Financial Literacy Among Medical Trainees and Faculty: A Pilot Study

INTRODUCTION

Medical education systems are trained to produce efficient, thorough clinicians. These programs provide limited training on personal finances. The current socioeconomic climate for medical trainees includes increasing education debt and stagnating reimbursement. We conducted a survey-based cross-sectional pilot study at an academic institution targeted at residents, fellows, and attendings of all medical specialties. Our aim was to understand baseline levels of financial literacy at different training and career stages, which can inform targeted interventions to improve this crucial aspect of physician well-being.

METHODS

A survey was devised with the assistance of a certified financial planner. This survey was distributed at an academic institution targeting residents, fellows, and attendings. The survey was anonymous, and no identifying data were collected. Two reminders were sent to subjects to complete the survey.

RESULTS

A total of 50 physicians completed the survey in 2021. There were eight responses from interns, 14 responses from residents (post-graduate year 2 or later), 14 responses from fellows, and nine responses from attendings. The majority of our respondents reported not having any particular financial education, and over 70% of respondents reported that their graduate education had not provided them with the tools needed for personal financial success.

CONCLUSION

Financial education and financial literacy are important topics that need to be further incorporated into the medical education pathway. Physicians are not well equipped in this realm, and further training is necessary. This study provides pilot data that highlight important aspects of physician knowledge and practices in regard to finances.

You are not lab rats at teaching hospitals: A systematic review of resident and fellow participation leads to improved colonoscopy

BACKGROUND

Participation in colonoscopies is an essential aspect of endoscopic training. The purpose of this study was to explore the impact of fellow/trainee participation on colonoscopy outcomes.

METHODS

This meta-analysis was registered on the International Prospective Register of Systematic Reviews (PROSPERO). From database inception to July 2022, studies investigating fellow involvement and colonoscopy outcomes were searched across Cochrane library, PubMed, and other databases. The random-effects model was applied to generate more conservative estimates. Sensitive analysis was conducted to explore whether the result would depend on a particular study. Egger's test and Begg's test were used to estimate the potential for publication bias.

RESULTS

Seventeen studies including 30,062 participants were included. We found that fellow/trainee involvement enhanced the overall rates of adenoma detection and polyp detection (OR = 1.26, 95% CI = 1.14-1.40, p < 0.001; OR = 1.29, 95% CI = 1.02-1.63, p = 0.020, respectively). The mean number of adenoma/polyps per colonoscopy was also higher with fellow/trainee participation (MD = 0.12, 95% CI = 0.08-0.17, p < 0.001; MD = 0.15, 95% CI = 0.02-0.28, p = 0.020, respectively).

CONCLUSION

In addition to its educational purpose, fellow or trainee involvement is associated with beneficial effects on colonoscopy outcomes.

Single Surgeon versus Co-Surgeons in Primary Total Joint Arthroplasty: Does "Two Is Better than One" Apply to Surgeons?

BACKGROUND

As the demand for total joint arthroplasties (TJA) increases steadily, so does the pressure to train future surgeons and, at the same time, achieve optimal outcomes. We aimed to identify differences in operative times and short-term surgical outcomes of TJAs performed by co-surgeons versus a single attending surgeon.

METHODS

A retrospective analysis of 597 TJAs, including 239 total hip arthroplasties (THAs) and 358 total knee arthroplasties (TKAs) was conducted. All operations were performed by one of four fellowship-trained attending surgeons as the primary surgeon. The assisting surgeons were either attendings or residents.

RESULTS

In 51% of THA and in 38% of TKA, two attending surgeons were scrubbed in. An additional scrubbed-in attending was not found to be beneficial in terms of surgical time reduction or need for revision surgeries within the postoperative year. This was also true for THAs and for TKAs separately. An attending co-surgeon was associated with a longer hospital stay (p = 0.028). Surgeries performed by fewer surgeons were associated with a shorter surgical time (p = 0.036) and an increased need for blood transfusion (p = 0.033). Neither the rate of intraoperative complications nor revisions differed between groups, regardless of the number of attending surgeons scrubbed in or the total number of surgeons.

CONCLUSION

A surgical team comprised of more than a single attending surgeon in TJAs was not found to reduce surgical time, while the participation of residents was not related with worse patient outcomes.

Are there differences in cardiothoracic surgery performed by trainees versus fully trained surgeons?

OBJECTIVES

We sought to assess the safety of training in cardiothoracic surgery comparing outcomes of cases performed by trainees versus fully trained surgeons.

METHODS

EmBase, Scopus, PubMed, and OVID MEDLINE were searched in August 2021 independently by two authors. A third author arbitrated decisions to resolve disagreements. Inclusion criteria were articles on cardiothoracic surgery reporting on outcomes for trainees. Studies were assessed for appropriateness as per CBEM criteria. Eight hundred and ninety-two results were obtained, 27 represented best evidence (2-meta-analyses, 1-RCT, and 24 retrospective cohort studies).

RESULTS

In all 474,160 operative outcomes were assessed for 434,535 coronary artery bypass grafting (CABG) (431,329 on-pump vs. 3206 off-pump), 3090 AVR, 1740 MVR/repair, 26,433 mixed, 3565 congenital, and 4797 thoracic procedures. In all 398,058 cases were performed by trainees and 75,943 by consultants. One hundred fifty-nine cases were indeterminate. There were no statistically significant differences in the patients' preoperative risk scores. All studies excluded extreme high-risk patients in emergency setting, patients with poor left ventricular function, and reoperation cases that were undertaken by consultants. There were no differences in cardiopulmonary bypass and clamp times for CABG. Times for valve replacement and repair cases were longer for trainees. There were no differences in the postoperative outcomes including perioperative myocardial infarction, resternotomy for bleeding, stroke, renal failure, intensive therapy unit length of stay, and total length of stay. One study reported no differences on angiographic graft patency at 1 year. There were no differences in in-hospital or midterm mortality out to 5-years.

DISCUSSION

Trainees can perform cardiothoracic surgery in dedicated high-volume units with outcomes comparable to those of fully trained surgeons.

A Multi-Center Comparison of Orthopaedic Attending and Resident Learning Styles

OBJECTIVE

Effective education of orthopedic residents requires an understanding of how they process information. To date however no literature has described resident learning styles based on the updated Kolb Learning Style Inventory (KLSI) v4.0. The purpose of this study is to identify common learning styles amongst orthopedic residents and attendings and evaluate the effect that race, gender, and resident/attending status have on learning styles.

DESIGN

The KLSI v4.0 and a demographic survey were distributed to 103 orthopedic attendings and residents at two academic centers during the 2019 to 2020 academic year. Frequencies and descriptive statistics were reported. Learning styles based on gender, race, attending versus resident status, and institution were evaluated. A p-value < 0.05 was considered significant.

SETTING

This is a multi-center study performed at two academic, university based orthopedic surgery departments.

PARTICIPANTS

Orthopaedic surgery residents and attending surgeons.

RESULTS

At both institutions, the combined response rate for the KLSI v4.0 was 66% and 68% for the demographic surgery. The three most common learning styles recorded were: Deciding (26.5%), Acting (17.6%), and Thinking (17.6%). Learning styles were compared by gender, race, attending and/or resident status, and institution with no statistically significant difference found between any of the comparisons (p > 0.05).

CONCLUSION

The majority of orthopedic surgeons have Deciding, Acting, or Thinking learning styles, which are categorized by motivation to achieve goals, disciplined and logical reasoning, and the use of theories and models to solve problems. However, not all residents and attendings utilize these common learning styles. A mismatch in learning styles between residents and attendings could result in poor educational experiences. Understanding the learning styles of orthopedic surgeons has implications for improving evaluation interpretation, mentorship pairing, quality of life, and resident remediation.

Focusing hospitalist roles on either admitting or rounding facilitates unit-based assignment and is associated with improved discharge efficiency

BACKGROUND

Unit-based teams may improve care delivery for hospitalized patients but can be challenging to implement broadly across all acute care units in a hospital.

OBJECTIVE

To determine the effect of a Lean-guided transition to hospital-wide unit-based assignment on care delivery outcomes.

DESIGN, SETTING, AND PARTICIPANTS

The study was a retrospective time-series with primary outcomes of discharge efficiency, 30-day readmissions, and length of stay, performed at a 336-bed tertiary academic referral hospital in the Pacific Northwest with approximately 17,000 admissions annually.

INTERVENTION

Implementation of a Lean-guided quality improvement intervention included division of hospitalist duties into 'admitters' and 'rounders,' with simulated patient flow exercises to determine the optimal staffing model.

MAIN OUTCOMES AND MEASURES

Discharge efficiency (number of patients discharged by hospitalists divided by the number of hospitalist patient encounter days per month) and 30-day readmissions were compared using the t-test or chi-square, and length of stay was analyzed in a multivariate time-series regression model.

RESULTS

The intervention was associated with a significant improvement in discharge efficiency, by 0.014 (from 0.168 to 0.181) discharges/encounter (95% CI = 0.024, 0.004), p = 0.009. Mean length of stay decreased by 0.98 days (95% CI 0.50, 1.47) after adjustment for patient age, patient type (medical versus surgical), critical care admissions, and discharge disposition, without a corresponding change in 30-day readmission rate (12.2% (1948/15,902) pre-intervention to 11.7% (397/3379) post-intervention (p = 0.42)).

CONCLUSIONS

Dividing hospitalist roles into admitters and rounders enabled implementation of unit-based teams across the hospital, with corresponding improvements in discharge efficiency and length of stay.

Prevalence of and Associations With Distress and Professional Burnout Among Otolaryngologists: Part I, Trainees

OBJECTIVE

To assess the prevalence of distress and burnout in otolaryngology trainees, including associations with relevant sociodemographic and professional factors, and to compare these results with those of attending otolaryngologists.

STUDY DESIGN

A cross-sectional survey of trainees and attending physicians.

SETTING

Twelve academic otolaryngology programs.

METHODS

Distress and burnout were measured with the Expanded Physician Well-being Index and the 2-item Maslach Burnout Inventory. The Patient Health Questionnaire-2 and Generalized Anxiety Disorder-2 were used to screen for depressive disorders and anxiety disorders, respectively. Associations with sociodemographic and professional characteristics were assessed.

RESULTS

Of the 613 surveys administered to trainees and attending physicians, 340 were completed (56%). Among 154 trainees, distress was present in 49%, professional burnout in 35%, positive depressive disorder screening in 5%, and positive anxiety disorder screening in 16%. In univariable analysis, female gender, hours worked in a typical week (HW), and nights on call in a typical week (NOC) were significantly associated with distress. In multivariable analysis, female gender (odds ratio, 3.91; P = .001) and HW (odds ratio for each 10 HW, 1.89; P = .003) remained significantly associated with distress. Female gender, HW, and NOC were significantly associated with burnout univariably, although only HW (odds ratio for each 10 HW, 1.92; P = .003) remained significantly associated with burnout in a multivariable setting. Attending physicians had less distress than trainees (P = .02) and felt less callous and less emotionally hardened than trainees (P < .001).

CONCLUSION

Otolaryngology trainees experience significant work-place distress (49%) and burnout (35%). Gender, HW, and NOC had the strongest associations with distress and burnout.

Prevalence of and Associations With Distress and Professional Burnout Among Otolaryngologists: Part II, Attending Physicians

OBJECTIVE

To ascertain the prevalence of and associations with distress and professional burnout among academic otolaryngology attending physicians.

STUDY DESIGN

Cross-sectional survey.

SETTING

Twelve US academic otolaryngology programs.

METHODS

A questionnaire was administered that encompassed sociodemographic and professional features, the Expanded Physician Well-being Index for distress, the 2-item Maslach Burnout Inventory for professional burnout, the Patient Health Questionnaire-2 screen for major depressive disorder, and the Generalized Anxiety Disorder-2 screen for generalized anxiety disorder.

RESULTS

The survey response rate was 56% and included 186 attending physicians. The average respondent age was 47 years; 72% were men; 93% were married or partnered; and 86% had children. Distress was present in 40%, professional burnout in 26%, positive depression screening in 8%, and positive anxiety screening in 11%. In a univariable setting, age, hours worked in a typical week, nights on call in a typical week, and years of practice were significantly associated with distress, although in a multivariable setting, only hours worked in a typical week remained significantly associated with a positive Expanded Physician Well-being Index screen (odds ratio for each 10-hour increase, 2.61; 95% CI, 1.73-3.93; P < .001). In a univariable setting, hours worked in a typical week was significantly associated with a positive Maslach Burnout Inventory screen.

CONCLUSION

Distress or professional burnout occurs in more than a quarter of academic otolaryngology attending physicians, whereas the prevalence of depression or anxiety is approximately 10%. The number of hours worked per week had the strongest association with distress and burnout. These findings may be used to develop and implement programs to promote physician well-being and mitigate professional burnout.

A Graduated Responsibility Supervising Resident Experience Using Mastery Learning Principles

This article was migrated. The article was marked as recommended. Introduction: Supervising other residents and independently running an emergency department (ED) is different from anything residents are asked to do in their early years of residency. There is often little training for this new responsibility. We created a new supervising experience that allows residents to progressively master skills associated with independently running an ED. Methods: We created an experience where PGY-3 residents supervised at our community site, removing the difficulties associated with an academic site such as junior residents and multiple consultants but requiring them to perform all other duties expected of the attending. Residents were scheduled in blocks of 4 shifts to allow them to iteratively improve their performance. Mastery was defined as 23 of 24 points across two shift evaluations, with 3 points available across 4 domains of Organization, Leadership/Communication, Flow and Patient Care. Residents who achieved this standard were allowed to progress to a more advanced supervising experience. Results: Eighty three percent of PGY-3 residents (10/12) achieved the mastery standard by the end of the year. Residents scored highest in Leadership/Communication (2.67 out of 3). They scored lowest on Flow (2.41 out of 3). Ninety percent of residents felt that the experience prepared them for being an attending. Discussion: A mastery learning-based supervising experience successfully allows residents to progressively acquire skills associated with running a busy ED. We plan to continue to evaluate the effectiveness of this intervention by examining the number of residents meeting the mastery standard as well as feedback from residents and faculty.

Fellow and Attending Surgeon Operative Notes are Deficient in Reporting Established Quality Indicators for Roux-en-Y Gastric Bypass: A Preliminary Retrospective Analysis of Operative Dictation

Introduction

Surgeons must dictate the important components of any invasive procedure in a comprehensive, yet concise, operative report. This documentation is vital for communicating operative events and has implications for providing additional healthcare and planning future operations. The quality of surgical care may be impaired in the absence of such communication. Evidence suggests that the quality of reports dictated by trainees and surgeons is poor despite its importance. This investigation analyzed and compared the quality of fellow and staff surgeon Roux-en-Y Gastric Bypass (RYGB) narrative dictations against validated and reliable quality indicators (QIs) for this procedure.

Methods

A total of 40 bariatric fellow reports and 40 attending RYGB narrative reports were retrospectively analyzed.

Results

Fellows had a mean completion of 66.4% +/- 3.1% as compared to 61.5% +/- 7.6% for attendings (p<0.0001). Fellows statistically outperformed attendings on all subsections except patient, closure, and postoperative details. Attendings statistically outperformed fellows on closure details only (63.8 +/- 7.5 vs 50.5 +/- 12.0, p=0.002).

Conclusions

Bariatric surgery trainees outperform attending surgeons in RYGB operative dictation. The clinical significance of this difference is unknown. However, both groups are deficient in reporting at least one-third of items deemed essential to RYGB operative reporting. This indicates a need for further education in RYGB dictation for practicing surgeons and trainees. It also lends interest in exploring alternative forms of operative communication such as synoptic operative reporting in bariatric surgery.

Further Evaluation of a Practitioner Model for Increasing Eye Contact in Children With Autism

Cook et al. recently described a progressive model for teaching children with autism spectrum disorder (ASD) to provide eye contact with an instructor following a name call. The model included the following phases: contingent praise only, contingent edibles plus praise, stimulus prompts plus contingent edibles and praise, contingent video and praise, schedule thinning, generalization assessments, and maintenance evaluations. In the present study, we evaluated the extent to which modifications to the model were needed to train 15 children with ASD to engage in eye contact. Results show that 11 of 15 participants acquired eye contact with the progressive model; however, eight participants required one or more procedural modifications to the model to acquire eye contact. In addition, the four participants who did not acquire eye contact received one or more modifications. Results also show that participants who acquired eye contact with or without modifications continued to display high levels of the behavior during follow-up probes. We discuss directions for future research with and limitations of this progressive model.

A Practitioner Model for Increasing Eye Contact in Children With Autism

Although many teaching techniques for children with autism spectrum disorder (ASD) require the instructor to gain the child's eye contact prior to delivering an instructional demand, the literature contains notably few procedures that reliably produce this outcome. To address this problem, we evaluated the effects of a sequential model for increasing eye contact in children with ASD. The model included the following phases: contingent praise only (for eye contact), contingent edibles plus praise, stimulus prompts plus contingent edibles and praise, contingent video and praise, schedule thinning, and maintenance evaluations for up to 2 years. Results indicated that the procedures increased eye contact for 20 participants (one additional participant did not require consequences). For 16 participants, praise (alone) was not sufficient to support eye contact; however, high levels of eye contact were typically maintained with these participants when therapists used combined schedules of intermittent edibles or video and continuous praise. We discuss some limitations of this model and directions for future research on increasing eye contact for children with ASD.

Measurement of Neurophysiological Signals of Ignoring and Attending Processes in Attention Control

Attention control is the ability to selectively attend to some sensory signals while ignoring others. This ability is thought to involve two processes: enhancement of sensory signals that are to be attended and the attenuation of sensory signals that are to be ignored. The overall strength of attentional modulation is often measured by comparing the amplitude of a sensory neural response to an external input when attended versus when ignored. This method is robust for detecting attentional modulation, but precludes the ability to assess the separate dynamics of attending and ignoring processes. Here, we describe methodology to measure independently the neurophysiological signals of attending and ignoring using the intermodal attention task (IMAT). This task, when combined with electroencephalography, isolates neurophysiological sensory responses in auditory and visual modalities, when either attending or ignoring, with respect to a passive control. As a result, independent dynamics of attending and of a ignoring can be assessed in either modality. Our results using this task indicate that the timing and cortical sources of attending and ignoring effects differ, as do their contributions to the attention modulation effect, pointing to unique neural trajectories and demonstrating sample utility of measuring them separately.

Resistance to change and relapse of observing

Four experiments examined relapse of extinguished observing behavior of pigeons using a two-component multiple schedule of observing-response procedures. In both components, unsignaled periods of variable-interval (VI) food reinforcement alternated with extinction and observing responses produced stimuli associated with the availability of the VI schedule (i.e., S+). The components differed in the rate of food arranged (Rich  = VI 30 s; Lean  =  VI 120 s). In Experiment 1, following baseline training, extinction of observing involved removal of both food and S+ deliveries, and reinstatement was examined by presenting either response-independent food or S+ deliveries. In Experiment 2, extinction involved removal of only food deliveries while observing responses continued to produce S+. Reinstatement was examined by delivering food contingent upon the first two food-key responses occurring in the presence of the S+. Experiment 3 assessed ABA renewal of observing by extinguishing food-key and observing responses in the presence of one contextual stimulus (i.e., B) and then returning to the original training context (i.e., A) during continued extinction. Experiment 4 examined resurgence by introducing food reinforcement for an alternative response during extinction, and subsequently removing that alternative source of food. Across experiments, relative resistance to extinction and relapse of observing tended to be greater in the component previously associated with the higher rate of primary reinforcement. Relapse of observing or attending to stimuli associated with primary reinforcement appears to be impacted by frequency of primary reinforcement in a manner similar to responding maintained directly by primary reinforcement.

A theory of attending and reinforcement in conditional discriminations

A model of conditional discrimination performance (Davison & Nevin, 1999) is combined with the notion that unmeasured attending to the sample and comparison stimuli, in the steady state and during disruption, depends on reinforcement in the same way as predicted for overt free-operant responding by behavioral momentum theory (Nevin & Grace, 2000). The rate of observing behavior, a measurable accompaniment of attending, is well described by an equation for steady-state responding derived from momentum theory, and the resistance to change of observing conforms to predictions of momentum theory, supporting a key assumption of the model. When probabilities of attending are less than 1.0, the model accounts for some aspects of conditional-discrimination performance that posed problems for the Davison-Nevin model: (a) the effects of differential reinforcement on the allocation of responses to the comparison stimuli and on accuracy in several matching-to-sample and signal-detection tasks where the differences between the stimuli or responses were varied across conditions, (b) the effects of overall reinforcer rate on the asymptotic level and resistance to change of both response rate and accuracy of matching to sample in multiple schedules, and (c) the effects of fixed-ratio reinforcement on accuracy. Some tests and extensions of the model are suggested, and the role of unmeasured events in behavior theory is considered.