Unprofessionalism in anesthesiology: A qualitative study on classifying unprofessional behavior in anesthesiology residency education

STUDY OBJECTIVE

This study aims to identify the domains that constitute behaviors perceived to be unprofessional in anesthesiology residency training programs.

DESIGN

Qualitative study.

SETTING

Anesthesiology residency training programs.

PATIENTS

Not applicable. The participants involved residents, fellows, and faculty members purposefully sampled in four US-based anesthesiology residency programs.

INTERVENTIONS

Participants were asked to submit examples of unprofessional behavior they witnessed in anesthesiology residents, fellows, or faculty members via a Qualtrics link.

MEASUREMENTS

Not applicable. The behavior examples were independently reviewed and categorized into themes using content analysis.

MAIN RESULTS

A total of 116 vignettes were collected, resulting in a final list of 111 vignettes after excluding those that did not describe behavior exhibited by anesthesiology faculty or trainees. Fifty-eight vignettes pertained to unprofessional behaviors observed in faculty members and 53 were observed in trainees (residents and fellows). Nine unprofessionalism themes emerged in the analysis. The most common themes were VERBAL, SUPERVISION, QUALITY, ENGAGEMENT, and TIME. As to the distribution of role group (faculty versus trainee) by theme, unprofessional behaviors falling into the categories of BIAS, GOSSIP, LEWD, and VERBAL were observed more in faculty; whereas themes with unprofessional behavior primarily attributed to trainees included ENGAGEMENT, QUALITY, TIME, and SUPERVISION.

CONCLUSION

By reviewing reported professionalism-related vignettes within residency training programs, we identified classification descriptors for defining unprofessional behavior specific to anesthesiology residency education. Findings from this study enrich the definition of professionalism as a multi-dimensional competency pertaining to anesthesiology graduate medical education. This framework may facilitate preventative intervention and timely remediation plans for unprofessional behavior in residents and faculty.

Family Anesthesia Experience: Improving Social Support of Residents Through Education of Their Family and Friends

Introduction

The prevalence of burnout among anesthesiology residents is 41%-51%. Burnout is associated with medical errors, physician turnover, and substance use disorder. Social support and wellness may reduce burnout, but a barrier is support persons' lack of understanding of an anesthesiologist's work demands. We developed the Family Anesthesia Experience (FAX) to help support persons best support their resident.

Methods

FAX consisted of a 4-hour event with hands-on experience, didactics portion, and panel discussion. Participants learned about a typical day in the life of an anesthesiology resident, wellness, burnout, substance use disorder, and available support resources, and had hands-on experience with procedures. The panel discussion offered logistical information about anesthesiology residency and allowed support persons to ask panel members questions. A postevent survey collected feedback on the event.

Results

Fifty-one participants (first-year anesthesiology residents and their support persons) attended the event. Eight of 11 residents (73%) and 32 of 40 support persons (80%) completed the survey. All enjoyed the event, would recommend it to other anesthesiology resident support persons, and felt the event would improve communication and support. Most learned a moderate (35%) to large amount (50%) from the event. Qualitative feedback suggested most support persons found the event helpful in improving their understanding of anesthesiology residents' work demands.

Discussion

The FAX was well liked by participants. Although we did not assess specific knowledge gained and long-term effects of the 2022 event, evaluations of previous years' events suggest that the event improved participants' understanding of anesthesiology residents' work and stressors.

No Miracles in Two Minutes: A Randomized Controlled Study on the Impact of Preparatory Expansive Posing on Anesthesiology Residents' Performance in Mock Structured Oral Examinations

Background

The objective of this study was to evaluate the impact of engaging in preparatory expansive posing on the performance of anesthesiology trainees during a mock structured oral examination.

Methods

A total of 38 clinical residents at a single institution participated in this prospective randomized controlled study. Participants were stratified by clinical anesthesia year and randomly assigned to 1 of 2 orientation rooms to prepare for the examination. The preparatory expansive posing participants stood for 2 minutes with their hands and arms above their heads and with their feet approximately 1 ft apart. Conversely, the control participants sat quietly in a chair for 2 minutes. All participants then received the same orientation and examination. Faculty evaluation of resident performance, residents' self-assessment of performance, and anxiety score were collected.

Results

There was no evidence to support our primary hypothesis that residents who engaged in preparatory expansive posing for 2 minutes prior to a mock structured oral examination would score higher than their control counterparts (P = .68). There was no evidence to support our secondary hypotheses that preparatory expansive posing increases self-assessment of one's performance (P = .31) or reduces perceived anxiety during a mock structured oral examination (P = .85).

Conclusions

Preparatory expansive posing did not improve anesthesiology residents' mock structured oral examination performance or self-assessment of their performance, nor did it reduce their perceived anxiety. Preparatory expansive posing is likely not a useful technique in improving the performance of residents in structured oral examinations.

A Multi-Site Survey Study on the Association Between the COVID-19 Pandemic and United States Anesthesiology Residents' Mental Health

BACKGROUND

 At the onset of the coronavirus disease 2019 (COVID-19) pandemic, anesthesiology residency programs were impacted differently due to various factors such as the local severity of COVID-19, exposure to patient suffering, and inability to complete rotations. We sought to investigate the impact of local-level pandemic severity on the well-being of anesthesiology residents.

METHODS

 This multi-site study surveyed postgraduate year two residents from 15 United States (US) anesthesiology programs using the Perceived Stress Scale, Mini-Z, Patient Health Questionnaire-9,WHO-5 Well-Being Index,and the Multidimensional Scale of Perceived Social Support before the pandemic (baseline survey) and during the first COVID-19 surge (post survey).

RESULTS

 A total of 144 (65%) residents responded to the initial baseline survey; 73 (33%) responded to the post survey, and 49 (22%) completed both surveys. There was not a statistically significant difference in any well-being outcomes of participants between the surveys, nor was there a significant difference based on the severity of COVID-19 impact at the program's hospital. Male participants had higher perceived stress scores (β = 4.05, 95%CI: 0.42, 7.67, P = 0.03) and lower social support from family (β = -6.57, 95%CI: -11.64, -1.51, P = 0.01) at the post survey compared to female participants after controlling for baseline scores. Additionally, married participants or those with domestic partners reported higher perceived social support in the post survey (β = 5.79, 95%CI: -0.65, 12.23, P = 0.03).

CONCLUSION

 The local COVID-19 severity at a residency program did not disproportionately impact well-being scores among anesthesiology residents. Those most vulnerable to diminished well-being appeared to be male and single participants. As a result, targeted well-being interventions, including those aiming to increase social support, to higher-risk resident groups may be indicated. Future work is needed to assess the longstanding COVID-19 pandemic impacts on resident well-being.

A Perspective on Wellness in Anesthesiology Residency Programs: A Multi-Strategy Approach

Addressing resident wellness is an important topic given the high risk for burnout and depression in resident physicians compared with the general U.S. population. This article provides an overview of various approaches to help conceptualize and intervene on resident wellness, based on the 9-strategies framework to improve wellness laid out by Shanafelt and colleagues. This article outlines the most relevant literature in each strategy followed by the authors' experience within their anesthesiology residency program.

Defining and Addressing Anesthesiology Needs in Simulation-based Medical Education

BACKGROUND

This study's primary aim was to determine how training programs use simulation-based medical education (SBME), because SBME is linked to superior clinical performance.

METHODS

An anonymous 10-question survey was distributed to anesthesiology residency program directors across the United States. The survey aimed to assess where and how SBME takes place, which resources are available, frequency of and barriers to its use, and perceived utility of a dedicated departmental education laboratory.

RESULTS

The survey response rate was 30.4% (45/148). SBME typically occurred at shared on-campus laboratories, with residents typically participating in SBME 1 to 4 times per year. Frequently practiced skills included airway management, trauma scenarios, nontechnical skills, and ultrasound techniques (all ≥ 77.8%). Frequently cited logistical barriers to simulation laboratory use included COVID-19 precautions (75.6%), scheduling (57.8%), and lack of trainers (48.9%). Several respondents also acknowledged financial barriers. Most respondents believed a dedicated departmental education laboratory would be a useful or very useful resource (77.8%).

CONCLUSION

SBME is a widely incorporated activity but may be impeded by barriers that our survey helped identify. Barriers can be addressed by departmental education laboratories. We discuss how such laboratories increase capabilities to support structured SBME events and how costs can be offset. Other academic departments may also benefit from establishing such laboratories.

Reinvigorating an Academy of Medical Educators Using Ecological Systems Theory

The educational framework of communities of practice postulates that early learners join medical communities as social networks that provide a common identity, role modeling and mentorship, and experiential learning. While being elected into a medical society is an honor, member engagement in these groups can falter if the society membership is seen as an honorific rather than one requiring continuing participation. As an example, Academies of Medical Educators have been established by many academic medical centers to encourage collaboration, skill development, professional identity formation, and scholarship. The University of North Carolina established the Academy of Educators in 2006 to create a diverse community of educators to promote the scholarship, teaching skills, and professional identity of educators. Despite rapid growth to over 500 members, we had less than 30 participants at events over the 2017-2018 academic year. To increase member engagement and participation, our academy leadership team used Bronfenbrenner’s Ecological Systems Theory to design interventions at each layer of environmental influence, specifically at the microsystem, mesosystem, exosystem, macrosystem, and chronosystem levels. In this paper, we describe the multipronged approach used to increase the University of North Carolina Academy of Medical Educators event attendance from 30 to 1,000 faculty participants over the course of one academic year (2018-2019). This paper provides a model as to how medical societies can use ecological systems theory as a natural and comprehensive approach to plan and improve their member engagement and experience.

Transitioning to Virtual Meetings: Experiences From the Society for Education in Anesthesia Virtual Fall 2020 Meeting

The COVID-19 pandemic has forced organizers of traditional in-person continuing medical education conferences to transition to a virtual format. There are both advantages and disadvantages to this change in format. When planning a virtual meeting, several factors require consideration, including costs, virtual platforms, sponsorship, networking, and meeting logistics. This manuscript describes the authors' experiences of transforming the Society of Education in Anesthesia 2020 Fall Meeting into a virtual conference and explores the lessons learned and future impacts of this new medium.

Educating Anesthesiologists During the Coronavirus Disease 2019 Pandemic and Beyond

The coronavirus disease 2019 (COVID-19) pandemic has altered approaches to anesthesiology education by shifting educational paradigms. This vision article discusses pre-COVID-19 educational methodologies and best evidence, adaptations required under COVID-19, and evidence for these modifications, and suggests future directions for anesthesiology education. Learning management systems provide structure to online learning. They have been increasingly utilized to improve access to didactic materials asynchronously. Despite some historic reservations, the pandemic has necessitated a rapid uptake across programs. Commercially available systems offer a wide range of peer-reviewed curricular options. The flipped classroom promotes learning foundational knowledge before teaching sessions with a focus on application during structured didactics. There is growing evidence that this approach is preferred by learners and may increase knowledge gain. The flipped classroom works well with learning management systems to disseminate focused preclass work. Care must be taken to keep virtual sessions interactive. Simulation, already used in anesthesiology, has been critical in preparation for the care of COVID-19 patients. Multidisciplinary, in situ simulations allow for rapid dissemination of new team workflows. Physical distancing and reduced availability of providers have required more sessions. Early pandemic decreases in operating volumes have allowed for this; future planning will have to incorporate smaller groups, sanitizing of equipment, and attention to use of personal protective equipment. Effective technical skills training requires instruction to mastery levels, use of deliberate practice, and high-quality feedback. Reduced sizes of skill-training workshops and approaches for feedback that are not in-person will be required. Mock oral and objective structured clinical examination (OSCE) allow for training and assessment of competencies often not addressed otherwise. They provide formative and summative data and objective measurements of Accreditation Council for Graduate Medical Education (ACGME) milestones. They also allow for preparation for the American Board of Anesthesiology (ABA) APPLIED examination. Adaptations to teleconferencing or videoconferencing can allow for continued use. Benefits of teaching in this new era include enhanced availability of asynchronous learning and opportunities to apply universal, expert-driven curricula. Burdens include decreased social interactions and potential need for an increased amount of smaller, live sessions. Acquiring learning management systems and holding more frequent simulation and skills sessions with fewer learners may increase cost. With the increasing dependency on multimedia and technology support for teaching and learning, one important focus of educational research is on the development and evaluation of strategies that reduce extraneous processing and manage essential and generative processing in virtual learning environments. Collaboration to identify and implement best practices has the potential to improve education for all learners.

Family Comes First: A Pilot Study of the Incorporation of Social Support Into Resident Well-being

BACKGROUND

Recent work has shown that understanding of work-related stress by family and friends is associated with increased resident well-being. However, it is often difficult for residents to communicate with their support persons (SPs), especially those who have minimal understanding of the medical field, regarding even the most basic functions of their role in the health care system. This study aimed to pilot test an innovative wellness event focusing on the social relatedness component of resident well-being.

METHODS

The target population included 30 new residents at 2 anesthesiology residency programs and their SPs in 2017. The Family Anesthesia Experience (FAX) began with didactic presentations and a panel discussion about wellness topics. It concluded with a multifaceted simulation experience. Participants were surveyed before and after the event. Measures included SPs' understanding of residents' work and residents' stress, burnout, resilience, and social support levels. Student t tests, Mann-Whitney U tests, Wilcoxon signed-rank tests, and repeated measures analysis of variance were used to examine the impact of the event.

RESULTS

Twenty-two (84.6%) of the 26 intervention clinical anesthesia year 1 residents who attended FAX completed the postevent surveys, and all intervention SPs (100%, n = 33) completed both pre-event and postevent surveys. The event was well received by the residents (100%) and their SPs (100%). Improvement in perceived understanding in the intervention SPs group (Pre: 1.44 ± 0.63, Post: 2.69 ± 0.33, P < .0001) was observed. Not all metrics of well-being for the residents achieved significance in change; however, decreased stress was observed compared with historical controls (Control: 1.91 ± 0.61, Intervention: 1.54 ± 0.42, P = .019).

CONCLUSION

The event led to improved SPs' understanding of the role of an anesthesiology resident.

Experience Is the Teacher of All Things: Prior Participation in Anesthesiology OSCEs Enhances Communication of Treatment Options With Simulated High-Risk Patients

BACKGROUND

The objective of this study was to investigate whether previous experiences within an anesthesiology-based Objective Structured Clinical Examination (OSCE) assessing communication and professionalism skills was associated with improved performance in a subsequent anesthesiology-based OSCE scenario.

METHODS

This retrospective multi-center study used the performance data of 44 Post Graduate Year 4 clinical anesthesia residents from 3 US anesthesiology residency programs on an OSCE scenario that assessed the residents' effectiveness of discussing anesthesiology-specific treatment options with a high-risk patient. Residents from 2 of the programs had no prior anesthesiology-based OSCE experience. Residents from the third program had previously participated in 4 separate multi-scenario anesthesiology-based OSCE sessions in the 2 years prior to this study. Participating residents completed the same scenario at their respective institutions' simulation center. Ten performances were randomly selected for double rating to assess the interrater reliability of the assessments. Interrater reliability was good for the scenario (intraclass correlation coefficient = 0.66, 95% confidence interval = 0.12-0.90). Performance difference between groups with different OSCE experience status were examined using an independent sample t test, with a Wilcoxon-Mann-Whitney test as a sensitivity analysis.

RESULTS

Independent sample t test found prior OSCE experience was significantly associated with higher performance scores (t = 2.53, P = .02). The Wilcoxon-Mann-Whitney test result confirmed this finding (z = 3.28, P = .001).

CONCLUSIONS

Findings from this study provide preliminary evidence that anesthesiology-based OSCE experience is associated with improved performance in an OSCE scenario, specifically regarding discussions of treatment options with high-risk patients.

Surgical Echocardiography of the MV: Focus on 3D

The mitral valve remains a complex structure where multiple forms of pathology can be seen. Mitral regurgitation continues to be one of the most common valvular diseases in the industrialized world. While intraoperative 2-dimensional transesophageal echocardiography has been commonplace for some time, 3-dimensional technology has emerged and has shown great benefit for diagnosis and guidance during mitral valve surgery. In the hands of a trained sonographer, high-quality real-time images can easily be obtained and correlate well with gross anatomical findings. The use of multiple angled views and color Doppler within 3-dimensional transesophageal echocardiography has become a valuable asset in the understanding and interpretation of the mitral valve for surgical interventions.

Comparing Real-time Versus Delayed Video Assessments for Evaluating ACGME Sub-competency Milestones in Simulated Patient Care Environments

Background

Simulation is an effective method for creating objective summative assessments of resident trainees. Real-time assessment (RTA) in simulated patient care environments is logistically challenging, especially when evaluating a large group of residents in multiple simulation scenarios. To date, there is very little data comparing RTA with delayed (hours, days, or weeks later) video-based assessment (DA) for simulation-based assessments of Accreditation Council for Graduate Medical Education (ACGME) sub-competency milestones. We hypothesized that sub-competency milestone evaluation scores obtained from DA, via audio-video recordings, are equivalent to the scores obtained from RTA.

Methods

Forty-one anesthesiology residents were evaluated in three separate simulated scenarios, representing different ACGME sub-competency milestones. All scenarios had one faculty member perform RTA and two additional faculty members perform DA. Subsequently, the scores generated by RTA were compared with the average scores generated by DA. Variance component analysis was conducted to assess the amount of variation in scores attributable to residents and raters.

Results

Paired t-tests showed no significant difference in scores between RTA and averaged DA for all cases. Cases 1, 2, and 3 showed an intraclass correlation coefficient (ICC) of 0.67, 0.85, and 0.50 for agreement between RTA scores and averaged DA scores, respectively. Analysis of variance of the scores assigned by the three raters showed a small proportion of variance attributable to raters (4% to 15%).

Conclusions

The results demonstrate that video-based delayed assessment is as reliable as real-time assessment, as both assessment methods yielded comparable scores. Based on a department’s needs or logistical constraints, our findings support the use of either real-time or delayed video evaluation for assessing milestones in a simulated patient care environment.

The Use of Simulation to Improve Family Understanding and Support of Anesthesia Providers

Introduction  Burnout in medical providers is associated with work dissatisfaction, reduction in patient safety, and provider depression. Simulation is a tool effectively used for specific task training but has not been broadly used as a means to combat medical professional stress and enhance wellness. The authors created a medical simulation program targeted at those involved in the social support of medical providers. The hypothesis was that education of non-medical persons involved in social support would translate into an enhanced understanding of the demands among medical providers in anesthesiology. This understanding would thereby open communication pathways within the social support system and contribute to enhanced wellness among providers. Methods To assess effectiveness and benefits of the event, survey data were obtained from anesthesia providers and their adult support persons before and after the event. The anesthesia providers were queried on their perception regarding the benefit of the event for their support persons. Support persons were asked questions regarding their understanding of the role of an anesthesia provider. Results Sixty-three family members and friends (adult=30, child=33) participated in a two-hour simulation event including activities for participants of all ages. Twenty-nine (96.7%) adult participants (age ≥ 14) completed the support person surveys before and/or after the event. The post-event survey results revealed participants' satisfaction with the event (n=26, 100%). This simulation event also demonstrated an improved understanding of the demands among anesthesia providers by their support persons (seven items, P values range from less than .0001 to .0313). Most anesthesia providers who attended the event enjoyed it a significant amount (n=19, 82.6%). Most providers whose primary work-related support persons attended the event believed that it would be easier to communicate work-related issues (n=12, 85.7%). Conclusion We outline "The Family Anesthesia Experience Day" as a wellness initiative for anesthesia providers. Our study demonstrated improved understanding of support persons' knowledge about anesthesia providers' work-related stress via an immersive two-hour simulation-based learning experience. The event was well-received and may be a useful approach to provide support persons with an opportunity to learn about and better support their beloved anesthesia provider.

Utilization of the Flipped Classroom in Anesthesiology Graduate Medical Education: An Initial Survey of Faculty Beliefs and Practices About Active Learning

BACKGROUND

Flipped classroom (FC) is an active learning (AL) technique thought to have potential benefits in anesthesiology resident education. This survey aimed to determine the frequency of FC utilization, barriers of utilization, and means to overcome these barriers.

METHOD

A web-based questionnaire was developed to survey anesthesiology faculty on their knowledge of and experience with FC. The Society of Academic Associations of Anesthesiology and Perioperative Medicine sent the survey to all United States core program directors (PD) via their list serve with a request for the PDs to forward the survey invitation to their clinical faculty. Descriptive statistics were summarized.

RESULTS

A total of 244 anesthesiology faculty completed the survey. Reported faculty understanding of AL and FC were 57%. Of these faculty, 87% utilized AL and 57% utilized FC in their personal teaching practice during the past year (spring 2015-spring 2016). The most prevalent barriers to utilization of FC were faculty concern that learners would not come to class prepared or participate in class, faculty comfort with delivering traditional lectures, lack of faculty knowledge of necessary technological tools, and faculty concern about perceived increase in time needed to create a FC session. Eighty-nine percent of all faculty desired education on FC with preference for institutional workshops or grand rounds.

CONCLUSIONS

Our survey found a discrepancy between faculty knowledge of FC and usage of this method in anesthesiology resident teaching. More educational resources are warranted to address barriers and familiarize faculty with FC applications in anesthesiology resident education.

Platelet Counts and Postoperative Stroke After Coronary Artery Bypass Grafting Surgery

BACKGROUND

Declining platelet counts may reveal platelet activation and aggregation in a postoperative prothrombotic state. Therefore, we hypothesized that nadir platelet counts after on-pump coronary artery bypass grafting (CABG) surgery are associated with stroke.

METHODS

We evaluated 6130 adult CABG surgery patients. Postoperative platelet counts were evaluated as continuous and categorical (mild versus moderate to severe) predictors of stroke. Extended Cox proportional hazard regression analysis with a time-varying covariate for daily minimum postoperative platelet count assessed the association of day-to-day variations in postoperative platelet count with time to stroke. Competing risks proportional hazard regression models examined associations between day-to-day variations in postoperative platelet counts with timing of stroke (early: 0-1 days; delayed: ≥2 days).

RESULTS

Median (interquartile range) postoperative nadir platelet counts were 123.0 (98.0-155.0) × 10/L. The incidences of postoperative stroke were 1.09%, 1.50%, and 3.02% for platelet counts >150 × 10/L, 100 to 150 × 10/L, and <100 × 10/L, respectively. The risk for stroke increased by 12% on a given postoperative day for every 30 × 10/L decrease in platelet counts (adjusted hazard ratio [HR], 1.12; 95% confidence interval [CI], 1.01-1.24; P= .0255). On a given day, patients with moderate to severe thrombocytopenia were almost twice as likely to develop stroke (adjusted HR, 1.89; 95% CI, 1.13-3.16; P= .0155) as patients with nadir platelet counts >150 × 10/L. Importantly, such thrombocytopenia, defined as a time-varying covariate, was significantly associated with delayed (≥2 days after surgery; adjusted HR, 2.83; 95% CI, 1.48-5.41; P= .0017) but not early postoperative stroke.

CONCLUSIONS

Our findings suggest an independent association between moderate to severe postoperative thrombocytopenia and postoperative stroke, and timing of stroke after CABG surgery.

Use of Key Performance Indicators to Improve Milestone Assessment in Semi-Annual Clinical Competency Committee Meetings

BACKGROUND

The Accreditation Council for Graduate Medical Education's Next Accreditation System requires residency programs to semiannually submit composite milestone data on each resident's performance. This report describes and evaluates a new assessment review procedure piloted in our departmental Clinical Competency Committee (CCC) semi-annual meeting in June 2016.

METHODS

A modified Delphi technique was utilized to develop key performance indicators (KPI) linking milestone descriptors to clinical practice. In addition, the CCC identified six specific milestone sub-competencies that would be prescored with objective data prior to the meeting. Each resident was independently placed on the milestones by 3 different CCC faculty members. Milestone placement data of the same cohort of 42 residents (Clinical Anesthesia Years 1-3) were collected to calculate inter-rater reliability of the assessment procedures before and after the implemented changes. A survey was administrated to collect CCC feedback on the new procedure.

RESULTS

The procedure assisted in reducing meeting time from 8 to 3.5 hours. Survey of the CCC members revealed positive perception of the procedure. Higher inter-rater reliability of the milestone placement was obtained using the implemented KPIs (Intraclass correlation coefficient [ICC] single measure range: before=.53-.94, after=.74-.98).

CONCLUSION

We found the new assessment procedure beneficial to the efficiency and transparency of the assessment process. Further improvement of the procedure involves refinement of KPIs and additional faculty development on KPIs to allow non-CCC faculty to provide more accurate resident evaluations.

Results of a Flipped Classroom Teaching Approach in Anesthesiology Residents

BACKGROUND

In a flipped classroom approach, learners view educational content prior to class and engage in active learning during didactic sessions.

OBJECTIVE

We hypothesized that a flipped classroom improves knowledge acquisition and retention for residents compared to traditional lecture, and that residents prefer this approach.

METHODS

We completed 2 iterations of a study in 2014 and 2015. Institutions were assigned to either flipped classroom or traditional lecture for 4 weekly sessions. The flipped classroom consisted of reviewing a 15-minute video, followed by 45-minute in-class interactive sessions with audience response questions, think-pair-share questions, and case discussions. The traditional lecture approach consisted of a 55-minute lecture given by faculty with 5 minutes for questions. Residents completed 3 knowledge tests (pretest, posttest, and 4-month retention) and surveys of their perceptions of the didactic sessions. A linear mixed model was used to compare the effect of both formats on knowledge acquisition and retention.

RESULTS

Of 182 eligible postgraduate year 2 anesthesiology residents, 155 (85%) participated in the entire intervention, and 142 (78%) completed all tests. The flipped classroom approach improved knowledge retention after 4 months (adjusted mean = 6%; P = .014; d = 0.56), and residents preferred the flipped classroom (pre = 46%; post = 82%; P < .001).

CONCLUSIONS

The flipped classroom approach to didactic education resulted in a small improvement in knowledge retention and was preferred by anesthesiology residents.

A Descriptive Survey of Anesthesiology Residency Simulation Programs: How Are Programs Preparing Residents for the New American Board of Anesthesiology APPLIED Certification Examination?

BACKGROUND

Anesthesiology residency programs may need new simulation-based programs to prepare residents for the new Objective Structured Clinical Examination (OSCE) component of the American Board of Anesthesiology (ABA) Primary Certification process. The design of such programs may require significant resources, including faculty time, expertise, and funding, as are currently needed for structured oral examination (SOE) preparation. This survey analyzed the current state of US-based anesthesiology residency programs regarding simulation-based educational programming for SOE and OSCE preparation.

METHODS

An online survey was distributed to every anesthesiology residency program director in the United States. The survey included 15 to 46 questions, depending on each respondent's answers. The survey queried current practices and future plans regarding resident preparation specifically for the ABA APPLIED examination, with emphasis on the OSCE. Descriptive statistics were summarized. χ and Fisher exact tests were used to test the differences in proportions across groups. Spearman rank correlation was used to examine the association between ordinal variables.

RESULTS

The responding 66 programs (49%) were a representative sample of all anesthesiology residencies (N = 136) in terms of geographical location (χ P = .58). There was a low response rate from small programs that have 12 or fewer clinical anesthesia residents. Ninety-one percent (95% confidence interval [CI], 84%-95%) of responders agreed that it is the responsibility of the program to specifically prepare residents for primary certification, and most agreed that it is important to practice SOEs (94%; 95% CI, 88%-97%) and OSCEs (89%; 95% CI, 83%-94%). While 100% of respondents reported providing mock SOEs, only 31% (95% CI, 24%-40%) of respondents provided mock OSCE experiences. Of those without an OSCE program, 75% (95% CI, 64%-83%) reported plans to start one. The most common reasons for not having an OSCE program already in place, and the perceived challenges for implementing an OSCE program, were the same: lack of time (faculty and residents), expertise in OSCE development and assessment, and funding.

CONCLUSIONS

The results provide data from residency programs for benchmarking their simulation curriculum and ABA APPLIED Examination preparation offerings. Despite agreement that residency programs should prepare residents for the ABA APPLIED Examination, many programs have yet to implement an OSCE preparation program, in part due to lack of financial resources, faculty expertise, and time. Additionally, in contrast to the SOE, the OSCE is a new format for ABA primary certification. As a result, the lack of consensus concerning preparation needs could be related to the amount information that is available regarding the examination content and assessment process.

A systematic review of the effectiveness of flipped classrooms in medical education

CONTEXT

There are inconsistent claims made about the effectiveness of the flipped classroom (FC) in medical education; however, the quality of the empirical evidence used to back up these claims is not evident. The aims of this review are to examine the scope and quality of studies on the FC teaching approach in medical education and to assess the effects of FCs on medical learning.

METHODS

A literature search was conducted using the major electronic databases in 2016. Peer-reviewed papers were screened and reviewed according to explicit inclusion criteria. The scope and quality of all resultant studies were evaluated. Studies identified as using controlled designs were further synthesised to assess the effects of FCs on learning.

RESULTS

A total of 118 articles were obtained. Full texts of 82 articles were reviewed. Nine of the included 46 articles used a controlled design when examining the effects of the FC. There were generally positive perceptions of the FC approach. However, the effects of FCs on changes in knowledge and skills were less conclusive as the effect sizes ranged from d = -0.27 to 1.21, with a median of 0.08. The varying direction and magnitude of the effect sizes, together with their 95% confidence interval, which contained zero, suggested the lack of strong evidence for the effectiveness of FCs in promoting knowledge acquisition above and beyond the traditional learning methods.

CONCLUSIONS

There has been a recent increase of research rigor and variety in measures of effectiveness in studies on the FC in medical education. The FC is a promising teaching approach to increase learners' motivation and engagement. More solid evidence on its effect on changes in knowledge and skills are warranted. Further studies should also examine the long-term effects of FCs with regard to knowledge retention and transfer of knowledge to professional practice and patient care.

The predictive value of pre-recruitment achievement on resident performance in anesthesiology

STUDY OBJECTIVE

Selecting candidates for residency positions is challenging and there is little research on the correlation between commonly used selection criteria and subsequent performance in anesthesiology. This study examined the association between the selection measures and post-recruitment performance in residency.

DESIGN

Retrospective review of archival data.

SETTING

Anesthesiology residency program at a large academic anesthesiology department.

SUBJECTS

Residents who were matched to the anesthesiology program over 9years (graduation classes of 2006 to 2014).

INTERVENTIONS

None.

MEASUREMENTS

The pre-recruitment achievements included a comprehensive list of measures obtained from residents' application portfolios in conjunction with interview performance. The post-recruitment examination outcomes consisted of the in-training examination (ITE) scores in the three clinical anesthesia (CA) years and first-attempt success on the written board certification examination administered by the American Board of Anesthesiology (ABA). Scholarly output during residency was measured by publication record. Clinical performance at the conclusion of residency was independently rated by three faculty members. Bivariate analysis and regression models were conducted to examine association between predictors and outcomes.

MAIN RESULTS

High United States Medical Licensing Examination (USMLE) scores, class rank in medical school and interview performance were predictive of high examination scores in residency and good clinical performance. Class rank appeared to be the best predictor of scholarly publication and pursuing an academic career beyond residency.

CONCLUSIONS

Comparative performance with classmates (i.e., class rank) in medical school appeared to be an effective predictor of overall performance in residency, which warrants more attention in future study. Although interview performance is subject to recruitment team members' interpretation, it is an important measure to include in recruitment decisions.

Combined Aortic Valve Replacement and Renal Cell Carcinoma Thrombectomy

Although nephrectomy for renal cell carcinoma with inferior vena cava invasion is a common procedure, it is rare to have level IV invasion necessitating cardiopulmonary bypass (CPB). Furthermore, it is exceptionally rare to perform cardiac surgery concomitantly with this resection. We report a case in which an aortic valve replacement was done in the same surgical setting as a level IV thrombectomy. We have demonstrated that although it can be difficult to manage the coagulopathy post-CPB, this can be successfully accomplished with adequate prior preparation and a coordinated team effort.

Echocardiographic Discovery of Doubled Interatrial Septum

A double-walled interatrial septum is a rare congenital cardiac anomaly characterized by a distinct echolucent cavity between the atria formed by 2 separate interatrial septae. It may be a variant of other well-recognized cardiac anomalies such as persistent venous valve of the sinus venosus or cor triatriatum. Although uncommon, it may be associated with thromboembolic disease due to stagnant flow in the septal cavity. Awareness of this rare entity and its clinical significance along with a thorough echocardiographic examination to rule out similarly presenting or coexisting conditions are the key to an accurate diagnosis and appropriate management.

A Novel Core Competencies-Based Academic Medicine Curriculum: Description and Preliminary Results

BACKGROUND

Physicians practice health care in a rapidly changing system that requires more than the delivery of safe and effective care. Modern physicians must also acquire skills beyond direct patient care. Residency programs must, therefore, prepare physicians to meet these demands by providing appropriate education and training.

METHODS

We designed, implemented and assessed an academic medicine curriculum in the first post-graduate year. This curriculum provides comprehensive exposure to necessary non-patient contact related physician skills. Topics centered around four domains: critical appraisal of literature of literature, quality improvement, professional development, and teaching. Each of these domains is linked to the six core competencies established by the Accreditation Council for Graduate Medical Education's (ACGME). Instruction includes small-group learning sessions with additional time for self-directed online modules and a faculty-mentored quality improvement research project that is presented at a graduation symposium. All residents completed a survey evaluation of the curriculum before and after the course via open-ended questions and Likert responses (0-5). We assessed improvement in resident confidence with each curricular domain using mean Likert score change and 95% confidence intervals (CI).

RESULTS

Residents improved at all curricular domains measured. The most significant mean changes included confidence in: poster presentations (2.7; 95% CI: 1.9-3.5), plan-do-check-act cycle (2.5; 95% CI: 2.1-2.9), quality improvement projects (2.4; 95% CI: 1.9-2.9), and abstract presentation (2.3; 95% CI: 1.6-3.0).

CONCLUSIONS

We found that the academic medicine rotation (AMR) is feasible in a large academic setting. Furthermore, the AMR allows early exposure to and improvement in essential non-patient contact related physician skills required by the ACGME core competencies and assessed through the milestones.

Enhancement of anesthesiology in-training exam performance with institution of an academic improvement policy

BACKGROUND

Anesthesiology resident physicians across the United States complete an annual in-training examination (ITE). The ITE evaluates resident knowledge and provides personalized feedback to guide future study in low scoring sections(1). Performance on the ITE correlates with outcomes on the American Board of Anesthesiology (ABA) written board examination(2). Over the last several years, declining ITE scores were observed at the University of North Carolina (UNC). In response to this decline, our department reprioritized the ITE by instituting an academic improvement policy (AIP). The AIP employed both reward for satisfactory achievement and consequence for under-performance to elevate the ITE as a "high stakes" examination. Our hypothesis was that implementation of this AIP would improve ITE scores.

METHODS

ITE scores were compiled from 150 residents in the Department of Anesthesiology at UNC for graduating classes from 2004-2015. Data is presented as the number of residents scoring below the 20th percentile when compared to the national distribution before and after the AIP. In addition, average USMLE Step 1 three-digit scores for each graduating class were compared to average ITE percentile scores of the corresponding graduating class (USMLE does not provide percentile scores).

RESULTS

Between 2009 and 2013, the number of residents who scored below the 20th percentile on the ITE increased steadily to a peak of 10 in 2011. After implementation of the AIP in July 2011, there was an 80% decrease in those scoring below the 20th percentile, from 10 to 2 residents (p<0.05).

CONCLUSIONS

Anesthesiology resident ITE scores improved after implementation of an academic improvement policy.

Assessing the Impact of a Regional Anesthesia Workshop on Anesthesiology Residents' Perceived Comfort in Performing Peripheral Nerve Blocks

BACKGROUND

Different methods of regional anesthesia education have been described in the literature, but none have proven to be superior. The objective of this study was to evaluate the educational value as perceived by the anesthesia resident of a regional anesthesia workshop.

METHODS

Twenty-eight anesthesia residents participated in a workshop, which reviewed nerve blocks of the upper and lower extremities. Prior to the workshop, each resident completed a survey assessing their confidence in their ability to perform 13 nerve blocks. At the conclusion of the workshop and at 3 months post-workshop, the residents completed similar surveys. Paired sample t-test was used to compare pre- and post-workshop confidence levels.

RESULTS

Twenty-eight residents completed the pre-, post-, and 3-month follow-up questionnaires. There was a statistically significant increase in residents' confidence level post-workshop for 11 block s evaluated. This was sustained in 5 blocks at the 3 month follow-up survey. Senior residents had higher baseline confidence scores when compared to junior residents. When all blocks were considered, junior residents demonstrated a statistically signifi cant increase in confidence level in independently performing nerve blocks immediately post workshop and at 3 month follow-up. Senior residents had a statistically significant increase in confidence level immediately post workshop, but not at the 3 month follow-up. 100% of participants found the workshop to be beneficial. Participants with less prior experience showed sustained increase in comfort levels at 3 months post-workshop (p=0.007).

CONCLUSIONS

Based on self-reported trainee comfort level, the workshop was an effective teaching tool. Future workshops might be most effective when targeted at learners with less baseline regional anesthesia experience. Peripheral nerve block workshops can provide an important adjunct in the regional anesthesia ed ucation of resident anesthesiologists.

Trends in cardiac surgery-associated acute renal failure in the United States: a disproportionate increase after heart transplantation

Acute renal failure (ARF) is common after cardiac surgery and more frequent after complex cardiac surgery. While the incidence of ARF is increasing after coronary artery bypass graft (CABG) surgery, trends in other forms of cardiac surgery remain unclear. We investigated the trend of ARF in various cardiac procedures and compared patterns using CABG surgery as a reference group. The study population consisted of discharges from the Nationwide Inpatient Sample from 1988 to 2003, grouped according to surgery as: CABG, CABG with mitral valve, CABG with other valve, valve alone, and heart transplant. Standard diagnostic codes were used to identify ARF among discharges. Multivariable regression was used to determine trends in ARF among various procedures with CABG as a reference group. The incidence of ARF increased in all five groups (p < 0.001) over the 16-year period. The ARF incidence was highest in the heart transplant group (17%). Compared to the CABG population, patients following heart transplantation developed ARF at higher rates during the study period. In contrast, while ARF increased over time in other groups, the rates of rise were slower than in CABG patients. Among heart surgery procedures, ARF incidence is highest in heart transplantation. The incidence of ARF is also increasing at a faster rate in this group of patients in contrast to other procedure groups when compared to CABG surgery. The disproportionate increase in ARF burden after heart transplantation is a concern due to its strong association with chronic kidney disease and mortality.