Relationship Between Residents' Physiological Stress and Faculty Leadership Skills in a Department of Surgery

BACKGROUND

Leadership skills of team leaders can impact the functioning of their teams. It is unknown whether attending surgeons' leadership skills impact residents' physiological stress. This study sought to (1) assess the relationship between attending surgeons' leadership skills and residents' physiological stress and (2) to characterize lifestyle behaviors associated with resident physiological stress. We hypothesized that strong attending leadership skills would be associated with low resident physiological stress.

STUDY DESIGN

This prospective observational cohort study was conducted at a single urban, academic medical center in the US, over 12 months. Residents were enrolled during their rotation of 1 to 2 months on the Trauma and ICU services. The primary predictor was the attending surgeons' leadership skills that were measured using a weekly survey filled out by residents, using the Surgeons' Leadership Inventory (SLI). The SLI uses a 4-point Likert scale to measure surgeons' leadership skills across eight domains. The primary outcome was residents' physiological stress, which was measured by their Heart Rate Variability (HRV). We recorded the residents' HRV with a WHOOP strap that was continuously worn on the wrist or the bicep. We used multivariate repeated measures gamma regression to assess the relationship between attending leadership skills and residents' physiological stress, adjusting for hours of sleep, age, and service.

RESULTS

Sixteen residents were enrolled over 12 months. The median attending surgeons' leadership score was 3.8 (IQR: 3.2-4.0). The median residents' percent of maximal HRV was 70.8% (IQR: 56.7-83.7). Repeated measure gamma regression model demonstrated a minimal nonsignificant increase of 1.6 % (95% CI: -5.6, 8.9; p-value = 0.65) in the percent of maximal HRV (less resident physiological stress) for every unit increase in leadership score. There was an increase of 2.9% (95% CI= 1.6, 4.2; p-value < 0.001) in the percent of maximal HRV per hour increase in sleep and a significant decrease of 10.9% (95% CI= -16.8, -5.2; < 0.001) in the percent of HRV when working in the ICU compared to the Trauma service.

CONCLUSION

This study revealed that more residents' sleep was associated with lower physiological stress. Attending surgeons' leadership skills were not associated with residents' physiological stress.

Which learning experiences support an interprofessional identity? A scoping review

In recent years, health professions researchers have suggested that a dual identity that includes both a professional and interprofessional identity is essential to interprofessionality. This scoping review sought to describe the learning experiences that may support the development of an interprofessional identity, providing direction for future research. A scoping review was conducted to identify papers published between 2000 and 2020 that provided empiric evidence to support the impact of planned or spontaneous learning experiences involving two or more healthcare professions that fostered the development of an "interprofessional identity," or a sense of belonging to an interprofessional community. Twelve papers were identified for inclusion. Articles varied regarding both the professional groups studied and the developmental levels of their participants. A wide variety of learning experiences were described in the identified studies, including designed activities and programs, as well as those occurring spontaneously in authentic clinical environments. Examples of longitudinal and integrated programs were also identified. The construct of an interprofessional identity and its potential impact on interprofessional practice has yet to be sufficiently studied. The results of this scoping review suggest that a variety of experiences that occur throughout the professional development trajectory may foster an interprofessional identity. Longitudinal, integrated interprofessional learning programs may result in a more long-lasting impact on interprofessional identity and these types of programs should be the focus of future research.

Understanding Barriers and Facilitators to Behavior Change After Implementation of an Interdisciplinary Surgical Non-Technical Skills Training Program in Rwanda

OBJECTIVE

Nontechnical skills, such as situation awareness, decision making, leadership, communication, and teamwork play a crucial role on the quality of care and patient safety in the operating room (OR). In our previous work, we developed an interdisciplinary training program, based on the NOTSS (Non-Technical Skills for Surgeons) taxonomy. The aim of this study was to understand the challenges faced by Rwandan surgical providers, who had undergone NOTSS training, to apply these nontechnical skills during subsequent operative surgery.

SETTING DESIGN

A sequential exploratory mixed method study design was used to assess how participants who took the NOTSS in Rwanda applied nontechnical skills in surgical care delivery. The qualitative phase of this study deployed a constructivist grounded theory approach. Findings from the qualitative phase were used to build a quantitative survey tool that explored themes that emerged from the first phase.

PARTICIPANTS

Participants were nurses and resident from the departments of Surgery, Anesthesia, Obstetric, and Gynecology, from the University of Rwanda who attended the NOTSS course in March 2018.

RESULTS

A total of 25 participants and 49 participants were respectively enrolled in the qualitative phase and quantitative phase. Participants noted that nontechnical skills implementation in clinical practice was facilitated by working with other personnel also trained in NOTSS, anticipation, and preparation ahead of the time; while lack of interdisciplinary communication, hierarchy, work overload, and an inconsistently changing environment compromised nontechnical skills implementation. Nontechnical skills were useful both inside and outside the operating. Participants reported that nontechnical skills implementation resulted in improved team dynamics, safer patient care, and empowerment.

CONCLUSION

Surgical care providers who took the NOTSS course subsequently implemented nontechnical skills both inside and outside of the OR. Human and system-based factors affected the implementation of nontechnical skills in the clinical setting.

Assessing the hidden curriculum for the care of patients with limited english proficiency: An instrument development

BACKGROUND

Patients with limited English proficiency (LEP) are a growing population in the United States at risk for disparities in quality and safety of care. Medical student competency to care for patients with LEP is impacted by a hidden curriculum (HC) that undermines the learning experience; yet to date, there is no way to measure it. Thus, we designed an instrument to assess this HC.

METHODS

Based on findings from previous qualitative work and input from medical students and experts in LEP and psychometrics, we developed a 23-item survey with four domains. We e-mailed this to 3^rd and 4^th year students from two medical schools in the US. We conducted principal axis factoring to determine the instrument's construct validity. Only items with a factor loading ≥0.50 were retained.

RESULTS

We obtained 111 complete responses. Twenty-two of the 23 original items were retained. Four factors/components emerged, which did not support the original proposed domains. Three factors loaded on a mix of role modeling, and learning environment, structural, and organizational variables, while the fourth factor retained two role modeling items. Based on the factor extraction solution, we restructured the instrument into three domains: role modeling, demonstration of effective systems, and consequences of structural barriers for patients with LEP (Cronbach's alpha: 0.81-0.95, total variance accounted for 53.7%).

DISCUSSION

The results led us to reassess the domain structure to create an instrument representing students' perceptions and context. Our instrument, the LEP-HC, will allow medical educators to investigate a specific and important HC and improve teaching about care of patients with LEP.

Inhibitory presynaptic 5-hydroxytryptamine(2A) receptors regulate evoked glutamate release from rat cerebellar mossy fibers

We studied the pharmacological characterization of the 5-hydroxytryptamine(2) (5-HT(2)) heteroreceptor located on glutamatergic cerebellar mossy fiber nerve terminals. Depolarization-evoked overflow of endogenous glutamate from rat cerebellar "giant" mossy fiber synaptosomes was inhibited by 5-HT or (+/-)-1-(2,5-dimethoxy-4-iodophenyl)-2-aminopropane [(+/-)-DOI], exhibiting pD(2) (= -log EC(50)) values of 7.37 and 7.29, respectively. Trazodone inhibited the depolarization-evoked glutamate overflow, exhibiting lower potency (pD(2) = 6.42) and lower efficacy with respect to 5-HT or (+/-)-DOI (maximal inhibition, 54%, compared with 70% for either 5-HT or (+/-)-DOI). Ketanserin, a 5-HT(2A)/5-HT(2C) receptor antagonist, counteracted the inhibitory effect of (+/-)-DOI or trazodone. Inhibition of glutamate overflow by 5-HT, (+/-)-DOI, or trazodone was prevented by the selective 5-HT(2A) receptor antagonist R-(+)-alpha-(2,3-dimethyoxyphenyl)-1-(2-(4-fluorophenyl)ethyl)-4-piperidine-methanol (MDL 100907), while the potent and selective 5-HT(2C) receptor antagonist 6-chloro-5-methyl-1-[6-(methylpyridin-3-yloxy)pyridin-3yl-carbamoyl] indoline (SB 242084) was ineffective. In cerebellar slices, MDL 100907 increased on its own the K(+)-evoked release of glutamate. It is concluded that the evoked release of glutamate from cerebellar mossy fibers can be controlled by inhibitory presynaptic 5-HT(2A) heteroreceptors, the receptors can be activated by endogenously released 5-HT, and trazodone behaves as a partial agonist at these receptors.

Serotonin inhibition of the NMDA receptor/nitric oxide/cyclic GMP pathway in human neocortex slices: involvement of 5-HT(2C) and 5-HT(1A) receptors

The NMDA receptor/nitric oxide (NO)/cyclic GMP pathway and its modulation by 5-hydroxytryptamine (5-HT) was studied in slices of neocortical samples obtained from patients undergoing neurosurgery. The cyclic GMP elevation produced by 100 microM NMDA was blocked by 100 microM of the NO synthase inhibitor N(G)-nitro-L-arginine (L-NOARG) or by 10 microM of the soluble guanylate cyclase inhibitor 1H-[1,2,4]oxadiazolo[4,3,-alpha] quinoxaline-1-one (ODQ). The NMDA effect was prevented by 5-HT or by the 5-HT(2) agonist (+/-)-1-(2, 5-dimethoxy-4-iodophenyl)-2-aminopropane ((+/-)-DOI; EC(50)=22 nM). The (+/-)-DOI inhibition was insensitive to the 5-HT(2A) receptor antagonist MDL 100907 or the 5-HT(2B) antagonist rauwolscine; it was largely prevented by 1 microM of the non-selective 5-HT(2C) antagonists mesulergine (5-HT(2A,B,C)), ketanserin (5-HT(2A,C)) or SB 200646A (5-HT(2B,C)); it was completely abolished by 0.1 microM of the selective 5-HT(2C) receptor antagonist SB 242084. The NMDA-induced cyclic GMP elevation also was potently inhibited by the selective 5-HT(2C) agonist RO 60-0175 and by the antidepressant trazodone, both added at 1 microM, in an SB 242084-sensitive manner. Finally, the 5-HT(1A) agonist 8-hydroxy-2-(di-n-propylamino) tetralin (8-OH-DPAT; 1 microM) inhibited the NMDA-evoked cyclic GMP response, an effect blocked by the selective 5-HT(1A) receptor antagonist WAY 100635. In conclusion, the NMDA receptor/NO/cyclic GMP pathway in human neocortex slices can be potently inhibited by activation of 5-HT(2C) or 5-HT(1A) receptors.

Disodium chromium(III) hexamolybdoiodate(VII) 24-hydrate, Na2Cr[IMo6O24]·24H2O

The title compound can be formulated as [Cr(H(2)O)(6)][Na(2)(H(2)O)(10)][IMo(6)O(24)].8H(2)O. The anion has the I atom on an inversion centre and has close to $\overline 3$m symmetry, with I-O bond lengths in the range 1.881-1.890 (2) A and Mo-O bond lengths in the ranges 1.697 (3)-1.714 (3), 1.915 (2)-1.948 (2) and 2.317 (2)-2.357 (2) A.