milestones version 2

Competency-based medical education is emphasized by institutions overseeing medical school and postgraduate training worldwide. The high rate of preventable errors in medicine underscores this need. Expanding physician competency beyond the domains of patient care and medical knowledge towards goals that emphasize a more holistic view of the healthcare system is one aspect of this emphasis. The Accreditation Council on Graduate Medical Education (ACGME), which oversees postgraduate training programs in the USA, has recently expanded to oversee training programs internationally. The original ACGME Milestones effort unveiled in 2013 was met with skepticism. Nevertheless, other outcomes-based education programs worldwide, including the CanMEDS framework (Canada), Tomorrow's Doctor (UK), and Scottish Doctor (Scotland), have suggested that milestones do offer advantages. Missing from the milestone rollout, however, was collaborative buy-in from multiple stakeholders such as from clinician-educators. Consequently, Milestones version 2 is in development. Specifically, these will address the need for specialty-specific milestones, and the usage of harmonized milestones. A concise history of the push towards outcomes-based medical education is presented and contextualized for physicians who must embrace the transition from teacher-based to learner-based outcomes.