Practical Guide to Qualitative Research in Surgical Education

This Guide to Statistics and Methods provides an overview of the selection and application of qualitative research in surgical education.

Defining Practice Readiness in Pediatric Surgery Fellowship: A Qualitative Analysis

INTRODUCTION

While competency-based training is at the forefront of educational innovation in General Surgery, Pediatric Surgery training programs should not wait for downstream changes. There is currently no consensus on what it means for a pediatric surgery fellow to be "practice-ready". In this study, we aimed to provide a framework for better defining competency and practice readiness in a way that can support the Milestones system and allow for improved assessment of pediatric surgery fellows.

METHODS

For this exploratory qualitative study, we developed an interview guide with nine questions focused on how faculty recognize competency and advance autonomy among pediatric surgery fellows. Demographic information was collected using an anonymous online survey platform. We iteratively reviewed data from each interview to ensure adequate information power was achieved to answer the research question. We used inductive reasoning and thematic analysis to determine appropriate codes. Additionally, the Dreyfus model was used as a framework to guide interpretation and contextualize the responses. Through this method, we generated common themes.

RESULTS

A total of 19 pediatric surgeons were interviewed. We identified four major themes from 127 codes that practicing pediatric surgeons associate with practice-readiness of a fellow: skill-based competency, the recognition and benefits of struggle, developing expertise and facilitating autonomy, and difficulties in variability of evaluation. While variability in evaluation is not typically included in the concept of practice readiness, assessment and evaluation were described by study participants as essential aspects of how practicing pediatric surgeons perceive practice readiness and competency in pediatric surgery fellows. Competency was further divided into interpersonal versus technical skills. Sub-themes within struggle included personal and professional struggle, benefits of struggle and how to identify and assist those who are struggling. Autonomy was commonly stated as variable based on the attending.

CONCLUSION

Our analysis yielded several themes associated with practice readiness of pediatric surgery fellows. We aim to further refine our list of themes using the Dreyfus Model as our interpretive framework and establish consensus amongst the community of pediatric surgeons in order to define competency and key elements that make a fellow practice-ready. Further work will then focus on establishing assessment metrics and educational interventions directed at achieving such key elements.

Faculty Entrustment and Resident Entrustability

Importance

As the surgical education paradigm transitions to entrustable professional activities, a better understanding of the factors associated with resident entrustability are needed. Previous work has demonstrated intraoperative faculty entrustment to be associated with resident entrustability. However, larger studies are needed to understand if this association is present across various surgical training programs.

Objective

To assess intraoperative faculty-resident behaviors and determine if faculty entrustment is associated with resident entrustability across 4 university-based surgical training programs.

Design, Setting, and Participants

This cross-sectional study was conducted at 4 university-based surgical training programs from October 2018 to May 2022. OpTrust, a validated tool designed to assess both intraoperative faculty entrustment and resident entrustability behaviors independently, was used to assess faculty-resident interactions. A total of 94 faculty and 129 residents were observed. Purposeful sampling was used to create variation in type of operation performed, case difficulty, faculty-resident pairings, faculty experience, and resident training level.

Main Outcomes and Measures

Observed resident entrustability scores (scale 1-4, with 4 indicating full entrustability) were compared with reported measures (faculty level, case difficulty, resident postgraduate year [PGY], resident gender, observation month) and observed faculty entrustment scores (scale 1-4, with 4 indicating full entrustment). Path analysis was used to explore direct and indirect effects of the predictors. Associations between resident entrustability and faculty entrustment scores were assessed by pairwise Pearson correlation coefficients.

Results

A total of 338 cases were observed. Cases observed were evenly distributed by faculty experience (1-5 years' experience: 67 [20.9%]; 6-14 years' experience: 186 [58%]; ≥15 years' experience: 67 [20.9%]), resident PGY (PGY 1: 28 [8%]; PGY 2: 74 [22%]; PGY 3: 64 [19%]; PGY 4: 40 [12%]; PGY 5: 97 [29%]; ≥PGY 6: 36 [11%]), and resident gender (female: 183 [54%]; male: 154 [46%]). At the univariate level, PGY (mean [SD] resident entrustability score range, 1.44 [0.46] for PGY 1 to 3.24 [0.65] for PGY 6; F = 38.92; P < .001) and faculty entrustment (2.55 [0.86]; R2 = 0.94; P < .001) were significantly associated with resident entrustablity. Path analysis demonstrated that faculty entrustment was associated with resident entrustability and that the association of PGY with resident entrustability was mediated by faculty entrustment at all 4 institutions.

Conclusions and Relevance

Faculty entrustment remained associated with resident entrustability across various surgical training programs. These findings suggest that efforts to develop faculty entrustment behaviors may enhance intraoperative teaching and resident progression by promoting resident entrustability.

Differential Electronic Survey Response: Does Survey Fatigue Affect Everyone Equally?

INTRODUCTION

Survey fatigue, a phenomenon where respondents lose interest or lack motivation to complete surveys, can undermine rigorously designed studies. Research during the COVID-19 pandemic capitalized on electronic surveys for maximum distribution, but with lower response rates. Additionally, it is unclear how survey fatigue affects surgical education stakeholders. This study aims to determine how response rates to an electronic survey, as a proxy for survey fatigue, differ among medical students (MS), surgery residents, and surgery faculty.

METHODS

Electronic surveys evaluating the surgical clerkship educational environment were distributed to third year MS, residents, and faculty at three academic institutions. Two reminder emails were sent. Groups with low response rates (<30%) received additional prompting. Response rates were compared using a chi-square test. Demographics of all survey respondents were collected and discussed. Baseline characteristics of the MS class, residency program, and Department of Surgery faculty from one institution were gathered and compared to respondents.

RESULTS

Surveys were sent to 283 third year MS, 190 surgery residents, and 374 surgical faculty. Response rates were 43%, 27%, and 20%, respectively (P < 0.0001). Male respondents, respondents of color, midlevel residents, and assistant professors had lower response rates compared to the baseline cohort.

CONCLUSIONS

Our results demonstrate a statistically significant difference in survey response rates among MS, residents, and faculty, and have identified various targets for further investigation. Loss of interest in these groups should be further evaluated with a goal of decreasing survey fatigue, increasing survey response rates, and improving the quality of survey data collected.

Medical students' perception of their 'distance travelled' in medical school applications

INTRODUCTION

Within medical school's holistic review of applicants includes a review of their distance travelled to get to this point in their education. The AAMC defines distance travelled (DT) as, 'any obstacles or hardships you've overcome to get to this point in your education or any life challenges you've faced and conquered'. What medical students consider as their distance travelled has not been explored. The authors sought to identify the factors medical students perceive are important for medical school admissions to consider when assessing someone's 'distance travelled' by asking current medical students to share their DT experiences along with the barriers and facilitators they encountered on their medical school journey.

METHODS

The authors conducted semi-structured interviews with US medical students through purposeful sampling methods. The social-ecological model framework was used to develop questions to elicit participants' experiences that contributed to their distance travelled. Interviews were conducted in 2021 and ranged from 60-75 minutes. Transcribed interviews were qualitatively analysed using interpretive description.

RESULTS

A total of 31 medical students from seven medical schools were included in the study. Overall, participants defined distance travelled as an applicant's hardships (e.g. being the primary caregiver for a family member) and privileges (e.g. having physician parents) they experienced. Three major themes were identified: (1) individual-level characteristics and factors, (2) interpersonal relationships and (3) aspects of the participants' community and society.

DISCUSSION

Our findings show that medical school applicants considered DT to be a valuable component of a holistic medical school admission process. Participants' experiences of DT were varied and complex. Our research suggests that admissions teams for medical schools should incorporate more comprehensive recruitment practices and inclusive methodological frameworks to accurately capture the diversity of identities and experiences of medical school applicants and to consider the factors that shape their journey to medical schools.

Faculty perception of resident promotion and prevention associated behaviors in the operating room to facilitate intra-operative learning

BACKGROUND

Previous work has demonstrated that residents are able to accurately perceive the intraoperative motivational style of faculty. Additionally, alignment of motivational style between residents and faculty has been demonstrated to enhance resident intraoperative autonomy. This study evaluated if faculty perception of resident behaviors aligned with resident self-perception in order to identify ways of enhancing intraoperative learning.

METHODS

General surgery residents were asked to complete a self-assessment evaluating their own intraoperative behaviors. Conversely, faculty rated how strongly the residents exhibited these behaviors in the operating room.

RESULTS

Of the 10 intraoperative behaviors that were evaluated, eight demonstrated no correlation between resident self-perception and faculty perception of resident behavior. Similarly, inconsistent correlations emerged when behaviors were assessed according to the self-reported gender and race of the resident.

CONCLUSION

Faculty are not able to accurately perceive the motivational style of residents. Strategies to improve faculty perception of resident motivational style may enhance intraoperative learning.

Sources of Joy in Medical Educators as Described by the PERMA Model

Phenomenon: Burnout is prevalent amongst long-practicing physicians. For medical educators, it has deleterious effects not only on the educator themselves, but also the students they are teaching. Though significant research has focused on factors associated with burnout, there is limited understanding of its counter: how physicians, particularly medical educators, derive joy from their work. Approach: This qualitative study included 15 highly-rated clinician educators in Internal Medicine who took part in individual semi-structured interviews. Participants were invited to discuss their sources of professional joy. After transcription, we used thematic content analysis: 50 themes were identified. Themes were then coded using the domains of the PERMA (Positive Emotion, Engagement, Relationships, Meaning, and Accomplishment) model of positive psychology, assigning each theme a best fit domain. Forty-five themes were mapped into the PERMA model. Findings: When describing professional joy, highly-rated clinician educators displayed high levels of overlap with all domains of the PERMA model. Interaction with the learner was a prominent source of professional joy, particularly within Positive Emotion, Engagement, and Relationship domains. Insights: Our findings indicate that the PERMA model appropriately defines the sources of professional joy for these educators. Future research could employ this model to identify targets for interventions aimed at amplifying joy at work for this group.

Entrustment decision-making in genetic counseling supervision: Exploring supervisor and student perspectives to enhance training practices

Entrustment decisions are an essential part of genetic counseling supervision and have the potential to influence a student's progression toward autonomy. However, there is often uncertainty among supervisors regarding how and when to make these decisions and very few studies have examined the impact of these decisions on students. This study utilized a mixed methods approach including surveys of genetic counseling supervisors (n = 76) and students (n = 86) as well as qualitative interviews with genetic counseling supervisors (n = 20) and students (n = 20) that explored factors that influence the entrustment decisions of genetic counseling supervisors and their effect on genetic counseling students. Genetic counseling supervisors and students were recruited from various organizations across the United States and Canada and represented a range of geographic regions, hospital systems, and genetic counseling programs. A hybrid process of deductive and inductive coding and thematic analysis was used to evaluate and interpret transcripts from the supervisor and student interviews. All participants identified advantages of increased autonomy during training. However, many supervisors reported low entrustment, seldom allowing students to complete unsupervised sessions or supervised cases without interruption. Entrustment decisions were heavily influenced by student ability and confidence, as well as patient feedback. Students emphasized the negative impact of decreased entrustment on their confidence and described clear benefits to increased autonomy before, during, and after the genetic counseling appointment. Supervisors identified various barriers to entrustment pertaining to the student, clinical setting, and the patient, whereas students more often emphasized barriers pertaining to themselves. Our results highlight a tension between the clear advantages of increased entrustment and autonomy and various barriers to the provision of these opportunities. Additionally, our data suggest several ways to enhance the supervisor-student relationship and promote additional learning opportunities to support student-centered supervision.

"You've Got Gratitude!"- A Multispecialty and Multi-institution Program Encouraging Expressions of Gratitude

OBJECTIVE

Efforts to improve physician well-being have focused on gratitude, which predicts health and happiness. Despite reported benefits, expressions of gratitude in healthcare can seem infrequent. Here, we describe Gratitude-Grams, an intervention to cultivate expressions of gratitude throughout a department.

METHODS/APPROACH

Piloted in our Department of Surgery and adopted by others, Gratitude-Grams employs a web-based platform (Qualtrics). Program feedback was solicited during teaching conferences using an anonymous department survey.

RESULTS

Gratitude-Grams streamlines and encourages expressions of gratitude while minimizing maintenance, cost, and time. The platform has been highly utilized and well-received in our Department of Surgery.

CONCLUSION

Expressing and receiving gratitude has been shown to be critical for well-being. Gratitude-Grams is a highly utilized, simple, and attainable system to support expressions of gratitude and is ready for rapid implementation.

"I Came up Short on the Academic Ladder": A Grounded Theory Study of Careerism in Academic Surgery

OBJECTIVE

This study aims to explore the definition of career success in academic surgery.

BACKGROUND

Career success in academic surgery is frequently defined as the achievement of a specific title, from full professor to department chair. This type of definition is convenient and established but potentially incomplete. The business literature has a more nuanced view of the relationship between titles and success, but this relationship has not been studied in medicine.

METHODS

Semi-structured interviews were conducted from May to November 2020. Data were analyzed in an iterative fashion using grounded theory methodology to develop a conceptual model.

RESULTS

We conducted 26 semi-structured interviews with practicing surgeons differing in years of experience; 12 (46%) participants were female, mean age of 48. Participants included 5 chairs of surgery, 6 division chiefs, and 7 past or current presidents of national societies. Four themes emerged on the importance of titles: Some study participants reported that (1) titles are a barometer of success; others argued that (2) titles are not a sufficient metric to define success; (3) titles are a means to an end; and (4) there is a desire to achieve the title of a respected mentor.

CONCLUSIONS

As the definition of career success in academic surgery changes to encompass a broader range of interests and ambitions, the traditional markers of success must come into review. Academic surgeons see the value of titles as a marker of success and as a means to achieving other goals, but overwhelmingly our interviewees felt that titles were a double-edged sword and that a more inclusive definition of academic success was needed.

Implementation of a Smartphone-Based Platform for Operative Feedback at Tenwek Hospital in Kenya: A Mixed Methods Study

BACKGROUND

The SIMPL operative feedback tool is used in many U.S. surgical residency programs. However, the challenges of implementation and benefits of the web-based platform in low- and middle-income countries are unknown. The aim of this study was to evaluate implementation of SIMPL in a general surgery residency training program in Kenya.

METHODS

SIMPL was pilot tested at Tenwek Hospital from January through December 2021. Participant perspectives of SIMPL were elicited through a survey and semi-structured interviews. Descriptive statistics were used to analyze survey data. Inductive qualitative content analysis of interview responses was performed by two independent researchers.

RESULTS

Fourteen residents and six faculty (100% response rate) were included in the study and completed over 600 operative assessments. All respondents reported numerical evaluations and dictated feedback were useful. Respondents felt that SIMPL was easy to use, improved quality and frequency of feedback, helped refine surgical skills, and increased resident autonomy. Barriers to use included participants forgetting to complete evaluations, junior residents not submitting evaluations when minimally involved in cases, and technological challenges. Suggestions for improvement included expansion of SIMPL to surgical subspecialties and allowing senior residents to provide feedback to juniors. All respondents wanted to continue using SIMPL, and 90% recommended use at other programs.

CONCLUSION

Residents and faculty at Tenwek Hospital believed SIMPL were a positive addition to their training program. There were a few barriers to use and suggestions for improvement specific to the training environment in Kenya, but this study demonstrates it is feasible to use SIMPL in settings outside the U.S. with the appropriate resources.

The Demands of Surgery Residency: More Than Just Duty Hours?

INTRODUCTION

Efforts to improve surgical resident well-being could be accelerated with an improved understanding of resident job demands and resources. In this study, we sought to obtain a clearer picture of surgery resident job demands by assessing how residents distribute their time both inside and outside of the hospital. Furthermore, we aimed to elucidate residents' perceptions about current duty hour regulations.

METHODS

A cross-sectional survey was sent to 1098 surgical residents at 27 US programs. Responses regarding work hours, demographics, well-being (utilizing the physician well-being index), and perceptions of duty hours in relation to education and rest, were collected. Data were evaluated using descriptive statistics and content analysis.

RESULTS

A total of 163 residents (14.8% response rate) were included in the study. Residents reported a median total patient care hours per week of 78.0 h. Trainees spent 12.5 h on other professional activities. Greater than 40% of residents were "at risk" for depression and suicide based on physician well-being index scores. Four major themes associated with education and rest were identified: 1) duty hour definitions and reporting mechanisms do not completely reflect the amount of work residents perform, 2) quality patient care and educational opportunities do not fit neatly within the duty hour framework, 3) resident perceptions of duty hours are impacted the educational environment, and 4) long work hours and lack of adequate rest negatively affect well-being.

CONCLUSIONS

The breadth and depth of trainee job demands are not accurately captured by current duty hour reporting mechanisms, and residents do not believe that their current work hours allow for adequate rest or even completion of other clinical or academic tasks outside of the hospital. Many residents are unwell. Duty hour policies and resident well-being may be improved with a more holistic accounting of resident job demands and greater attention to the resources that residents have to offset those demands.

Attributions and perpetrators of incivility in academic surgery

Purpose

Although incivility has been described in other specialties, little is known about the attributes and perpetrators of it in academic surgery. The goal of this study was to identify attributes and commonly associated perpetrators of incivility experienced by trainees and faculty at academic surgery programs in the U.S.

Methods

A web-based survey including the Workplace Incivility Scale (WIS) and questions regarding attributions and perpetrators of incivility was sent to trainees and faculty at academic institutions across the U.S. In addition to descriptive statistics, multivariable regression models were built to determine the impact of perpetrator type and number on overall incivility scores.

Results

We received 367 of 2,661 (13.8%) responses. Top three reasons for incivility were surgery hierarchy (50.1%), respondent's gender (33.8%) and intergenerational differences (28.1%). Faculty (58.6%), patients (36.8%), and nursing staff (31.9%) were the most reported parties responsible for incivility. Female surgeons reported experiencing incivility more frequently from all three top responsible parties (i.e., faculty, patients, and nurses) when compared to other gender identities. Additionally, those who reported faculty (β = 0.61, 95%CI 0.39-0.82) or nurses (β = 0.23, 95%CI 0.009-0.45) as perpetrators of incivility reported an increase in overall incivility scores.

Conclusions

Incivility in surgery is frequently attributed to surgery hierarchy, gender, and intergenerational differences. Surgical trainees and faculty reported that faculty, patients, and nurses were the most commonly identified as responsible for uncivil events in the surgical workforce. Exposure to a greater variety of perpetrators of incivility increases overall levels of incivility, emphasizing the importance of eliminating incivility from all sources.

Supplementary Information

The online version contains supplementary material available at 10.1007/s44186-023-00129-1.

Incivility, Work Withdrawal, and Organizational Commitment Among US Surgeons

OBJECTIVE

To evaluate the prevalence of incivility among trainees and faculty in cardiothoracic surgery, general surgery, plastic surgery, and vascular surgery in the U.S, and to determine the association of incivility on job and work withdrawal and organizational commitment.

BACKGROUND

Workplace incivility has not been described in surgery and can negatively impact the well-being of individuals, teams, and organizations at-large.

METHODS

Using a cross-sectional, web-based survey study of trainees and faculty across 16 academic institutions in the U.S., we evaluated the prevalence of incivility and its association with work withdrawal and organizational commitment.

RESULTS

There were 486 (18.3%) partial responses, and 367 (13.8%) complete responses from surgeons [including 183 (56.1%) faculty and 143 (43.9%) residents or fellows]. Of all respondents, 92.2% reported experiencing at least 1 form of incivility over the past year. Females reported significantly more incivility than males (2.4 ± 0.91 versus 2.05 ± 0.91, P < 0.001). Asian Americans reported more incivility than individuals of other races and ethnicities (2.43 ± 0.93, P = 0.003). After controlling for sex, position, race, and specialty, incivility was strongly associated with work withdrawal (β = 0.504, 95% CI: 0.341-0.666). There was a significant interaction between incivility and organizational commitment, such that highly committed individuals had an even greater impact of incivility on the outcome of job and work withdrawal (β = 0.178, 95% CI: 0.153-0.203).

CONCLUSIONS

Incivility is widespread in academic surgery and is strongly associated with work withdrawal. Leaders must invest in strategies to eliminate incivility to ensure the well-being of all individuals, teams, and organizations at-large.

The Michigan Action Progress System (MAPS): Enhancing a Culture of Professionalism, Accountability, and Psychological Safety

OBJECTIVE

To prioritize trainee well-being, promote professionalism, and allow individuals to raise concerns without fear of retribution, one surgical department created an innovative process by which individuals can raise concerns and obtain subsequent support.

DESIGN AND SETTING

The University of Michigan Department of Surgery implemented the Michigan Action Progress System (MAPS) in February 2021.

PARTICIPANTS

General Surgery residents, faculty, and staff voluntarily participate in MAPS.

RESULTS

Since implementation, there have been 26 entries into MAPS. Petitioners included students (10, 38%), residents and fellows (7, 27%), staff (1, 4%), faculty (1, 4%), and anonymous petitioners (7, 27%). Concerns regarding racism (1, 4%), bullying (11, 52%), gender discrimination (1, 4%), and other incidents (8, 38%) were addressed though MAPS.

CONCLUSIONS

We have successfully implemented an innovative system that focuses on the needs of the user, consolidates handling of concerns, and emphasizes transparency, documentation, education, and improvement to promote a culture of professionalism and accountability.

How Program Directors Understand General Surgery Resident Wellness

OBJECTIVE

Burnout among general surgery residents is prevalent. Guidance on how program directors (PDs) can effectively intervene on general surgery resident wellness is lacking. In this study, we explore how PDs learn about burnout among their residents and support their well-being.

DESIGN

Semi-structured interviews were conducted with PDs. Interviews were transcribed and coded by study team dyads who utilized an inductive coding approach, and then reconciled via consensus. Interpretive description was the qualitative analytical method.

SETTING

Program tours to 15 general surgery programs during the exploratory phase of the SECOND Trial.

PARTICIPANTS

Fifteen general surgery PDs.

RESULTS

PDs identified the utility of contextual information in understanding resident wellness and implementing program-specific resident wellness initiatives. Three themes relating to PD awareness of resident burnout and well-being were identified: (1) PDs used conventional and novel methods to collect data from multiple information sources, including residents, faculty, staff, institutional representatives, and anonymous parties. (2) These contextualized data inspired the development of responsive strategies to effect programmatic changes that improved education and wellness. (3) Barriers to acquiring and utilizing information exist, requiring careful analysis, creative problem solving, as well as persistence and dedication to resident wellness.

CONCLUSIONS

Qualitative analysis of general surgery residency PDs yielded insightful knowledge about gathering and responding to information to support resident wellness, including successful strategies and areas of caution. The experience of these PDs can guide others in evaluating their wellness goals and initiatives for their own residents.

The utilization of educational resources published by the Thoracic Surgery Residents Association

OBJECTIVE

The Thoracic Surgery Residents Association (TSRA) is a trainee-led cardiothoracic surgery organization in North America that has published a multitude of educational resources. However, the utilization of these resources remains unknown.

METHODS

Surveys were constructed, pilot-tested, and emailed to 527 current cardiothoracic trainees (12 questions) and 780 former trainees who graduated between 2012 and 2019 (16 questions). The surveys assessed the utilization of TSRA educational resources in preparing for clinical practice as well as in-training and American Board of Thoracic Surgery (ABTS) certification examinations.

RESULTS

A total of 143 (27%) current trainees and 180 (23%) recent graduates responded. A higher proportion of recent graduates compared with current trainees identified as male (84% vs 66%; P = .001) and graduated from 2- or 3-year traditional training programs (81% vs 41%; P < .001), compared with integrated 6-year (8% vs 49%; P < .001) or 4 + 3 (11% vs 10%; P = .82) pathways. Current trainees most commonly used TSRA resources to prepare for the in-training exam (75%) and operations (73%). Recent graduates most commonly used them to prepare for Oral and/or Written Board Exams (92%) and the in-training exam (89%). Among recent graduates who passed the ABTS Oral Board Exam on the first attempt, 82% (97/118) used TSRA resources to prepare, versus only 48% (25/52) of recent graduates who passed after multiple attempts, failed, have not taken the exam, or preferred not to answer (P < .001).

CONCLUSIONS

Current cardiothoracic trainees and recent graduates have utilized TSRA educational resources extensively, including to prepare for in-training and ABTS Board examinations.

How We Do It: An Innovative General Surgery Mentoring Program

OBJECTIVE

The taxing nature of surgery residency is well-documented in the literature, with residents demonstrating high rates of burnout, depression, suicidal thoughts, sexual harassment, and racial discrimination. Mentoring has been shown to improve camaraderie, address challenges of underrepresentation in medicine, and be associated with lower burnout. However, existing formal mentoring programs tend to be career-focused and hierarchal without opportunity to discuss important sociocultural issues. An innovative approach is needed to address these cultural and anthropological issues in surgery residencies while creating camaraderie and learning alternative perspectives across different levels of training. We sought to describe the framework we used to fill these needs by creating and implementing a novel mentoring program.

DESIGN

A vertical, near-peer mentoring system of 7 groups was created consisting of the following members: 1 to 2 medical students, a PGY-1 general surgery resident, a PGY-4 research resident, and a faculty member. Meetings occur every 3 to 4 months in a casual setting with the first half of the meeting dedicated to intentional reflection and the second half focused on an evidence-based discussion regarding a specific topic in the context of surgery (i.e., burnout, discrimination, allyship, and finding purpose).

SETTING

Program implementation took place at the University of Michigan in Ann Arbor, MI.

PARTICIPANTS

Medical students, general surgery residents, and general surgery faculty were recruited.

CONCLUSIONS

We have successfully launched the pilot year of a cross-spectrum formal mentoring program in general surgery. This program emphasizes camaraderie throughout training while providing opportunities for evidence-based discussion regarding sociocultural topics. We have included increased opportunities for community inclusivity and mentoring while allowing trainees and faculty members to discuss sensitive topics in a supportive environment. We plan to continue developing the program with robust evaluation and to expand the program to other surgical specialties and to other institutions.

"Why would you want to do that?"Surgical Interns Reflect on Discouragement From Entering Surgical Fields

INTRODUCTION

Decreasing numbers of medical students are choosing to pursue surgical careers. This study highlights individual experiences of surgical interns receiving discouragement from pursuing surgery as a career.

METHODS

We interviewed 24 incoming surgical interns from 7 institutions and 7 surgical subspecialties about their experiences with discouragement from surgery.

RESULTS

All surgical interns discussed experiencing discouragement from pursuing surgery as a career. Family, friends, the general public, and medical professionals, including surgeons, served as sources of discouragement. Reasons for discouragement fell into 3 main themes: The Surgeon and Surgical Culture, The Sacrifices, and The Sexism. Despite its pervasiveness, participants reconciled the discouragement received.

DISCUSSION

Discouragement from surgery is pervasive and centered around surgeon stereotypes and perceptions of surgical culture, significant personal sacrifices required, and traditional gender-related expectations. These results highlight the importance of individual surgeons' comments on student experience and can be used to improve the perception of surgery amongst prospective interns.

Gender Microaggressions During Virtual Residency Interviews and Impact on Ranking of Programs During the Residency Match

BACKGROUND

Microaggressions are one form of gender bias contributing to gender disparities and mistreatment, but their prevalence during virtual residency interviews has not been explored.

OBJECTIVE

To explore applicants' recall of experiencing gender microaggressions during virtual residency interviews and whether these experiences affected programs' rank position on applicants' rank lists.

METHODS

Fourth-year medical students at a single institution who participated in the 2021 Match were surveyed after submitting their rank lists. Students were surveyed categorically on (1) their recall of the frequency they experienced 17 gender microaggressions during interviews, and (2) how these affected reported ranking of programs on their rank lists.

RESULTS

Sixty-one percent (103 of 170) of eligible students responded to the survey. Seventy-two percent (36 of 50) of women experienced at least one microaggression compared to 30% (9 of 30) of men. The largest difference was in the experience of environmental microaggressions, which are demeaning cues communicated individually or institutionally, delivered visually, or that refer to climate (P<.001). Women experienced more microaggressions than men in nonsurgical (P=.003) and surgical specialties excluding obstetrics and gynecology (P=.009). When microaggressions were experienced at 1 to 2 programs, 36% of applicants (26 of 73) reported significantly lowering program ranking, compared to 5% (1 of 19) when microaggressions occurred at more than 5 programs (P=.038).

CONCLUSIONS

Women applicants experience more microaggressions than men do during nonsurgical and male-dominated surgical specialty residency interviews. Respondents who recalled experiencing microaggressions at fewer programs were more likely to report significantly lowering the rank of those programs compared to those who experienced them at more programs.

Racial and socioeconomic inequity in the financial stress of medical school

Background: The authors analyzed the distribution of medical student debt and identified demographic features that placed students at high risk for increased debt and financial stress.

Methods: From April to May 2019, a cross-sectional, anonymous, web-based survey was administered to first-year (M1) to fourth-year (M4) medical students at the University of Michigan to assess financial literacy, debt burden, financial stress, and demographic factors. A total of 216 of 680 (32%) students completed the survey. Respondents voluntarily answered 15 multiple-choice questions on personal finance and 30 questions on their demographics, current financial situation, and debt burden. To quantify debt burden, students estimated anticipated education-related debt in one of four categories: no debt, $1–99,999; $100,000–$199,999; and $200,000 or more. A chi-square test was used to identify associations between categorical variables and logistic regression was used to identify risk factors for debt and worry.

Results: Fifty-four respondents (25%) reported $0 in education related debt, while 44 (16%) had $200,000 or more. Race (p=0.006), first-generation college student status (p=0.004), first-generation medical student status (p<0.001), household income (p<0.001), and parental education (p=0.008) were associated with higher levels of debt. Students who were underrepresented in medicine (URiM) had higher odds of higher debt compared to Arab and Asian students (p=0.02). URiM students (p=0.02), first-generation college students (p=0.009), and parental education (p=0.01) were associated with increased financial stress. Additionally, female students had higher odds of increased financial stress (OR=1.85, p=0.045) on logistic regression.

Conclusions: URiM and socioeconomically disadvantaged students feel the burden of the high cost of medical school disproportionately more, suggesting that our current systems are not adequately supporting these students. Reducing this burden may serve to further promote diversity in medicine.

Identifying Strategies for Struggling Surgery Residents

BACKGROUND

Struggling residents are not uncommon in general surgery. Early identification of these residents and effective remediation remain imperfect.

MATERIALS AND METHODS

We performed a survey of program directors (PD) across all general surgery residencies. Survey questions included the following: demographic information about the program and PD, 10 vignettes about hypothetical residents struggling in various ACGME milestones to assess how PDs would address these deficiencies, and self-reported PD preparedness and availability of resources to support struggling residents.

RESULTS

In total, we received 82 responses to our survey. All PDs who participated in our study reported having struggling residents in their program. The three most common ways struggling residents are identified were faculty word-of-mouth, formal evaluations such as milestones and ABSITE performance, and resident word-of-mouth. Over 18% of PDs reported having little to no relevant training in addressing the needs of a struggling resident, and 65.9% of PDs did not feel that their program had 'completely adequate' resources to address these needs. In the majority of cases, PDs offer mentorship with themselves or other faculty as a remediation strategy with infrequent use of other resources.

CONCLUSIONS

Strategies to identify struggling residents and remediation strategies varied widely across programs. Diversifying remediation approaches should be considered for more effective remediation.

TrustEd: A Tool for Developing Intraoperative Entrustment Skills

OBJECTIVE

Toolkits to assess progressive resident autonomy are integral to the movement toward competency-based surgical education. OpTrust is one such tool validated for intraoperative assessment of both faculty and resident entrustment behaviors. We developed a supplementary tool to OpTrust that would aid faculty and residents in making meaningful improvements in entrustment behavior by providing talking points and reflection items tailored to different motivational styles as defined by Regulatory Focus Theory (RFT).

DESIGN

Existing literature about surgical entrustment was used to build a list of sample dialogue and self-reflection items to use in the operating room. This list was distributed as a survey to individuals familiar with OpTrust and RFT, asking them to categorize each item as Promotion-oriented, Prevention-oriented, or Either. The respondents then met to discuss survey items that did not reach a consensus until the group agreed on their categorization.

SETTING

University of Wisconsin, School of Medicine and Public Health, Madison, Wisconsin Michigan Medicine, Ann Arbor, Michigan PARTICIPANTS: Clinician and education researchers familiar with intraoperative entrustment and RFT RESULTS: Eight respondents completed the survey categorizing the talking points and reflection items by RFT (100% response rate). Six of these respondents attended the additional meeting to discuss discordant items. The input from this panel was used to develop "TrustEd," the supplementary tool that faculty and residents can quickly reference before beginning a case.

CONCLUSION

Although tools such as OpTrust allow intraoperative entrustment behaviors to be quantified, TrustEd offers concrete strategies for faculty and residents who are interested in improving those behaviors over time. Further study is needed to assess whether the use of TrustEd does in fact lead to durable behavior change and improvement in OpTrust scores.

Assessing changes in the quality of quantitative health educations research: a perspective from communities of practice

BACKGROUND

As a community of practice (CoP), medical education depends on its research literature to communicate new knowledge, examine alternative perspectives, and share methodological innovations. As a key route of communication, the medical education CoP must be concerned about the rigor and validity of its research literature, but prior studies have suggested the need to improve medical education research quality. Of concern in the present study is the question of how responsive the medical education research literature is to changes in the CoP. We examine the nature and extent of changes in the quality of medical education research over a decade, using a widely cited study of research quality in the medical education research literature as a benchmark to compare more recent quality indicators.

METHODS

A bibliometric analysis was conducted to examine the methodologic quality of quantitative medical education research studies published in 13 selected journals from September 2013 to December 2014. Quality scores were calculated for 482 medical education studies using a 10-item Medical Education Research Study Quality Instrument (MERSQI) that has demonstrated strong validity evidence. These data were compared with data from the original study for the same journals in the period September 2002 to December 2003. Eleven investigators representing 6 academic medical centers reviewed and scored the research studies that met inclusion and exclusion criteria. Primary outcome measures include MERSQI quality indicators for 6 domains: study design, sampling, type of data, validity, data analysis, and outcomes.

RESULTS

There were statistically significant improvements in four sub-domain measures: study design, type of data, validity and outcomes. There were no changes in sampling quality or the appropriateness of data analysis methods. There was a small but significant increase in the use of patient outcomes in these studies.

CONCLUSIONS

Overall, we judge this as equivocal evidence for the responsiveness of the research literature to changes in the medical education CoP. This study identified areas of strength as well as opportunities for continued development of medical education research.

Overcoming COVID-19: Strategies to Mitigate the Perpetuated Gender Achievement Gap

Sex inequity in academic achievement was well documented before the COVID-19 pandemic, and evolving data suggest that women in academic surgery are disproportionately disadvantaged by the pandemic. This perspective piece reviews currently accepted solutions to the sex achievement gap, with their associated shortcomings. We also propose innovative strategies to overcoming barriers to sex equity in academic medicine that broadly fall into three categories: strategies to mitigate inequitable caregiving responsibilities, strategies to reduce cognitive load, and strategies to value uncompensated, impactful work. These approaches address inequities at the system-level, as opposed to the individual-level, lifting the burden of changing the system from women.

Resident Perceptions of Faculty Behaviors Promoting Learner Operative Skills and Autonomy

OBJECTIVE

To better understand the resident perceived faculty factors associated with the promotion of resident operative skill and autonomy DESIGN: Qualitative retrospective analysis utilizing anonymous open-ended comments from residents on department of surgery faculty teaching evaluations and cross references them to observed faculty entrustment scores SETTING: Single tertiary midwestern allopathic academic medical center using data obtained between January 2016-August 2019 PARTICIPANTS: Forty-six resident and fourteen faculty surgeons from general, plastic, thoracic, and vascular surgery sections.

RESULTS

Themes of personal traits, the working environment created, and teaching techniques employed were identified across resident promoting attendings and resident limiting attendings. Promoting attendings employed preoperative goal setting, increased operative autonomy, and postoperative feedback while creating environments conducive to learning by promoting teamwork and collaboration. Alternatively, limiting attendings used more ineffective teaching techniques including micromanaging, lack of delegation, and treating residents as observers. Additionally, trainees described these operating room environments as stressful and strained.

CONCLUSIONS

Qualitative analysis of resident teaching evaluations of attending surgeons highlights the importance of relationships between learner and teacher, the learning environment, and teaching techniques. Continuous professional development programs centered on entrustment and promoting behaviors have the potential to disseminate strategies to enhance educator skills among surgeons.

Increased Intraoperative Faculty Entrustment and Resident Entrustability Does Not Compromise Patient Outcomes After General Surgery Procedures

BACKGROUND

Intraoperative resident autonomy has been compromised secondary to expectations for increased supervision without defined parameters for safe progressive independence, diffusion of training experience, and more to learn with less time. Surgical residents who are insufficiently entrusted during training attain less autonomy, confidence, and even clinical competency, potentially affecting future patient outcomes.

OBJECTIVE

To determine if OpTrust, an educational intervention for increasing intraoperative faculty entrustment and resident entrustability, negatively impacts patient outcomes after general surgery procedures.

METHODS

Surgical faculty and residents received OpTrust training and instruction to promote intraoperative faculty entrustment and resident entrustability. A post-intervention OpTrust cohort was compared to historical and pre-intervention OpTrust cohorts. Multivariable logistic and negative binomial regression was used to evaluate the impact of the OpTrust intervention and time on patient outcomes.

SETTING

Single tertiary academic center.

PARTICIPANTS

General surgery faculty and residents.

MAIN OUTCOMES AND MEASURES

Thirty-day postoperative outcomes, including mortality, any complication, reoperation, readmission, and length of stay.

RESULTS

A total of 8890 surgical procedures were included. After risk adjustment, overall patient outcomes were similar. Multivariable regression estimating the effect of the OpTrust intervention and time revealed similar patient outcomes with no increased risk (P > 0.05) of mortality {odds ratio (OR), 2.23 [95% confidence interval (CI), 0.87-5.6]}, any complication [OR, 0.98 (95% CI, 0.76-1.3)], reoperation [OR, 0.65 (95% CI, 0.42-1.0)], readmission [OR, 0.82 (95% CI, 0.57-1.2)], and length of stay [OR, 0.99 (95% CI, 0.86-1.1)] compared to the historic and pre-intervention OpTrust cohorts.

CONCLUSIONS

OpTrust, an educational intervention to increase faculty entrustment and resident entrustability, does not compromise postoperative patient outcomes. Integrating faculty and resident development to further enhance entrustment and entrustability through OpTrust may help facilitate increased resident autonomy within the safety net of surgical training without negatively impacting clinical outcomes.

Racial and socioeconomic inequalities in the financial stress of medical school

Background: The authors analyzed the distribution of medical student debt and identified demographic features that placed students at high risk for increased debt and financial stress. Methods: From April to May 2019, a cross-sectional, anonymous, web-based survey was administered to first-year (M1) to fourth-year (M4) medical students at the University of Michigan to assess financial literacy, debt burden, financial stress, and demographic factors. A total of 216 of 680 (32%) students completed the survey. Respondents voluntarily answered 15 multiple-choice questions on personal finance and 30 questions on their demographics, current financial situation, and debt burden. To quantify debt burden, students estimated anticipated education-related debt in one of four categories: no debt, $1–99,999; $100,000–$199,999; and $200,000 or more. A chi-square test was used to identify associations between categorical variables and logistic regression was used to identify risk factors for debt and worry. Results: Fifty-four respondents (25%) reported $0 in education related debt, while 44 (16%) had $200,000 or more. Race (p=0.006), first-generation college student status (p=0.004), first-generation medical student status (p<0.001), household income (p<0.001), and parental education (p=0.008) were associated with higher levels of debt. Students who were underrepresented in medicine (URiM) had higher odds of higher debt compared to Arab and Asian students (p=0.02). URiM students (p=0.02), first-generation college students (p=0.009), and parental education (p=0.01) were associated with increased financial stress. Additionally, female students had higher odds of increased financial stress (OR=1.85, p=0.045) on logistic regression. Conclusions: URiM and socioeconomically disadvantaged students feel the burden of the high cost of medical school disproportionately more, suggesting that our current systems are not adequately supporting these students. Reducing this burden may serve to further promote diversity in medicine.

Natural Language Processing to Estimate Clinical Competency Committee Ratings

OBJECTIVE

Residency program faculty participate in clinical competency committee (CCC) meetings, which are designed to evaluate residents' performance and aid in the development of individualized learning plans. In preparation for the CCC meetings, faculty members synthesize performance information from a variety of sources. Natural language processing (NLP), a form of artificial intelligence, might facilitate these complex holistic reviews. However, there is little research involving the application of this technology to resident performance assessments. With this study, we examine whether NLP can be used to estimate CCC ratings.

DESIGN

We analyzed end-of-rotation assessments and CCC assessments for all surgical residents who trained at one institution between 2014 and 2018. We created models of end-of-rotation assessment ratings and text to predict dichotomized CCC assessment ratings for 16 Accreditation Council for Graduate Medical Education (ACGME) Milestones. We compared the performance of models with and without predictors derived from NLP of end-of-rotation assessment text.

RESULTS

We analyzed 594 end-of-rotation assessments and 97 CCC assessments for 24 general surgery residents. The mean (standard deviation) for area under the receiver operating characteristic curve (AUC) was 0.84 (0.05) for models with only non-NLP predictors, 0.83 (0.06) for models with only NLP predictors, and 0.87 (0.05) for models with both NLP and non-NLP predictors.

CONCLUSIONS

NLP can identify language correlated with specific ACGME Milestone ratings. In preparation for CCC meetings, faculty could use information automatically extracted from text to focus attention on residents who might benefit from additional support and guide the development of educational interventions.

The Reporting of Race and Ethnicity in Surgery Literature

Importance

The reporting of race provides transparency to the representativeness of data and helps inform health care disparities. The International Committee of Medical Journal Editors (ICMJE) developed recommendations to promote quality reporting of race; however, the frequency of reporting continues to be low among most medical journals.

Objective

To assess the frequency as well as quality of race reporting among publications from high-ranking broad-focused surgical research journals.

Design, Setting, and Participants

A literature review and bibliometric analysis was performed examining all human-based primary research articles published in 2019 from 7 surgical journals: JAMA Surgery, Journal of the American College of Surgeons, Annals of Surgery, Surgery, American Journal of Surgery, Journal of Surgical Research, and Journal of Surgical Education. The 5 journals that stated they follow the ICMJE recommendations were analyzed against the 2 journals that did not explicitly claim adherence.

Main Outcomes and Measures

Measured study outcomes included race reporting frequency and use of the ICMJE recommendations for quality reporting of race.

Results

A total of 2485 publications were included in the study. The mean (SD) frequency of reporting of race and ethnicity in publications of ICMJE vs non-ICMJE journals was 32.8% (8.4) and 32.0% (20.9), respectively (P = .72). Adherence to ICMJE recommendations for reporting race was more frequent in ICMJE journals than non-ICMJE journals (mean [SD] of 73.1% [17.8] vs 37.0% [10.2]; P < .001).

Conclusions and Relevance

The frequency of race and ethnicity reporting among surgical journals is low. A journal's statement of adherence to ICMJE recommendations did not affect the frequency of race and ethnicity reporting; however, there was an increase in the use of ICMJE quality metrics. These findings suggest the need for increased and more standardized reporting of racial and ethnic demographic data among surgical journals.

Is Initial Board Certification Associated With Better Early Career Surgical Outcomes?

OBJECTIVE

To determine if initial American Board of Surgery certification in general surgery is associated with better risk-adjusted patient outcomes for Medicare patients undergoing partial colectomy by an early career surgeon.

BACKGROUND

Board certification is a voluntary commitment to professionalism, continued learning, and delivery of high-quality patient care. Not all surgeons are certified, and some have questioned the value of certification due to limited evidence that board-certified surgeons have better patient outcomes. In response, we examined the outcomes of certified versus noncertified early career general surgeons.

METHODS

We identified Medicare patients who underwent a partial colectomy between 2008 and 2016 and were operated on by a non-subspecialty trained surgeon within their first 5 years of practice. Surgeon certification status was determined using the American Board of Surgery data. Generalized linear mixed models were used to control for patient-, procedure-, and hospital-level effects. Primary outcomes were the occurrence of severe complications and occurrence of death within 30 days.

RESULTS

We identified 69,325 patients who underwent a partial colectomy by an early career general surgeon. The adjusted rate of severe complications after partial colectomy by certified (n = 4239) versus noncertified (n = 191) early-career general surgeons was 9.1% versus 10.7% (odds ratio 0.83, P = 0.03). Adjusted mortality rate for certified versus noncertified early-career general surgeons was 4.9% versus 6.1% (odds ratio 0.79, P = 0.01).

CONCLUSION

Patients undergoing partial colectomy by an early career general surgeon have decreased odds of severe complications and death when their surgeon is board certified.

Identifying institutional factors in general surgery resident wellness and burnout

BACKGROUND

Effects of the institutional macrocosm on general surgery resident wellbeing have not been well studied. We sought to identify organizational factors that impact resident wellness and burnout.

METHODS

Using a modified Delphi technique, an open-ended survey and two subsequent iterations were distributed to wellness stakeholders at two institutions to identify and stratify institutional factors in six burnout domains.

RESULTS

Response rates for each survey round were 29/106 (27%), 30/46 (65%) and 21/30 (70%). Top factors identified in each domain were: CONCLUSION: A modified Delphi technique prioritized institutional wellness and burnout factors. Top factors identified were compensation, vacation time, and autonomy. These results can direct future scholarship of barriers/facilitators of resident wellbeing.

Applying to be Doctors of Tomorrow: A Qualitative Study Exploring Motivations Towards Applying to a Medical Pipeline Program

PURPOSE

To identify the motivations of adolescent students applying into medical pipeline programs that are focused on populations underrepresented in medicine.

METHODS

The Doctors of Tomorrow (DoT) program is a medical pipeline program between the University of Michigan Medical School and Cass Technical High School in Detroit, Michigan, USA. As a component of the application process, ninth-grade students complete multiple free response essays that allow students to articulate their reasons for applying and their goals for participation in the program. Between 2013 and 2019, 323 ninth-grade students applied to DoT and 216 were accepted. The authors qualitatively analyzed all applications using theoretical coding methods to identify common themes discussed by students regarding their motivations for applying. The authors used Dedoose 8.3.17 (Los Angeles, CA) for qualitative analysis.

RESULTS

Four main themes emerged after coding and thematic analysis: (1) Career Aspiration, (2) Exposure to the Medical Field, (3) Breadth of Mentorship, and (4) Longitudinal Professional Development. 'Health Disparities in Minority Communities,' a code used when students commented on issues of race, social determinants of health, and health disparities as motivators, was not identified as frequently as the other codes, despite it being a main topic within the pipeline program.

CONCLUSIONS

Applicants to medical school pipeline programs articulate similar intrinsic motivations that can be used to inform what drives students to apply. Pipeline programs should consider these intrinsic motivations, while also creating structured activities from which students can learn and gain tangible benefits when designing curricula. While ninth-grade students acknowledge health disparities in minority communities, their current level of personal experience may not lead them to identify these disparities as significant motivators, and pipeline leaders should be aware of this when designing lesson plans concerning these topics.

Trainee Wellness and Safety in the Context of COVID-19: The Experience of One Institution

The COVID-19 pandemic has had significant ramifications for provider well-being. During these unprecedented and challenging times, one institution's Department of Surgery put in place several important initiatives for promoting the well-being of trainees as they were redeployed to provide care to COVID-19 patients. In this article, the authors describe these initiatives, which fall into 3 broad categories: redeploying faculty and trainees, ensuring provider safety, and promoting trainee wellness. The redeployment initiatives are the following: reframing the team mindset, creating a culture of grace and forgiveness, establishing a multidisciplinary wellness committee, promoting centralized leadership, providing clear communication, coordinating between departments and programs, implementing phased restructuring of the department's services, establishing scheduling flexibility and redundancy, adhering to training regulations, designating a trainee ombudsperson, assessing physical health risks for high-risk individuals, and planning for structured deimplementation. Initiatives specific to promoting provider safety are appointing a trainee safety advocate, guaranteeing personal protective equipment and relevant information about these materials, providing guidance regarding safe practices at home, and offering alternative housing options when necessary. Finally, the initiatives put in place to directly promote trainee wellness are establishing an environment of psychological safety, providing mental health resources, maintaining the educational missions, solidifying a sense of community by showing appreciation, being attentive to childcare, and using social media to promote community morale. The initiatives to carry out the department's strategy presented in this article, which were well received by both faculty and trainee members of the authors' community, may be employed in other departments and even outside the context of COVID-19. The authors hope that colleagues at other institutions and departments, independent of specialty, will find the initiatives described here helpful during, and perhaps after, the pandemic as they develop their own institution-specific strategies to promote trainee wellness.

Vigilance, Resilience, and Intent to Pursue Medicine Among Underrepresented Students

This article was migrated. The article was marked as recommended. It is crucial that we understand what challenges still exist for underrepresented in medicine (URiM) students on the path to medicine in order to design more effective pipeline programs. Resilience and its relationship to success in medicine is a growing area of interest in medical education, and the concept of vigilance has been studied in the context of the health of racialized groups. We sought to measure the roles of resilience and vigilance on URiM students' commitment to entering the medical field as well as the relationship between these two factors. A survey including the 10- item Connor Davidson Resilience Scale, the abbreviated Heightened Vigilance Scale, and questions measuring perceptions of everyday discrimination and intentions to pursue medicine was distributed to participants of Doctors of Tomorrow, a University of Michigan Medical School pipeline program focused on high school and undergraduate students. We detected significant relationship between resilience and intention to pursue medicine via Fisher's exact test (p=0.004). There was no significant relationship between vigilance and intention to pursue medicine nor between vigilance and resilience. We conclude that including resilience development for URiM students in pipeline program curricula could enhance URiM student matriculation to medical school.

Interpretive description: A flexible qualitative methodology for medical education research

BACKGROUND

Qualitative research approaches are increasingly integrated into medical education research to answer relevant questions that quantitative methodologies cannot accommodate. However, researchers have found that traditional qualitative methodological approaches reflect the foundations and objectives of disciplines whose aims are recognizably different from the medical education domain of inquiry (Thorne, 2016, Interpretive description. New York, NY: Routledge). Interpretive description (ID), a widely used qualitative research method within nursing, offers an accessible and theoretically flexible approach to analysing qualitative data within medical education research. ID is an appropriate methodological alternative for medical education research, as it can address complex experiential questions while producing practical outcomes. It allows for the advancement of knowledge surrounding educational experience without sacrificing methodological integrity that long-established qualitative approaches provide.

PURPOSE

In this paper, we present interpretive description as a useful research methodology for qualitative approaches within medical education. We then provide a toolkit for medical education researchers interested in incorporating interpretive description into their study design. We propose a coherent set of strategies for identifying analytical frameworks, sampling, data collection, analysis, rigour and the limitations of ID for medical education research. We conclude by advocating for the interpretive description approach as a viable and flexible methodology for medical education research.

Do Internal or External Characteristics More Reliably Predict Burnout in Resident Physicians: A Multi-institutional Study

INTRODUCTION

Surgical residents have been shown to experience high rates of burnout. Whether this is influenced predominately by intrinsic characteristics, external factors, or is multifactorial has not been well studied. The aim of this study was to explore the relationship between these elements and burnout. We hypothesized that residents with higher emotional intelligence scores, greater resilience and mindfulness, and better work environments would experience lower rates of burnout.

METHODS

General surgery residents at 7 sites in the US were invited to complete an electronic survey in 2019 that included the 2-item Maslach Burnout Inventory, Brief Emotional Intelligence Scale, Revised Cognitive and Affective Mindfulness Scale, 2-Item Connor-Davidson Resilience Scale, Utrecht Work Engagement Scale, and Job Resources scale of the Job Demands-Resources Questionnaire. Individual constructs were assessed for association with burnout, using multivariable logistic regression models. Residents' scores were evaluated in aggregate, in groups according to demographic characteristics, and by site.

RESULTS

Of 284 residents, 164 completed the survey (response rate 58%). A total of 71% of respondents were at high risk for burnout, with sites ranging from 57% to 85% (p = 0.49). Burnout rates demonstrated no significant difference across gender, PGY level, and respondent age. On bivariate model, no demographic variables were found to be associated with burnout, but the internal characteristics of emotional intelligence, resilience and mindfulness, and the external characteristics of work engagement and job resources were each found to be protective against burnout (p < 0.001 for all). However, multivariable models examining internal and external characteristics found that no internal characteristics were associated with burnout, while job resources (coeff. -1.0, p-value <0.001) and work engagement (coeff. -0.76, p-value 0.032) were significantly protective factors. Rates of engagement overall were high, particularly with respect to work "dedication."

CONCLUSIONS

A majority of residents at multiple institutions were at high risk for burnout during the study period. Improved work engagement and job resources were found to be more strongly associated with decreased burnout rates when compared to internal characteristics. Although surgical residents appear to already be highly engaged in their work, programs should continue to explore ways to increase job resources, and further research should be aimed at elucidating the mediating effect of internal characteristics on these external factors.

Identification of promotion and prevention associated surgeon behaviors in the operating room to facilitate resident self-regulated learning

BACKGROUND

The regulatory focus theory (RFT) posits that people can pursue goals with a promotion or prevention focus. Greater alignment of RFT motivational styles between faculty and residents may enhance resident operative autonomy. This study establishes a set of faculty behaviors residents can identify to infer faculty motivational styles.

METHODS

10 behaviors associated with promotion and prevention motivational styles were identified. General surgery residents rated faculty on how strongly they exhibit these behaviors. Faculty conducted a self-assessment of how strongly they exhibit these behaviors.

RESULTS

There is a positive correlation between resident and faculty ratings for the promotion-associated behaviors of "works quickly," "high energy," and "mostly provides broad oversight," and for the prevention-associated behaviors of "works slowly and deliberately," "quiet and calm," and "preference for vigilant strategies."

CONCLUSION

Residents can observe faculty operative behaviors to infer faculty motivational styles. Residents may use this knowledge to adjust to faculty motivational styles and enhance operative interactions.

Reference letters for subspecialty medicine residency positions: are they valuable for decision-making? Results from a Canadian study

BACKGROUND

The letter of recommendation is currently an integral part of applicant selection for residency programs. Internal medicine residents will spend much time and expense completing sub-specialty away electives to obtain a letter of recommendation. The purpose of this study was 1) to examine a large sample of reference letters in order to define essential components of a high-quality letter, and 2) to elucidate the relationship between quality of reference letter and the letter writer.

METHODS

We conducted a two-phase study. In phase one, a large sample of letters of recommendation was examined using an audit tool as a coding framework. A 5-point composite endpoint of high-quality letter components was subsequently developed. In phase two, program director letters were compared to non-program director home institution and non-home institution elective letters based on inclusion of components of the 5-point composite endpoint using Chi square testing.

RESULTS

715 letters were examined (398 non-program director home institution letters, 201 program director letters, and 116 non-home institution elective letters). High-quality letter components were: nature of relationship, duration of relationship, In Training Evaluation Report information, research involvement and comments on areas for improvement. Program director letters had a significantly higher proportion (10.4%) of all 5 high-quality components, compared to 0% in both non-program director home institution letters and elective letters (p < 0.001). A significantly higher proportion of program director letters had 4-5 high-quality components (62.5%) compared to 2% of non-program director home institution letters and 0% of elective letters (p < 0.0001).

CONCLUSIONS

Letters of recommendation from elective rotations are of the poorest quality and such rotations should not be pursued for the sole purpose of obtaining a letter. The low quality of elective letters leads to the recommendation that writers should decline to write them, programs should not require them and trainees should not request them. Program directors write the highest quality letters and should be a resource for faculty development. Clinical supervisors can use the 5-point composite endpoint as a guide when writing letters for applicants.