Preparation for airway management in Australia and New Zealand ICUs during the COVID -19 pandemic

BACKGROUND

This paper aimed to describe the airway practices of intensive care units (ICUs) in Australia and New Zealand specific to patients presenting with COVID-19 and to inform whether consistent clinical practice was achieved. Specific clinical airway guidelines were endorsed in March 2020 by the Australian and New Zealand Intensive Care Society (ANZICS) and College of Intensive Care Medicine (CICM).

METHODS AND FINDINGS

Prospective, structured questionnaire for all ICU directors in Australia and New Zealand was completed by 69 ICU directors after email invitation from ANZICS. The online questionnaire was accessible for three weeks during September 2020 and analysed by cloud-based software. Basic ICU demographics (private or public, metropolitan or rural) and location, purchasing, airway management practices, guideline uptake, checklist and cognitive aid use and staff training relevant to airway management during the COVID-19 pandemic were the main outcome measures. The 69 ICU directors reported significant simulation-based inter-professional airway training of staff (97%), and use of video laryngoscopy (94%), intubation checklists (94%), cognitive aids (83%) and PPE "spotters" (89%) during the airway management of patients with COVID-19. Tracheal intubation was almost always performed by a Specialist (97% of ICUs), who was more likely to be an intensivist than an anaesthetist (61% vs 36%). There was a more frequent adoption of specific airway guidelines for the management of COVID-19 patients in public ICUs (94% vs 71%) and reliance on specialist intensivists to perform intubations in private ICUs (92% vs 53%).

CONCLUSION

There was a high uptake of a standardised approach to airway management in COVID-19 patients in ICUs in Australia and New Zealand, likely due to endorsement of national guidelines.

Clinical Teaching: An Evidence-based Guide to Best Practices from the Council of Emergency Medicine Residency Directors

Clinical teaching is the primary educational tool use to train learners from day one of medical school all the way to the completion of fellowship. However, concerns over time constraints and patient census have led to a decline in bedside teaching. This paper provides a critical review of the literature on clinical teaching with a focus on instructor teaching strategies, clinical teaching models, and suggestions for incorporating technology. Recommendations for instructor-related teaching factors include adequate preparation, awareness of effective teacher attributes, using evidence-based-knowledge dissemination strategies, ensuring good communication, and consideration of environmental factors. Proposed recommendations for potential teaching strategies include the Socratic method, the One-Minute Preceptor model, SNAPPS, ED STAT, teaching scripts, and bedside presentation rounds. Additionally, this article will suggest approaches to incorporating technology into clinical teaching, including just-in-time training, simulation, and telemedical teaching. This paper provides readers with strategies and techniques for improving clinical teaching effectiveness.

Primary Care Clinician and Clinic Director Experiences of Professional Bias, Harassment, and Discrimination in an Underserved Agricultural Region of California

IMPORTANCE

Many rural and agricultural communities experience hardship from a shortage of clinicians. The aging of the clinician population threatens future supply in these areas. Developing policies to build a sustainable workforce requires the understanding of experiences from those currently in medical practice. Previous research about rural clinicians has primarily sampled non-Latinx white men, and to a lesser extent, non-Latinx white women; to date, no study has examined differences by race/ethnicity, sexual orientation, or gender identity.

OBJECTIVE

To describe the professional experiences of a diverse group of primary care clinicians and clinic directors in an underserved rural and agricultural region of California.

DESIGN, SETTING, AND PARTICIPANTS

In this qualitative study, semistructured in-depth qualitative interviews were performed with clinicians and clinic directors from December 1, 2017, to December 31, 2018, with a present or recent medical practice in the central San Joaquin Valley region of California. Participants (N = 26) consisted of physicians, nurse practitioners, and clinic directors practicing in primary care settings. Settings included solo and group private practice, academic training programs, community health centers, and rural health clinics.

MAIN OUTCOMES AND MEASURES

Personal experiences as primary care clinicians and clinic directors, and perceived associations with gender, race/ethnicity, sexual orientation, and gender identity.

RESULTS

Of 26 primary care clinicians and clinic directors interviewed, 16 (62%) identified as female, 12 (46%) identified as non-Latinx white, and 3 (12%) identified as a member of a sexual and gender minority group. Participants who self-identified as female, nonwhite, and of certain sexual orientation and gender identity minority groups described burnout from bias, harassment, and hostility in their professional relationships with colleagues and health care staff. These experiences intensified their feelings of community isolation and professional isolation. Harassment and institutional discrimination were factors in the decision of participants to change practices or exit the region entirely. Discriminatory acts against members of sexual and gender minority groups were the most severe, including threats to licensure and denial of hospital admitting privileges. In contrast to the minority group participants, the remaining participants expressed little to no awareness of these negative experiences, or the association between these experiences and retention.

CONCLUSIONS AND RELEVANCE

Professional harassment and discrimination may hamper efforts to improve clinician and clinic director recruitment and retention in underserved rural and agricultural areas and may pose barriers to addressing health disparities within those communities. Additional investigation appears to be needed to assess the extent to which professional harassment and discrimination affect clinicians and clinic directors in similar communities across the United States.

Residency and Fellowship Program Administrator Burnout: Measuring Its Magnitude

BACKGROUND

Little is known about the level of burnout among program administrators (PAs) working in graduate medical education.

OBJECTIVE

We created a national database with baseline burnout data for PAs from residency and fellowship programs, including intention to leave their current positions.

METHODS

A cross-sectional study was conducted in July 2017 to assess levels of burnout in a national cohort of PAs, who were largely members of online specialty forums. The Copenhagen Burnout Inventory (CBI) was used to measure burnout. Univariate analysis produced descriptive statistics for CBI. We performed a 2-sample t test to measure differences in average burnout scores for those who had thoughts of resigning from their positions and those who had not.

RESULTS

Of the approximately 10 205 national PAs, we sampled 1126 (11%). Of the 1126 individuals who received the study information, 931 (83%) completed the baseline survey. Total mean scores for all subscales were elevated (personal: 53.7, SD 21.4; work-related: 52.0, SD 22; and client-related: 30.6, SD 20.8; each scale ranged from 0, low, to 100, high). Burnout scores differed between those contemplating leaving their jobs and those who were not, across all subscales of CBI, including personal (64.2 versus 42.4, -24.18 to -19.44 confidence interval [CI]), work-related (63.5 versus 39.7, -26.12 to -21.35 CI), and client-related (36.6 versus 24.2, -14.95 to -9.84 CI; P < .0001 for all).

CONCLUSIONS

In this national survey of PAs, burnout scores measured by the CBI were higher among those who had considered leaving their positions.

Organizational constraints as root causes of role conflict

PURPOSE

The purpose of this paper is to gain a better understanding of the difficulties encountered in the hybrid roles of physician-managers (P-Ms), examine the impact of organizational constraints on the role conflicts experienced by P-Ms and explore the different ways their two roles are integrated.

DESIGN/METHODOLOGY/APPROACH

A qualitative approach was adopted, using six focus groups made up of clinical co-managers, medical directors and P-Ms. In all, 43 different people were interviewed to obtain their perceptions of the day-to-day realities of the role of the P-M. The data collected were subsequently validated.

FINDINGS

Although the expectations of the different groups involved regarding the role of P-Ms are well understood and shared, there are significant organizational constraints affecting what P-Ms are able to do in their day-to-day activities, and these constraints can result in role conflicts for the people involved. Such constraints also affect the ways P-Ms integrate the two roles. The authors identify three role hybridization profiles.

PRACTICAL IMPLICATIONS

The results afford a better understanding of how organizational constraints might be used as levers of organizational change to achieve a better hybridization of the dual roles of P-Ms.

ORIGINALITY/VALUE

This paper seeks to reach beyond a simple identification of constraints affecting the dual roles of P-Ms by analyzing how such constraints impact on these professionals' day-to-day activities. Results also enable us to further refine Katz and Kahn's (1966) role model, in addition to identifying hybridization profiles.

Step Up-Not On-The Step 2 Clinical Skills Exam: Directors of Clinical Skills Courses (DOCS) Oppose Ending Step 2 CS

Recently, a student-initiated movement to end the United States Medical Licensing Examination Step 2 Clinical Skills and the Comprehensive Osteopathic Medical Licensing Examination Level 2-Performance Evaluation has gained momentum. These are the only national licensing examinations designed to assess clinical skills competence in the stepwise process through which physicians gain licensure and certification. Therefore, the movement to end these examinations and the ensuing debate merit careful consideration. The authors, elected representatives of the Directors of Clinical Skills Courses, an organization comprising clinical skills educators in the United States and beyond, believe abolishing the national clinical skills examinations would have a major negative impact on the clinical skills training of medical students, and that forfeiting a national clinical skills competency standard has the potential to diminish the quality of care provided to patients. In this Perspective, the authors offer important additional background information, outline key concerns regarding the consequences of ending these national clinical skills examinations, and provide recommendations for moving forward: reducing the costs for students, exploring alternatives, increasing the value and transparency of the current examinations, recognizing and enhancing the strengths of the current examinations, and engaging in a national dialogue about the issue.

Measuring Burnout Among Psychiatry Clerkship Directors

OBJECTIVE

The primary purpose of this study was to determine the prevalence of burnout among Psychiatry clerkship directors.

METHODS

Psychiatry clerkship directors were solicited via email to complete an electronic version of the Maslach Burnout Inventory-General Survey and the Respondent Information Form.

RESULTS

Fifty-four out of 110 surveys (49%) were completed. Fourteen percent of respondents scored in the "high exhaustion" category, 21.6% scored in the "low professional efficacy" category, 20.4% scored in the "high cynicism" category, and 15.1% of respondents met threshold for at least two of the three categories. Those who scored in the "low professional efficacy" category reported higher levels of salary support for research, while those who scored in the "high cynicism" category reported lower levels of salary support at a trend level. Those who scored in the "high cynicism" category were younger.

CONCLUSIONS

Approximately 14-22 percent of psychiatry clerkship directors reported some level of burnout depending on the subscale used. Future studies should aim to better identify those clerkship directors who are at greatest risk for becoming burned out by their educational role and to clarify the link between salary support for research, age, and burnout.

Aesthetic Surgery Fellowship Selection Criteria: A National Fellowship Director Survey

BACKGROUND

Desirable candidate characteristics for aesthetic surgery fellowship applicants remain unknown because of a lack of data in the literature.

OBJECTIVES

This study aims to identify the criteria used to select applicants for aesthetic surgery fellowship in the United States.

METHODS

A 38-question survey was sent in April 2015 to all directors of fellowships endorsed by the American Society for Aesthetic Plastic Surgery (n = 20) in the United States. The survey investigated various factors including residency training and fellowship interview. A 5-point Likert scale was used to grade 33 influential factors from 1 ("not at all important") to 5 ("essential"); a separate 5-point Likert scale was used for 5 controversial factors from 1 ("very negative impact") to 5 ("very positive impact").

RESULTS

Sixty-five percent (13 out of 20) of directors responsed. The most important factors were letters of recommendation by well-established plastic surgeons (4.6 ± 0.7), interpersonal skills (4.5 ± 0.8), overall interview performance (4.5 ± 0.7), professionalism and ethics (4.4 ± 1.0), and letters of recommendation by aesthetic surgeons (4.4 ± 1.2). The least important factors were Alpha Omega Alpha Honor Medical Society membership (1.8 ± 0.6), postgraduate degrees (1.9 ± 0.9), US Medical Licensing Examination (USMLE) Step 2 Clinical Knowledge (CK)/Comprehensive Osteopathic Medical Licensing Examination (COMLEX) Level 2 Cognitive Evaluation and USMLE/COMLEX Step 3 score (1.9 ± 0.9), and research fellowships (2.0 ± 0.6).

CONCLUSIONS

This study provides data on the aesthetic surgery fellowship directors' perceptions about the criteria important for applicant selection. We trust that fellowship directors, residency programs, and applicants find this data useful as they prepare for the aesthetic surgery fellowship match.

Resident and Program Director Perceptions of Aesthetic Training in Plastic Surgery Residency: An Update

Background

This is the third survey exploring the quality of cosmetic training in plastic surgery residency. We focused on determining: (1) the applied modalities and extent of resident exposure; and (2) resident confidence in performing variable cosmetic procedures.

Objectives

To analyze trends in resident exposure and confidence in aesthetic plastic surgery procedures from the standpoint of program directors (PDs) and residents.

Methods

The survey was developed and e-mailed to 424 residents enrolled in the ASAPS Residents Program and 95 PDs. Both independent and integrated programs were included. The questions were posed in a five-point ranking format. Univariate statistical analysis was used to examine all aspects. The results were analyzed in relation to our previous surveys in 2008 and 2011.

Results

Thirty-three PDs (34.7%) and 224 (52.8%) residents responded. Residents felt most confident with abdominoplasty, breast reduction, and augmentation-mammaplasty. Facial aesthetic procedures, especially rhinoplasty and facelift, were perceived as "challenging." The three most preferred modalities of aesthetic education were, in descending order, residents' clinic, staff cosmetic patients, and cadaver dissections. Both residents and PDs felt a need for more training especially in facial procedures. Only 31.5% of residents who planned to focus on cosmetic surgery felt ideally prepared integrating cosmetic surgery into their practice (compared to 50% in previous surveys).

Conclusions

Despite improvements observed from 2008 to 2011 published surveys, there are still challenges to be met especially in facial cosmetic procedures. It is suggested that resident clinics and cadaver courses be universally adopted by all training programs.

Internal Medicine Program Directors' Perceptions of the "All In" Match Rule: A Cross-Sectional Survey

BACKGROUND

Since 2013, the National Resident Matching Program (NRMP) has asked all programs to declare themselves to be "all in" or "all out" for the NRMP. Before this rule was enacted, program directors who were surveyed expressed concerns about what they anticipated with the change, including resources for increased applications and potential delays with residency start times.

OBJECTIVE

This study investigated the positive and negative effects of the rule change on recruiting seen from the perspective of internal medicine (IM) program directors.

METHODS

In this mixed model cross-sectional survey, Accreditation Council for Graduate Medical Education-accredited IM program directors were surveyed regarding their impressions of the impact of the policy change. Data were aggregated using constant comparative analysis.

RESULTS

A total of 127 of 396 (32%) IM program directors responded, and 122 of 127 (96%) identified their program as "all in." A total of 110 respondents expressed impressions of the rule change, with 48% (53 of 111) reporting positive responses, 28% (31 of 111) neutral responses, and 24% (27 of 111) negative responses. Programs with higher percentages of visa-holding residents had lower positive responses (37% [22 of 60] versus 61% [31 of 51]). Resident quality was felt to be unchanged or improved by most program directors (93%, 103 of 111), yet 24% (27 of 112) reported increases in delayed start times for visa-holding residents. Qualitative analysis identified increased fairness, at the expense of an increase in program resources as a result of the change.

CONCLUSIONS

A slight majority of residency programs reported a neutral or negative impression of the rule change. Since the rule change, program directors noted increased application volume and delayed residency starts for visa-holding residents.

Incentive Implementation in Physician Practices: A Qualitative Study of Practice Executive Perspectives on Pay for Performance

Pay-for-performance (P4P) programs offer health care providers financial incentives to achieve predefined quality targets. Practice executives sit at a key nexus point for determining how P4P programs are implemented in physician practices. Using a qualitative interview design, this article examines the role practice executives play in the implementation of P4P programs and how their perspectives and decisions can influence the success of these programs. The authors identified five key findings related to practice executives’ views on P4P: quality incentives are better than utilization incentives, quality incentives are bonus rewards, quality incentives are agents for change, providers do not feel they have control over attaining quality targets, and the ways in which quality is measured are problematic. The authors discuss five different ways in which practice executives distribute rewards to physicians. These findings may help payers more effectively design and implement financial rewards for quality.

Physician empowerment programme; a unique workshop for physician-managers of community clinics

BACKGROUND

The physician manager role in the health care system is invaluable as they serve as role models and quality setters. The requirements from physician managers have become more demanding and the role less prestigious; yet burnout and its prevention in this group have received little attention. Physician leadership development programmes have generally dealt directly with skill and knowledge acquisition. The aim of this research was to evaluate an intensive workshop designed to modify attitudes and improve skills of physician-managers of community clinics, through focus on personal well-being and empowerment.

METHODS

Two hundred fifty six physicians affiliated with Clalit Health Services, the largest health maintenance organization in Israel, participated in 16 IMPACT courses during the years 2013-2015. The programme comprised five full days during a two-week period, including an overnight and follow-up meetings three and six weeks later. Theoretical knowledge, experiential learning, practical tools, deep personal exercises, and simulations were conveyed through individual and group work. Topics included: models of self-awareness, outcome thinking, determining a personal and organizational vision, and creating a personal approach to leadership. At the end of each course, and by email at 6 or more months after completion of the course, participants were asked to anonymously respond to closed questions (on a scale of 1-6) and an open question.

RESULTS

Mean scores for the contribution of IMPACT to participants' role of physician manager were 5.3 at the end of the course, and 4.7 at 6 or more months later. Mean scores at 6 or more months were 5.0 regarding the contribution of the programme to personal development, 4.4 regarding satisfaction in the role of physician manager, and 4.6 regarding their coping with managerial dilemmas.

CONCLUSION

A workshop that focused on personal growth and self-awareness increased physicians' job satisfaction and their sense of managerial capability, coping with managerial dilemmas, and belonging to the organization.

IN PURSUIT OF INCREASED LEADERSHIP EFFECTIVENESS

As you strive to develop your craft as a leader, some fundamental elements have the potential to deliver a huge impact on your effectiveness. Here are three: 1. An integrated leadership philosophy. 2. An understanding of what really drives the people in your organization. 3. An overarching responsibility to connect the threads.

Programmatic barriers to providing culturally competent end-of-life care

Despite many efforts to increase access to end-of-life care, culturally diverse groups are still not being served. Interviews of 22 hospice and palliative care program directors in one southeastern state indicated that directors overestimated how well programs are doing in meeting the needs of diverse groups but were very interested in implementing cultural diversity training for their staff. Those who were more concerned about such issues had recruited more diverse volunteers into their programs. The presence of diverse staff or volunteers predicted a more diverse patient population. A number of efforts were underway to develop cultural competence and provide culturally competent care. Several directors reported no efforts in this direction, however. Directors described programmatic barriers and resources needed. The authors concluded that directors should provide leadership in their agencies in welcoming diversity. Implications for further research and work within the larger end-of-life care field are discussed.

Intent to Build Hepatitis C Treatment Capacity Within Family Medicine Residencies: A Nationwide Survey of Program Directors: A CERA Study

BACKGROUND AND OBJECTIVES

In the current interferon-free era, family medicine is in a unique position to deliver hepatitis C (HCV) treatment with adequate training. Little is known about attitudes of family medicine program directors (PDs) toward capacity building within their residency programs. We report the results of a nationwide survey of family medicine PDs to examine these attitudes.

METHODS

This study was part of a CERA (Council of Academic Family Medicine Educational Research Alliance) omnibus survey administered to family medicine PDs between February 2015 and March 2015. Attitudes were assessed using a Likert scale ranging from 1=strongly disagree to 6=strongly agree.

RESULTS

We surveyed 452 physicians, with 273 responses (response rate 61%). The majority of PDs (78%) believed that chronic HCV represented a significant problem for primary care, and 61.9% believed their program should take steps to build capacity in HCV treatment. There was no effect of regional HCV prevalence, residency program context, or PD characteristics on intent to build capacity.

CONCLUSIONS

This is the first report to examine PDs intent to build capacity in HCV treatment in this interferon-free, direct antiviral era. Our findings highlight a historic opportunity to train family physicians and position them on the frontline as HCV treatment providers.

Derivation and Confirmation of Scales Measuring Medical Directors’ Attitudes About the Hospitalization of Nursing Home Residents

Objectives: To derive and confirm scales measuring medical director’s attitudes about hospitalization of nursing home residents.

Method: The authors surveyed nursing facility medical directors about the necessity of hospitalizing residents for eight clinical conditions and compared the ratings to those obtained from an expert panel to derive a relative hospitalization score. They also asked about factors that might influence hospitalization decisions. They performed a factor analysis to derive scales that measure attitudinal determinants of hospitalization and used the relative hospitalization score to confirm the scales.

Results: The survey had a 79% response rate. The relative hospitalization score demonstrated that medical directors were slightly less likely to recommend hospitalization than expert panel physicians. Factor analyses yielded 10 scales focusing on nursing home functioning, economics, resident specific considerations, and physician attitudes. Eight of the 10 scales had significant bivariable associations with the relative hospitalization score, and 6 had significant multivariable associations.

Discussion: Medical directors identify multiple determinants of hospitalization for nursing facility residents across several domains. Hospitalization decisions for nursing facility residents are complex and involve clinical and nonclinical factors.

In-Center Nutrition Practices of Clinics within a Large Hemodialysis Provider in the United States

BACKGROUND AND OBJECTIVES

Eating during hemodialysis treatment remains a controversial topic. It is perceived that more restrictive practices in the United States contribute to poorer nutritional status and elevated mortality compared with some other parts of the world. However, in-center food practices in the United States have not been previously described.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

In 2011, we conducted a survey of clinic practices and clinician (dietitian, facility administrator, and medical director) opinions related to in-center food consumption within a large dialysis organization. After the initial survey, we provided clinicians with educational materials about eating during treatment. In 2014, we performed a follow-up survey. Differences in practices and opinions were analyzed using chi-squared tests and logistic regression.

RESULTS

In 2011, 343 of 1199 clinics (28.6%) did not allow eating during treatment, 222 clinics (18.2%) did not allow drinking during treatment, and 19 clinics (1.6%) did not allow eating at the facility before or after treatment. In 2014, the proportion of clinics that did not allow eating during treatment had declined to 22.6% (321 of 1422 clinics), a significant shift in practice (P<0.001). Among the 178 (6.8%) clinics that self-reported that eating was "more allowed" in 2014, the main reason for this shift was an increased focus on nutritional status. Among clinicians, a higher percentage encouraged eating during treatment (53.1% versus 37.4%; P<0.05), and facility administrators and medical directors were less concerned about the seven reasons commonly cited for restricting eating during treatment in 2014 compared with 2011 (P<0.05 for all).

CONCLUSIONS

We found that 28.6% and 22.6% of hemodialysis clinics within the United States restricted eating during treatment in 2011 and 2014, respectively, a rate more than double that found in an international cohort on which we previously published. However, practices and clinician opinions are shifting toward allowing patients to eat. Additional research is warranted to understand the effect that these practices have on patient outcomes and outline best practices.

Prioritizing health leadership capabilities in Canada: Testing LEADS in a Caring Environment

This article is the first major empirical test of LEADS in a Caring Environment, the principal leadership capability framework in Canada. The results rank the perceived salience of leadership attributes, given time and budget constraints, while implementing a major organization reform in the Saskatchewan health system. The results also indicate important differences between self-assessed leadership behaviours versus observed behaviours in other leaders that may reflect participants' expectations of managers with designated authority.

Impact of organizational leadership on physician burnout and satisfaction

OBJECTIVE

To evaluate the impact of organizational leadership on the professional satisfaction and burnout of individual physicians working for a large health care organization.

PARTICIPANTS AND METHODS

We surveyed physicians and scientists working for a large health care organization in October 2013. Validated tools were used to assess burnout. Physicians also rated the leadership qualities of their immediate supervisor in 12 specific dimensions on a 5-point Likert scale. All supervisors were themselves physicians/scientists. A composite leadership score was calculated by summing scores for the 12 individual items (range, 12-60; higher scores indicate more effective leadership).

RESULTS

Of the 3896 physicians surveyed, 2813 (72.2%) responded. Supervisor scores in each of the 12 leadership dimensions and composite leadership score strongly correlated with the burnout and satisfaction scores of individual physicians (all P<.001). On multivariate analysis adjusting for age, sex, duration of employment at Mayo Clinic, and specialty, each 1-point increase in composite leadership score was associated with a 3.3% decrease in the likelihood of burnout (P<.001) and a 9.0% increase in the likelihood of satisfaction (P<.001) of the physicians supervised. The mean composite leadership rating of each division/department chair (n=128) also correlated with the prevalence of burnout (correlation=-0.330; r(2)=0.11; P<.001) and satisfaction (correlation=0.684; r(2)=0.47; P<.001) at the division/department level.

CONCLUSION

The leadership qualities of physician supervisors appear to impact the well-being and satisfaction of individual physicians working in health care organizations. These findings have important implications for the selection and training of physician leaders and provide new insights into organizational factors that affect physician well-being.

Training directors' self-assessment of forensic education within residency training

OBJECTIVE

The authors provide information pertaining to forensic education within psychiatry residency based upon training directors' self-assessment of their programs, utilizing the 2007 ACGME program requirements for forensic psychiatry as an assessment guideline.

METHODS

A sample of 100 general psychiatry residency training directors from 182 training programs in the USA were selected by a random number generator to complete a survey to evaluate forensic training provided within their residency programs.

RESULTS

Seventy-one percent of the 100 surveyed training directors completed and returned the questionnaire. Ninety-three percent of training director respondents reported their program meets the ACGME program requirements for graduate medical education in forensic psychiatry. The forensic topics covered most thoroughly in general psychiatry training are involuntary civil commitment and violence risk assessment. The topics covered least thoroughly include exposure to courtroom testimony, writing a forensic report, and evaluating a defendant's criminal responsibility. The respondents further indicated most forensic psychiatry topics are covered more extensively through educational exposure than through clinical exposure.

CONCLUSIONS

Greater effort may be required to emphasize clinical and educational exposure to certain forensic psychiatry topics during the course of general psychiatry residency training, to ensure that the forensic topics of greatest importance are appropriately addressed.

The 80-hour work week for residents: views from obstetric and gynecology program directors

In 2003, the Accreditation Council for Graduate Medical Education mandated an 80-hour work week restriction for residency programs. We examined program directors' views on how this mandate affects the education of Obstetrics and Gynecology residents. A 25 question survey was administered via Survey Monkey to Obstetrics and Gynecology program directors in the United States over three months in 2011. Fifty program directors (response rate of 28%) completed it with more men (62%) than women (38%) respondents. Overall, only 28% (14/50) responded that the program had improved, with significantly fewer men (5/14; 16.1%) than women (47.4% 9/19; p < 0.0169) directors reporting this. There was little perceived improvement in any of the six core ACGME performance objectives and in the CREOG scores, with the improvement ranging from 8% to 12%. In fact, while we observed the percentage of women directors reporting improvement in patient care and interpersonal and communication skills significantly higher compared with their male counterparts, the majority of women still reported either no improvement or a decline in these areas. Though our sample size was small, we found some significant difference between the views of male and female program directors. Both groups nonetheless responded with the majority with a decline or no change rather than a perceived improvement in any of the educational endeavors studied.

Expanding the scope of leadership training in medicine

All physicians take a leadership role at some point in their career-some exert influence in their practices and communities as informal leaders, and others hold formal leadership roles to which they are appointed or elected. These formal leadership roles convey power to those individuals who hold such positions. Formal leadership, however, is limited in its influence unless it is accompanied by a series of personal and interpersonal competencies that characterize both formal and informal leaders.Many physicians who do not hold formal leadership roles will be called on to provide (or will wish to provide) informal leadership at various times in their careers. Both formal and informal leaders should be trained in the personal and interpersonal competencies necessary for effective leadership to advance the principles-driven and values-oriented goals inherent in the health care enterprise.In this article, the author defines leadership and describes the characteristics of formal and informal leaders, then discusses the types of leadership and the power derived from different leadership roles. He concludes by arguing in favor of expanding the scope of leadership training to include informal as well as formal leaders.

Organizational insight for physician leaders: a critical perspective

Learn how to develop and institute the organizational awareness that leadership teams require to run healthy medical care systems.

Systematic training in internal medicine-pediatrics end of residency handoffs: residency director attitudes and perceived barriers

BACKGROUND

It is unclear why systematic training in end-of-residency clinic handoffs is not universal.

PURPOSES

We assessed Internal Medicine-Pediatrics (Med-Peds) residency program directors' attitudes regarding end-of-residency clinic handoff systems and perceived barriers to their implementation.

METHODS

We surveyed all Med-Peds program directors in the United States about end-of-residency outpatient handoff systems.

RESULTS

Program directors rated systems as important (81.5%), but only 31 programs (46.3%) utilized them. Nearly all programs with (29/31 [93.5%]), and most programs without systems (24/33 [72.7%]) rated them as important. Programs were more likely to have a system if the program director rated it important (p = .049), and less likely if they cited a lack of faculty interest (p = .023) or difficulty identifying residents as primary providers (p = .04).

CONCLUSIONS

Most program directors believe it important to formally hand off outpatients. Barriers to establishing handoff systems can be overcome with modest curricular and cultural changes.

The choice of alternatives to acute hospitalization: a descriptive study from Hallingdal, Norway

BACKGROUND

Hallingdal is a rural region in southern Norway. General practitioners (GPs) refer acutely somatically ill patients to any of three levels of care: municipal nursing homes, the regional community hospital or the local general hospital. The objective of this paper is to describe the patterns of referrals to the three different somatic emergency service levels in Hallingdal and to elucidate possible explanations for the differences in referrals.

METHODS

Quantitative methods were used to analyse local patient statistics and qualitative methods including focus group interviews were used to explore differences in referral rates between GPs. The acute somatic admissions from the six municipalities of Hallingdal were analysed for the two-year period 2010-11 (n = 1777). A focus group interview was held with the chief municipal medical officers of the six municipalities. The main outcome measure was the numbers of admissions to the three different levels of acute care in 2010-11. Reflections of the focus group members about the differences in admission patterns were also analysed.

RESULTS

Acute admissions at a level lower than the local general hospital ranged from 9% to 29% between the municipalities. Foremost among the local factors affecting the individual doctor's admission practice were the geographical distance to the different places of care and the GP's working experience in the local community.

CONCLUSION

The experience from Hallingdal demonstrates that GPs use available alternatives to hospitalization but to varying degrees. This can be explained by socio-demographic factors and factors related to the medical reasons for admission. However, there are also important local factors related to the individual GP and the structural preparedness for alternatives in the community.

[Research at regional hospitals in Denmark can be reinforced]

We examined the conditions for health research at regional hospitals in Denmark. The study was conducted as an interview-based case study containing interviews with key persons at the governing level as well as medical doctors at the operating level. The results showed that the settings and opportunities regarding health research vary between university hospitals and non-university regional hospitals. However our findings indicate, that focusing on a long-term strategy to implement health research in regional hospitals will enable these to be more active in health research.

Clinicians' experiences of becoming a clinical manager: a qualitative study

BACKGROUND

There has been an increased interest in recruiting health professionals with a clinical background to management positions in health care. We know little about the factors that influence individuals' decisions to engage in management. The aim of this study is to explore clinicians' journeys towards management positions in hospitals, in order to identify potential drivers and barriers to management recruitment and development.

METHODS

We did a qualitative study which included in-depth interviews with 30 clinicians in middle and first-line management positions in Norwegian hospitals. In addition, participant observation was conducted with 20 of the participants. The informants were recruited from medical and surgical departments, and most had professional backgrounds as medical doctors or nurses. Interviews were analyzed by systemic text condensation.

RESULTS

We found that there were three phases in clinicians' journey into management; the development of leadership awareness, taking on the manager role and the experience of entering management. Participants' experiences suggest that there are different journeys into management, in which both external and internal pressure emerged as a recurrent theme. They had not anticipated a career in clinical management, and experienced that they had been persuaded to take the position. Being thrown into the position, without being sufficiently prepared for the task, was a common experience among participants. Being left to themselves, they had to learn management "on the fly". Some were frustrated in their role due to increasing administrative workloads, without being able to delegate work effectively.

CONCLUSIONS

Path dependency and social pressure seems to influence clinicians' decisions to enter into management positions. Hospital organizations should formalize pathways into management, in order to identify, attract, and retain the most qualified talents. Top managers should make sure that necessary support functions are available locally, especially for early stage clinician managers.