3rd-year Residents Research Articles

Diagnostic value of routine CT perfusion imaging for radiology residents

To evaluate whether incorporating CT perfusion imaging can significantly enhance diagnostic CT accuracy in stroke detection. Two 3rd-year residents (3rd of 5 years of residency) reviewed CT scans of 200 patients with suspected stroke, consisting of 104 patients with a proven stroke and a control group with 96 patients. They analyzed each patient in a blinded and randomized manner in two runs. In one session, they had only non-contrast CT and CT angiography available for diagnosis; in the other session at a later time point, an additional CT perfusion imaging was available. The performance achieved by the two readers was determined in terms of AUC (area under the curve), accuracy, sensitivity, specificity, positive and negative predictive value and Cohen’s Kappa. Reader 1 achieved an AUC of 87.64% with the basic stroke-protocol vs. an AUC of 97.4% with an additional CT-perfusion given. Based on the DeLong test, these values differ significantly (p-value: 0.00017). Reader 2 achieved an AUC of 91.23% in basic stroke-protocol vs. an AUC of 96.42% with an additional CT-perfusion. These values also differ significantly (p-value: 0.02612).. The performance gain achieved with CT-perfusion is most evident in the decrease in the number of false classified cases (Reader 1: 24 to 5; Reader 2: 18 or 14 to 7) and the significant increase in Cohen’s kappa. Our study shows that additional CT-perfusion imaging in stroke diagnosis significantly improves the diagnostic reliability of residents. Therefore, it should be further investigated whether perfusion imaging should be a general standard of initial stroke diagnosis no matter of the onset.

Assessment and improvement of goals of care discussion by internal medicine residents.

191 Background: End-of-life goals and quality of life are intrinsically connected, focusing on providing care that maximizes comfort, dignity, and personal satisfaction during the final stages of life. Residents are primarily involved in Goals of care (GOC) discussion in hospitalized patients it is an integral component in Internal Medicine (IM) resident education. Literature has shown improved outcomes in delivering bad news by residents and oncology fellows after workshops, lectures, and courses. We aimed to improve Residents' competency in effective GOC discussion. Methods: We devised a questionnaire with the help of palliative care specialists and distributed it via a Google survey to the IM residents. After the survey, a palliative care specialist lectured about understanding the POLST form and components of Code Status Discussions. The same questionnaire was sent again. Five survey questions were used as post-lecture improvement parameters, and residents were stratified among three different classes: Interns, Year 2, and Year 3. Results: Before the lecture, residents were asked about their comfort level on a scale from 1-10, with 10 being the most comfortable conducting GOC discussions with the patient or the patient's family. As per the combined survey of all three classes, 50% of residents scored seven or above. Post lecture, 69.3% of intern year residents and 100% of 2nd and 3rd-year residents scored seven and above, which showed significant improvement in residents' comfort level while conducting GOC discussions. The parameters analyzed were the ability to explain SPIKES protocol for 'Breaking Bad News. Initially, 58.3% of the residents were comfortable explaining it, while 41.7 % answered negatively. After the survey, 84.6% from the intern year, 92.3% in 2nd year, and 77.8% of 3rd-year residents stated being comfortable with explaining SPIKES protocol. Another evaluated paradigm was the residents' ability to determine the patient's prognosis using any given scale/score (like the UCSF prognosis calculator). 33.3 % of the residents said 'yes' while 30.6% answered 'maybe.' Post-intervention, 100% of 3rd-year residents and 61.5% of 2nd-year residents, while 30.8% of intern-year residents said 'yes.' The cumulative mean of all three combined classes was 64.1%, which showed significant improvement compared to pre-intervention 33.3%. Conclusions: The results show that residents' comfort level of conducting GOC discussions improved with a single lecture on the topic. Further interventions and mentorship are needed. Intern-year residents were found to have a lower level of subjective comfort in conducting these discussions, which can be explained by their being relatively new to the work environment. A more integrated approach at the beginning of the residency training regarding GOC discussion training can improve interns' confidence and comfort for ensuing such discussions.

Comparison of Three Tracheal Intubation Procedures Using Personal Protective Equipment, Direct and Video Laryngoscopes: An Open, Randomized, Parallel Clinical Trial

Background: During the COVID-19 pandemic, severe respiratory failure is a life-threatening condition, and life-saving tracheal intubation is a high-risk aerosol- and droplet-generating procedure. It is crucial to protect healthcare workers without compromising patient safety during intubation. The use of personal protective equipment (PPE) and different types of laryngoscopes are measures to reduce the risk of infectious transmission that might impact the intubation process. Objectives: This study aimed to evaluate the effects of different levels of PPE and types of laryngoscopes on the duration of the intubation process and its success rate. Methods: We conducted an open, randomized, parallel clinical trial on non-COVID-19 adult patients scheduled for elective and emergency surgeries under general anesthesia from November 2021 to May 2022. Patients were divided into three groups: Group 1 was intubated using a video-guided laryngoscope with operators wearing level three PPE; group 2 was intubated using a direct laryngoscope with operators wearing level three PPE; and group 3 was intubated using a direct laryngoscope with operators wearing level two PPE. Intubation was performed by 2nd- and 3rd-year anesthesia residents. Results: The duration of intubation varied significantly among the groups, with Group 1 taking the longest time (P = 0.046). Group 3 had a higher success rate for first-attempt intubation (P = 0.056). Conclusions: The use of PPE and video-guided laryngoscopy had varying effects on the intubation procedure, with the most notable impact being on the overall length of intubation. Further research with a larger sample size is needed to validate these findings.

Comparing Leadership Skills of Senior Emergency Medicine Residents in 3-Year Versus 4-Year Programs During Simulated Pediatric Resuscitation: A Pilot Study.

The majority of pediatric patients in the United States (US) are evaluated and treated at general emergency departments. It is possible that discrepancies in length of emergency medicine (EM) residency training may allow for variable exposure to pediatric patients, critical resuscitations, and didactic events. The goal of this pilot study was to compare leadership skills of graduating EM residents from 3- to 4-year programs during simulated pediatric resuscitations using a previously validated leadership assessment tool, the Concise Assessment of Leader Management (CALM). This was a prospective, multicenter, simulation-based cohort pilot study that included graduating 3 rd - and 4 th -year EM resident physicians from 6 EM residency programs. We measured leadership performance across 3 simulated pediatric resuscitations (sepsis, seizure, cardiac arrest) using the CALM tool and compared leadership scores between the 3 rd - and 4 th -year resident cohorts. We also correlated leadership to self-efficacy scores. Data was analyzed for 47 participating residents (24 3 rd -year residents and 23 4 th -year residents). Out of a total possible CALM score of 66, residents from 3-year programs scored 45.2 [SD ± 5.2], 46.8 [SD ± 5.0], and 46.6 [SD ± 4.7], whereas residents from 4-year programs scored 45.5 [SD ± 5.2], 46.4 [SD ± 5.0], and 48.2 [SD ± 4.3] during the sepsis, seizure, and cardiac arrest cases, respectively. The mean leadership score across all 3 cases for the 3-year cohort was 46.2 [SD ± 4.8] versus 46.7 [SD ± 4.5] ( P = 0.715) for the 4-year cohort. These data show feasibility for a larger cohort project and, while not statistically significant, suggest no difference in leadership skills between 3 rd - and 4 th -year EM residents in our study cohort. This pilot study provides the basis of future work that will assess a larger multicenter cohort with the hope to obtain a more generalizable dataset.

Assessment of knowledge, attitude, and practice on early childhood caries among dental undergraduates and residents in China

BackgroundEarly childhood caries (ECC) causes severe, widespread oral health issues in children. Dental undergraduates and residents are expected to have a solid understanding of ECC for children’s oral health promotion. This study aimed to evaluate the knowledge, attitude, and clinical practice on ECC among dental undergraduates and residents in China.MethodsA 23-item electronic questionnaire was distributed to 598 dental undergraduates (4th- and 5th-year undergraduates) and residents (1st-, 2nd-, and 3rd-year residents) at the School of Stomatology, Wuhan University, China (in April–May 2023). SPSS Statistics was used to analyze the data using the Chi-square test at a significance level of 0.05.ResultsA total of 422 questionnaires were completed by participants (recovery rate: 70.6%) from various academic levels. Around 77.3% of participants had heard of ECC (mainly from textbooks), and only 27.5% considered themselves familiar with it. Residents (79.8%) had higher risk awareness of ECC on children’s overall health than undergraduates (58.3%) (p < 0.05), but only 54.0% of participants correctly defined ECC. Most participants had a positive understanding of ECC’s pathogenic factors and preventive measures, including feeding patterns (71.6%), fluoride application (93.4%), and teeth cleaning (93.1%). Furthermore, only 50.2% of participants encountered ECC cases in clinic.ConclusionsDespite having a suboptimal level of ECC-related knowledge and practice, dental undergraduates and residents in China demonstrated a more positive attitude towards its etiology-based prevention. Strengthening ECC education, guidance, and practice may enable them to gain a better understanding of ECC learning, which would benefit children’s oral health.

Simulation-based training using a novel Surabaya hysterectomy mannequin following video demonstration to improve abdominal hysterectomy skills of obstetrics and gynecology residents during the COVID-19 pandemic in Indonesia: a pre- and post-intervention study.

PurposeDuring the coronavirus disease 2019 (COVID-19) pandemic, the number of abdominal hysterectomy procedures decreased in Indonesia. The existing commercial abdominal hysterectomy simulation model is expensive and difficult to reuse. This study compared residents’ abdominal hysterectomy skills after simulation-based training using the Surabaya hysterectomy mannequin following a video demonstration.MethodsWe randomized 3rd- and 4th-year obstetrics and gynecology residents to a video-based group (group 1), a simulation-based group (group 2), and a combination group (group 3). Abdominal hysterectomy skills were compared between before and after the educational intervention. The pre- and post-tests were scored by blinded experts using the validated Objective Structured Assessment of Technical Skills (OSATS) and Global Rating Scale (GRS).ResultsA total of 33 residents were included in the pre- and post-tests. The OSATS and GRS mean differences after the intervention were higher in group 3 than in groups 1 and 2 (OSATS: 4.64 [95% confidence interval [CI], 2.90–6.37] vs. 2.55 [95% CI, 2.19–2.90] vs. 3.82 [95% CI, 2.41–5.22], P=0.047; GRS: 10.00 [95% CI, 7.01–12.99] vs. 5.18 [95% CI, 3.99–6.38] vs. 7.18 [95% CI, 6.11–8.26], P=0.006). The 3rd-year residents in group 3 had greater mean differences in OSATS and GRS scores than the 4th-year residents (OSATS: 5.67 [95% CI, 2.88–8.46]; GRS: 12.83 [95% CI, 8.61–17.05] vs. OSATS: 3.40 [95% CI, 0.83–5.97]; GRS: 5.67 [95% CI, 2.80–8.54]).ConclusionSimulation-based training using the Surabaya hysterectomy mannequin following video demonstration can be a bridge to learning about abdominal hysterectomy for residents who had less surgical experience during the COVID-19 pandemic.

The "Plan-Do-Check-Action" Plan Helps Improve the Quality of the "Standardized Training of Resident Physicians": An Analysis of the Results of the First Pass Rate.

Background: Medical education is a demanding lifelong learning process, which includes three tightly connected stages: college education, post-graduate education, and continuous education. Residency, the first several years after a college education, is a pivotal time in the development of a qualified doctor. Additionally, residents are the main force that undertakes much of the clinical work in hospitals. Therefore, guaranteeing and improving residents' clinical skills and abilities through the standardized training of resident physicians (STRP) is important. However, compared with other hospitals in the Zhejiang Province, the STRP assessment results of residents in our hospital were not satisfactory in recent years. Therefore, the objective of this study was to find the problems causing the unsatisfactory performance and identify the role of the “Plan-Do-Check-Action” (PDCA) plan in providing a valuable framework for future training.Methods: Relevant studies of STRP in China and abroad were investigated by the literature review. According to published data by the Health Commision of Zhejiang Province, we collected the STRP assessment rsults of a total number of 12,036 residents. The inclusion cretria of these residents include: (1) 3rd-year residents. (2) taking STRP in the Zhejiang Province during 2016–2018 or 2017–2019. (3) the first time taking the clinical practice ability examination (CPAE) in 2018 or 2019. The results of 634 3rd-year residents from The Second Affiliated Hospital of Zhejiang University (SAHZU) were provided by the Department of Medical Education and were analyzed in depth. Three hundred and eight residents from SAHZU received normal training and took the CPAE in 2018, whereas 326 residets received PDCA and took the CPAE in 2019. PDCA is a program designed to improve the performance of residency in SAHZU. It includes the formulation and implementation of specific training plans, the check of effects, and continuous improvements. There was no change in the STRP assessment in these 2 years and the indicator of performance in the STRP assessment was the first pass rate (FPR). Statistical analyses were performed using Pearson's chi-squared test, Yates-corrected chi-square test, or Fisher's exact test (SPSS Statistics, version 25). A P-value of < 0.05 was considered significant.Results: A total number of 6,180 and 5,856 examinees in the Zhejiang Province took the clinical practice ability examination in 2018 and 2019, respectively. In 2018, a total of 308 residents from 20 departments of the SAHZU took the STRP assessment. In 2019, a total of 326 residents from 22 departments of the SAHZU underwent the PDCA plan and took the STRP assessment. Compared with the results in 2018, the average FPR in the Zhejiang Province increased by 2.92% from 87.87 to 90.79% (P < 0.001). The FPR of the SAHZU increased by 7.88% from 85.06 to 92.94% (P = 0.001). In the SAHZU, the FPRs of the Department of Emergency and Department of Anesthesiology improved 34.51% (P = 0.024) and 20.36% (P = 0.004), respectively. There were no significant differences between the performances in the 2 years of the other 20 departments. There were improved results in the “Clinical Thinking and Decision-Making” and “Operation of Basic Skills” assessment stations with increases of 3.01% (P = 0.002) and 3.94% (P = 0.002), respectively. No statistically significant differences in the FPRs of the other six stations were found. The performances in all the stations in the final tests were better than in the stimulation tests (P < 0.001).Conclusions: Although our sample size was relatively small, our results showed a small success of the PDCA plan in improving the quality of the STRP, especially for the residents in the Departments of Emergency and Anesthesiology. The PDCA plan also contributed to enhancing residents' abilities in the “Clinical Thinking and Decision-Making” and “Operation of Basic Skills” stations. Taken together, the PDCA plan may provide a practical framework for developing future training plans.

Comparison of Simulation-Based versus Cadaveric-Tissue-Based Ocular Trauma Training on Novice Ophthalmologists: Repair of Corneal Laceration Model.

Purpose The aim of this study was to evaluate whether the simulated tissue models may be used in place of animal-based model for corneal laceration repair for surgical skills acquisition. Design Prospective randomized controlled trial. Participants Seventy-nine military and civilian 2nd- and 3rd-year ophthalmology residents and 16 staff ophthalmologists participating in the Tri-Service Ocular Trauma Skills Laboratory at the Uniformed Services University (Bethesda, MD). Methods Resident ophthalmologists underwent preliminary evaluation of their ability to close a 5-mm linear, full-thickness corneal laceration involving the visual axis. They then were randomized to undergo 90 to 120 minutes of either simulator-based (SIM) or swine cadaveric-tissue-based (CADAVER) corneal laceration repair. The same evaluation was performed post training. On a more limited basis, the study was repeated for attending ophthalmologists to act as a pilot for future analysis and test efficacy for "refresher" training. Main Outcome Measures Successful wound closure with secondary outcomes of suture length, tension, depth, and orientation, as graded by attending ophthalmologists. Results No significant difference in CADAVER versus SIM groups in the primary outcome of watertight wound closure of the corneal laceration. CADAVER group performed better than SIM group for certain metrics (suture depth, p = 0.009; length, p = 0.003; and tension, p = 0.043) that are associated with poor wound closure and increased amount of induced corneal astigmatism. For attending ophthalmologists, six of the eight in each group (SIM and CADAVER) retained or improved their skills. Conclusions For resident ophthalmologists, SIM training is sufficient for achieving the primary outcome of watertight wound closure. However, CADAVER training is superior for wound metrics for the ideal closure. For attending ophthalmologists, SIM training may be useful for retention of skills.

Attitudes of the Third-Year Clinical Anesthesiology Residents Toward an Independent Clinical Practice Rotation in COVID-19 Pandemic in Iran.

BackgroundCOVID-19 was a worldwide pandemic with international health emergencies and great challenges; health care personnel shortage and physician burnout is a potential major challenge that should be planned and managed; especially in those countries with a high COVID-19 occurrence.ObjectivesThis study was designed to assess the attitudes of 3rd-year anesthesiology residents toward an independent one month-length clinical care course for patients with COVID-19.MethodsA closed self-administered questionnaire was developed to assess the attitudes of 3rd-year clinical anesthesiology residents. A self-administered closed questionnaire was developed. Cronbach’s alpha was calculated to measure the reliability of the questionnaire; added with a factor analysis process.ResultsAll 19 clinical anesthesiology residents took part in the study, with a 100% response rate. Cronbach’s alpha for the reliability of the questionnaire was 0.678. The eigenvalue for 8 factors was equal to 1; however, further assessment led us to 7 factors.ConclusionsThis one-month period could improve the competencies of the 3rd year clinical anesthesiology residents based on their viewpoints. Since the COVID-19 pandemic is ongoing health and social problem worldwide, 3rd-year anesthesiology residents could help the health system to recover health care delivery faults regarding manpower; a promising point for crisis preparedness in the COVID-19 pandemic. Besides, there were many constructive results for the clinical anesthesiology residents regarding their training and clinical service delivery.

Exploratory analysis on the usage of Pi-score algorithm over endoscopic stone treatment step 1 protocol.

The Performance Improvement score (Pi-score) has been proven to be reliable to measure performance improvement during E-BLUS hands-on training sessions. Our study is aimed to adapt and test the score to EST s1 (Endoscopic Stone Treatment step 1) protocol, in consideration of its worldwide adoption for practical training. The Pi-score algorithm considers time measurement and number of errors from two different repetitions (first and fifth) of the same training task and compares them to the relative task goals, to produce an objective score. Data were obtained from the first edition of 'ART in Flexible Course', during four courses in Barcelona and Milan. Collected data were independently analyzed by the experts for Pi assessment. Their scores were compared for inter-rater reliability. The average scores from all tutors were then compared to the PI-score provided by our algorithm for each participant, in order to verify their statistical correlation. Kappa statistics were used for comparison analysis. Sixteen hands-on training expert tutors and 47 3rd-year residents in Urology were involved. Concordance found between the 16 proctors' scores was the following: Task 1=0.30 ("fair"); Task 2=0.18 ("slight"); Task 3=0.10 ("slight"); Task 4=0.20, ("slight"). Concordance between Pi-score results and proctor average scores per-participant was the following: Task 1=0.74 ("substantial"); Task 2=0.71 ("substantial"); Task 3=0.46 ("moderate"); Task 4=0.49 ("moderate"). Our exploratory study demonstrates that Pi-score can be effectively adapted to EST s1. Our algorithm successfully provided an objective score that equals the average performance improvement scores assigned by of a cohort of experts, in relation to a small amount of training attempts.

Teaching Glasgow Coma Scale Assessment by Videos: A Prospective Interventional Study among Surgical Residents

Objective Glasgow Coma Scale (GCS) assessment is vital for the management of various neurological, neurosurgical, and critical care disorders. Learning GCS scoring needs good training and practice. Due to limitation of teachers, the new entrants of the clinical team find it difficult to learn and use it correctly. Training through videos is being increasingly utilized in the medical field. This study aimed to evaluate the efficiency of video teaching of GCS scoring among general surgery residents. Materials and Methods A prospective study was done utilizing the freely available video at glasgowcomascale.org. The participants (general surgery residents, 1st–3rd year) were asked to assess and record their responses related to GCS both before and after watching the video. A blinded neurosurgeon recorded the correct responses separately. Statistical Analysis The difference between correct responses of the residents before and after watching the video was calculated using the “chi-square test.” p -Value ≤ 0.05 was taken as significant. Results There was a significant improvement in GCS scoring by residents after watching the videos ( p < 0.05). On estimating the responses separately, all the three responses (eye, verbal, and motor) improved significantly for 1st-year residents while only the motor response improved significantly for 2nd- and 3rd-year residents. The mode subjective improvement for the 1st-, 2nd-, and 3rd-year residents was 5, 4, and 3, respectively. Conclusion Training GCS scoring through videos is an effective way of teaching the surgery residents with maximum benefit to the junior-most ones.

A Comparative Assessment of Intraoperative Complication Rates in Resident-Performed Phacoemulsification Surgeries According to Najjar-Awwad Preoperative Risk Stratification.

IntroductionPhacoemulsification cataract surgery presents a challenge to resident surgeons with lower experience, which confronts with patient safety. In this study, we compared major intraoperative surgical complications of resident-performed phacoemulsification surgeries between cases with low intraoperative risk and random cases with unknown intraoperative risk.MethodsThis prospective randomized controlled study was done on patients who underwent phacoemulsification surgery by third- and fourth-year residents in Khatam-al-Anbia eye hospital, Mashhad, Iran. Preoperative risk was calculated using Najjar-Awwad risk score after slit lamp examination and the patients with scores 7 or higher were considered high-risk. Patients were randomly assigned into a study group, in which only low-risk cases were operated by third-year residents, or control group, in which third-year residents were able to operate any patient regardless of the risk score. In both groups, the remaining patients were operated by fourth-year residents. All intraoperative complications were recorded. Data were analyzed using SPSS, considering P<0.05 significant.ResultsOverall, 475 patients with cataract in the study (N=232) and control (N=243) groups were operated. Mean overall Najjar-Awwad risk scores did not differ significantly between the groups, but pseudoexfoliation and poor pupil dilatation occurred significantly more frequently in the control group (P=0.010 and P=0.014, respectively). Overall, 36 surgeries in the study group (15.5%) and 47 surgeries in the control group (19.3%) were complicated (P=0.273). There was a significant difference between the third- and fourth-year residents regarding the inability to complete continuous curvilinear capsulorhexis (P=0.033). The risk of overall and major complications in high-risk cases was significantly higher among those operated by 3rd-year residents compared with those operated by 4th-year residents (OR=3.45, 95% CI=1.2–9.9, P=0.016 and OR=6.37, 95% CI=1.99–20.34, P=0.001, respectively).ConclusionAlthough supervised resident-performed phacoemulsification has a relatively safe learning curve in our residency program, it is best to stratify preoperative risk and assign high-risk cases to senior residents with higher experience.

INTER- AND INTRA-OBSERVER RELIABILITY OF SCHATZKER, AO, AND LUO CLASSIFICATIONS FOR TIBIAL PLATEAU FRACTURES.

ABSTRACTObjective: To verify inter- and intra-observer agreement of three classification systems for tibial plateau fractures - Schatzker, AO/ASIF, and Luo’s - among orthopedic surgery residents. Methods: This cross-sectional study was conducted with 29 observers. Radiographic and tomographic imaging of the knee of 15 patients presenting with fractures were evaluated. After six weeks, the test was reapplied. The level of agreement was calculated by the Kappa index. Results: In test 1, inter-observer agreement of all residents, according to the Kappa index, for Schatzker classification was 0.226, for AO 0.431, and Luo’s 0.319. In test 2, values were 0.316, 0.333, and 0.347, respectively (p < 0.001). Regarding intra-observer analysis, the mean Kappa indexes of 1st-year residents were: Schatzker, 0.20; AO, 0.32; and Luo’s, 0.3. For 2nd-year residents, means were: 0.51, 0.58, and 0.38, respectively. As for 3rd-year, results were 0.42, 0.42, and 0.41, respectively (p < 0.001). Conclusion: AO/ASIF showed a better reproducibility than other classifications, with substantial inter- and intra-observer agreement. We also found a stronger agreement among 2nd- and 3rd-year residents. Level of Evidence III, Diagnostic Studies - Investigating a Diagnostic Test.

Safety and feasibility of single-port laparoscopic appendectomy as a training procedure for surgical residents.

Background:Single-port laparoscopic appendectomy (SPLA) is one of the most commonly performed single-port surgeries worldwide. This study aimed to determine whether the performance of SPLA by residents without sufficient experience as operators of conventional LA (CLA) is safe and feasible.Patients and Methods:Records of patients who underwent LA between March 2017 and February 2018 at a hospital in Korea were retrospectively analysed. Patients aged <18 years or >80 years were excluded from the study. SPLA and CLA were performed by two 2nd-year residents (junior group) and three 3rd-year residents (senior group). Demographic data, perioperative variables and surgical outcomes were compared.Results:During the study period, 154 patients underwent LA (104 SPLA and 50 CLA) performed by surgical residents. No differences were found between the SPLA and CLA groups in demographic data or perioperative variables, except for the drain insertion rate. The SPLA group had significantly shorter mean operation times than did the CLA group. No significant difference was observed between the junior and senior groups in the mean operation time for LA. Perioperative outcomes were not significantly different between groups. Fewer women underwent SPLA performed by 2nd-year residents compared with SPLA performed by 3rd-year residents. However, there were no differences in other general characteristics or perioperative outcomes.Conclusions:SPLA was safe and feasible when performed by junior residents. Surgical residents with sufficient experience as assistants during laparoscopic appendectomies could perform SPLA safely. Furthermore, SPLA could serve as a teaching procedure for surgical residents.

Abstract 190: Does Gender Matter? Addressing the Question of Gender Superiority in Resuscitation Leadership

Introduction: Effective team leadership is linked to better patient care during resuscitations. Several studies suggest a relationship between team leader gender and the quality of resuscitation leadership and clinical care. However, these studies have been either (1) retrospective investigations that do not capture clinical care processes or (2) simulation-based research involving novice medical student subjects. The objective of this study is to compare the quality of team leadership and clinical care between male- and female-led trauma resuscitation teams. Hypothesis: We hypothesize that team leader gender is not associated with differences in trauma team leadership and clinical care Methods: We performed a secondary analysis of prospectively acquired data by analyzing video recordings of trauma resuscitations at a Level 1 trauma center. Subjects (n=60) included 2 nd and 3 rd year emergency medicine and surgery residents functioning in the team leader role. Two video recorded observations for each participant (n=120) were coded for team leadership and clinical care by two sets of raters balanced with regard to gender and blinded to study hypothesis. Duplicate coding was performed on 10% of the observations. We analyzed data using random coefficient modeling (RCM), controlling for patient injury severity score and subject postgraduate training year. Results: We found no significant difference between men and women on team leadership behavior (p=.43; Men: M=7.63, SE = 0.54; Women: M = 8.67, SE = 0.74) nor on clinical care (p=.39; Men: M = 62.32, SE = 1.50; Women: M = 64.87, SE = 2.57). Effect sizes were modest in favor of women and nonsignificant for both team leadership behavior ( d = .26) and clinical care ( d =.21). Conclusion: Our prospective evaluation of team leadership quality and clinical care during trauma resuscitations does not support a male performance advantage, contradicting previous simulation-based work. Focusing on effective team leadership behaviors, not inherent traits and leadership styles, will allow resuscitation leaders to optimize their individual and team performance, irrespective of gender. Further work is needed to develop training and cognitive aids capable of supporting team leadership during complex resuscitative care.

Predictors for Failing the American Board of Radiology Core Examination.

OBJECTIVE. Since the American Board of Radiology (ABR) instituted its new board certification pathway, our residency program has had more residents fail the core examination than was typical with the prior pathway. We performed a single-center retrospective study to evaluate predictors of ABR core examination failure. MATERIALS AND METHODS. Data regarding U.S. Medical Licensing Examination (USMLE) steps 1 and 2, ACR diagnostic radiology in-training examinations, the number of image interpretations, academic degree (doctor of medicine or doctor of osteopathy), status as an American or foreign medical graduate, and Alpha Omega Alpha national medical honor society status were gathered and evaluated through logistic regression and generalized additive logistic regression. Data were gathered for all residents who took the ABR core examination from 2013 to 2017. RESULTS. Six of 30 residents (20%) failed the ABR core examination on the first attempt. The ACR in-training examination scores for 1st- and 3rd-year residents were significantly related to ABR core examination failure (p = 0.027 and p = 0.035, respectively), with significant nonlinearity (p = 0.037 and p = 0.033, respectively). The suggested baseline percentile score was the 30th percentile for 1st-year residents and the 20th percentile for 3rd-year residents. USMLE step 1 and 2 scores were significantly related to ABR core examination failure (p = 0.041 and p = 0.043, respectively), without significant nonlinearity (p = 0.35 and p = 0.09, respectively). However, residents with scores of less than 220 on USMLE steps 1 and 2 seemed to be at risk. CONCLUSION. Low scores on USMLE steps 1 and 2 and 1st- and 3rd-year ACR in-training examinations were associated with ABR core examination failure. If validated more broadly, these cutoffs may serve as predictors of ABR core examination failure and may facilitate identification and remediation of at-risk residents.

Evaluation of Change in Knowledge and Attitude of Emergency Medicine Residents after Introduction of a Rotation in Emergency Medical Services and Disaster Medicine.

Background:Saudi Board of Emergency Medicine (SBEM) graduates are involved in a 1-month rotation in emergency medical services (EMSs) and disaster medicine. The purpose of this study was to evaluate change in knowledge and attitude of EM residents after the introduction of the EMS and disaster medicine rotation.Materials and Methods:The study included 32 3rd-year SBEM residents. A pretest/posttest design and a five-point Likert scale were used. The data included a response to a questionnaire developed by EMS and disaster experts. The questionnaire was distributed on the 1st day of the rotation and 45 days after. Satisfaction questionnaires were distributed after the rotation. The data were analyzed using SPSS 20.Results:Twenty-five residents responded to the satisfaction survey (75%). The overall satisfaction with the course modules was high; the course content showed the highest level of satisfaction (96%), and the lowest satisfaction was for the air ambulance ride outs (56%). The results of the pre-/post-test questionnaire showed an increase of 18.5% in the residents mean score (P < 0.001). In the open-ended section, the residents requested that the schedule is distributed before the course start date, to have more field and hands-on experience, and to present actual disaster incidents as discussion cases. The residents were impressed with the organization and diversity of the lectures, and to a lesser extent for the ambulance ride outs and the mass casualty incident drill l. Seventy-one percent indicated that they would recommend this course to other residents.Conclusion/Recommendation:This study showed that a structured course in EMS and disaster medicine had improved knowledge and had an overall high level of satisfaction among the residents of the SBEM. Although overall satisfaction and improvement in knowledge were significant, there are many areas in need of better organization.

6 Financial Impact of Scribes in an Academic Emergency Department

Interest in scribe programs and their implementation in emergency departments (EDs) have grown considerably since they were first implemented in the early 1990s. Several publications describe the financial advantages to scribes, both in the community ED and out-patient clinic setting; however, there is limited information regarding the fiscal impact of a scribe program in an academic emergency medicine department. The University of North Carolina (UNC) Department of Emergency Medicine provides care to approximately 72,000 patients annually, with an admission rate of just below 30 percent. UNC is a certified level 1 trauma center, state burn center and TJC comprehensive stroke center with 30 total emergency medicine residents. Given the limited data on scribes in an academic setting, we implemented a scribe pilot program in March 2013 to evaluate the financial impact of scribes. For this study, June 2013 charts were examined retrospectively. Scribes were assigned to a PGY-2 physician, PGY-3 physician, nurse practitioner (NP), or an attending provider during an eight-hour shift during the busiest time of the day. To measure the impact of scribes on revenue, charts were broken into two groups consisting of patients seen with a scribe (n=461) and those seen without a scribe (n=744). Financial data collected included wRVUs and date of service (DOS) to time until the bill is finalized for the patient. Statistical analysis was done using a two-tailed T-test and with P values ≤ 0.05 considered statistically significant. In our study a total of 1,205 patient charts were reviewed. We analyzed data in several groups, including all charts for the month as well as in cohorts divided by level of provider training (3rd year residents, 2nd year residents, 1st year residents, NPs, attending only, and other care providers including medical students). Scribes did not significantly increase wRVUS when all providers were considered together (P=0.9056); however, they did show significance when charts for 3rd-year residents and patients seen only by attendings were evaluated separately (P=0.0006 and 0.0394 respectively). Further, significant decrease in DOS to the finalized patient bill was observed when scribed charts were compared to charts completed without scribe utilization (P=0.000). With senior residents and attending physician charts, significant increases in wRVUS were seen suggesting that scribes allowed for more complete documentation of the higher acuity patient population normally seen by these two groups of providers at our facility. Equally important, scribes allowed for timelier billing, suggesting quicker completion of charts. Limitations include the length of time evaluated and the use of an institution-funded, recently implemented scribe program to conduct this study. Additionally, data collected reflects provider performance only two months after scribe program implementation; time is required to allow scribes to mature into their roles as well as for providers to learn the best way to utilize them. As the use of scribes continue within the department and more physicians become familiar with their skill set, further studies will be conducted to determine the true financial impact of scribes in the academic setting.

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Introduction: New resident duty hour restrictions aimed at reducing sleep deprivation have the unintended consequences of limiting exposure to high-risk, low frequency diseases and reducing closed loop learning during each case. Sepsis is a bloodstream infection that presents in relatively subtle ways, is often confused with more common conditions that are less urgent and can be deadly unless detected and treated relatively quickly. Critical decision method (CDM) is an interviewing technique that allows improved recall and description of healthcare provider diagnostic and management thought processes. Simulation-based training offers a potential strategy to increase resident exposure to critical illnesses, such as sepsis, over a range of presentations and in a safe environment. Methods: Five study team members were trained in the CDM approach. Interviewer pairs included one experienced pediatrician [from critical care (CC) or emergency medicine (EM)] and one qualitative researcher. Interviews lasted one hour during which respondents identified challenging cases of sepsis. Interviews were transcribed and then coded for identified cues and strategies surrounding recognition of sepsis and early management. Prior to coding, a card sort technique was employed to identify potential coding categories. Post-coding investigators met to reconcile variances. The coding sheet was iteratively refined and clear definitions for each category and sub-category were developed. Simulation scenarios were developed based on critical incidents, interview findings and coding results, then a seperate cohort of pediatric residents and attendings were enrolled to pilot the scenarios. Measures included an adapted version of the situation awareness global assessment technique (SAGAT) to assess each participant’s understanding of the situation at three points in each scenario and novel PALS-based and early goal-directed therapy (EGDT) checklists to evaluate assessment and management skills. Results: Twenty-three patient-based sepsis incidents were discussed in 14 interviews (8 pediatric resident physicians, 3 pediatric EM attendings, and 3 pediatric CC attendings). Coding categories included classic indicators/consensus criteria, experience-based criteria, medical history and source of information. For example, for pediatric interns in particular concerns voiced by parents were an important cue as to the seriousness of the patient’s condition whereas experienced-based criteria were articulated more commonly by experienced clinicians, including distal perfusion, mental status changes, and ill-appearance. Critical cues identified drove the design of five scenarios presenting sepsis cases (2 compensated, 2 decompensated and 1 garden path) to support the development of perceptual skills and pattern recognition in the context of a challenging incident. Eighteen physicians (6 interns, 6 third-year residents, 5 EM attendings and 1 CC attending) were enrolled in the pilot course and randomized to 3 sepsis scenarios, as well as one non-sepsis scenario. Of the 54 sepsis scenarios, participants correctly identified sepsis in 33% (interns 29%, 3rd-year residents 38%, attendings 39%) as shown by the SAGAT, including only recognizing sepsis in 8 of 18 hypotensive (decompensated) patients. The novel PALS and EGDT checklists showed moderate levels of reliability (0.534, 0.446 respectively) when applied by video-based reviewers. Conclusions: CDM interviews revealed a set of critical cues and cue clusters that were integrated into simulation-based scenarios. Piloting of scenarios to distinguish novice and expert differences in recognition of sepsis prompted further revision of scenarios to realign cues misinterpreted in these pilot simulations. Additionally, novel assessment checklists were derived, validated and shown to be reliable. Currently, a full simulation-based course has been implemented for all first-year pediatric residents to accelerate their recognition and early management of sepsis.

Learning by Teaching an Unsuccessful “Cultural Sensitivity” Course

It has been several years since Sarah Willen conducted an ethnographic study of the cultural sensitivity course that a colleague and I taught to 3rd-year psychiatric residents. Although the results and feedback were not a surprise to me, they provided plenty of material for reflection on the factors that influenced its lack of success. Time has allowed me a more calm analysis and enabled me to consider possibilities that had not crossed my range of thoughts during the course or immediately thereafter.