Attending Supervision Research Articles

A Longitudinal Study of Adenoma Detection Rate in Gastroenterology Fellowship Training

Current guidelines suggest that a gastroenterology fellow in training needs to perform 140 colonoscopies to achieve competency. Data are limited regarding adenoma detection rate (ADR) in fellowship. To assess how fellow ADR correlates with number of colonoscopies performed. We performed a retrospective study examining consecutive colonoscopies performed by gastroenterology fellows. Fellow ADR before and after the 140 procedure benchmark was compared to colonoscopies performed by attending only with whom these fellows trained. A threshold for ideal procedure count was performed using ROC analysis. We analyzed 2021 average-risk colonoscopies performed by 10 gastroenterology fellows under the supervision of an attending physician. When fellows had performed <140 colonoscopies, the ADR was 27% compared with an ADR of 36% when fellows had performed >140 colonoscopies under attending supervision (p=0.02). The ADR of fellows who had performed >140 colonoscopies under attending supervision was greater than that of attending-only colonoscopies (36 vs. 25%, p<0.0001). A threshold of >325 (male patients) and 539 (female patients) colonoscopies was determined to be ideal for achieving adequate ADR based on ROC analysis. Our data suggest that ADR increases after fellows perform >140 colonoscopies under attending supervision, and thereafter surpasses the ADR of attending-only colonoscopies. Some of the differences may be driven by detection of small adenomas. The findings of this study suggest that a higher threshold for number of colonoscopies performed under attending supervision may be needed to achieve adequate ADR during fellowship prior to independent practice.

Does resident participation influence otolaryngology-head and neck surgery morbidity and mortality?

Patients may perceive resident procedural participation as detrimental to their outcome. Our objective is to investigate whether otolaryngology-head and neck surgery (OHNS) housestaff participation is associated with surgical morbidity and mortality. Case-control study. OHNS patients were analyzed from the American College of Surgeons National Surgical Quality Improvement Program 2006 to 2013 databases. We compared the incidence of 30-day postoperative morbidity, mortality, readmissions, and reoperations in patients operated on by resident surgeons with attending supervision (AR) with patients operated on by an attending surgeon alone (AO) using cross-tabulations and multivariable regression. There were 27,018 cases with primary surgeon data available, with 9,511 AR cases and 17,507 AO cases. Overall, 3.62% of patients experienced at least one postoperative complication. The AR cohort had a higher complication rate of 5.73% than the AO cohort at 2.48% (P < .001). After controlling for all other variables, there was no significant difference in morbidity (odds ratio [OR] = 1.05 [0.89 to 1.24]), mortality (OR = 0.91 [0.49 to 1.70]), readmission (OR = 1.29 [0.92 to 1.81]), or reoperation (OR = 1.28 [0.91 to 1.80]) for AR compared to AO cases. There was no difference between postgraduate year levels for adjusted 30-day morbidity or mortality. There is an increased incidence of morbidity, mortality, readmission, and reoperation in OHNS surgical cases with resident participation, which appears related to increased comorbidity with AR patients. After controlling for other variables, resident participation was not associated with an increase in 30-day morbidity, mortality, readmission, or reoperation odds. These data suggest that OHNS resident participation in surgical cases is not associated with poorer short-term outcomes. 3b Laryngoscope, 126:2263-2269, 2016.

Bedside Echocardiographically Guided Pericardiocentesis for Cardiac Tamponade after Coronary Artery Injury Secondary to Percutaneous Coronary Intervention: A Case Report and Descriptive Technique

Given over 2.64 million total percutaneous coronary interventions performed in the United States, and that acute cardiac tamponade is one of the most common complications of such percutaneous coronary interventions, clinicians should be familiar with diagnosing impending pericardial tamponade, and a simple and safe bedside technique for drainage. We describe a technique for echocardiographically guided rescue pericardiocentesis in the setting of acute tamponade to demonstrate the efficacy and safety of this technique for pericardial drainage with reduced complication risk as compared to a landmark-based approach. A case of a 52-year-old male was brought to the Emergency Department after a witnessed cardiac arrest. He underwent cardiac catheterization and percutaneous coronary stent implantation. Thirty minutes after stenting, the patient developed signs of cardiac tamponade, and point-of-care echocardiogram confirmed a pericardial effusion. An in-plane ultrasound-guided pericardiocentesis was successfully performed by the junior house-staff under direct attending supervision. Serial echocardiograms demonstrated preserved left ventricular systolic function without new effusion. The patient remained hemodynamically stable for 48 hrs following the procedure at which time the pericardial catheter was removed. Ultrasound image guided pericardiocentesis is a rapid and safe technique for pericardial drainage with reduced complication risk as compared to a landmark-based approach.

Are Orthopaedic Residents Competent at Performing Basic Nonoperative Procedures in an Unsupervised Setting? A "Pop Quiz" of Casting, Knee Arthrocentesis, and Pressure Checks for Compartment Syndrome.

Many patient care procedures are routinely performed by orthopaedic residents while not directly supervised by attending physicians. However, resident competence to perform these procedures is often presumed and not confirmed by objective measures. The purpose of this study was to formally evaluate 3 basic pediatric orthopaedic procedures commonly performed without attending supervision. All orthopaedic residents (n=20) were asked to complete 3 procedures (placement and removal of a short arm cast, aspiration of a knee joint, and compartment pressure checks of a leg) under direct attending supervision. Attending faculty developed a checklist for each procedure, listing the appropriate steps required and criteria with which to assess the final results. Scores were calculated, including means and SDs. Change in score by postgraduate year level was determined by simple linear regression. The mean score for short arm cast application and removal was 6.2 of a total possible score of 8, with an average 1.1 increase in score per year of training (P<0.001). Uneven cast padding and lack of full thumb motion were the most common reasons for losing points. Knee joint aspiration had an average score of 6.2 of 7, with an average increase in score of 0.3 per year of training (P=0.046). Lack of equipment preparation and not donning gloves in a sterile manner were the most common reasons for losing points. Measure of leg compartment pressures had an average score of 9.7 of 12, with an average increase in score of 0.5 per increase in year of training (P=0.087). Injecting an inappropriate amount of fluid and not recording measurements were the most common reasons for losing points. The ability of a resident to appropriately perform certain procedures without direct supervision improves with advancing level of training. The most junior residents might not appropriately be placing short arm casts, aspirating knee joints, or checking compartment pressures of the leg. Level II—Diagnostic.

Neurosurgical Skills Assessment: Measuring Technical Proficiency in Neurosurgery Residents Through Intraoperative Video Evaluations

Although technical skills are fundamental in neurosurgery, there is little agreement on how to describe, measure, or compare skills among surgeons. The primary goal of this study was to develop a quantitative grading scale for technical surgical performance that distinguishes operator skill when graded by domain experts (residents, attendings, and nonsurgeons). Scores provided by raters should be highly reliable with respect to scores from other observers. Neurosurgery residents were fitted with a head-mounted video camera while performing craniotomies under attending supervision. Seven videos, 1 from each postgraduate year (PGY) level (1-7), were anonymized and scored by 16 attendings, 8 residents, and 7 nonsurgeons using a grading scale. Seven skills were graded: incision, efficiency of instrument use, cauterization, tissue handling, drilling/craniotomy, confidence, and training level. A strong correlation was found between skills score and PGY year (P < 0.001, analysis of variance). Junior residents (PGY 1-3) had significantly lower scores than did senior residents (PGY 4-7, P < 0.001, t test). Significant variation among junior residents was observed, and senior residents' scores were not significantly different from oneanother. Interrater reliability, measured against other observers, was high (r= 0.581 ± 0.245, Spearman), as was assessment of resident training level (r= 0.583 ± 0.278, Spearman). Both variables were strongly correlated (r= 0.90, Pearson). Attendings, residents, and nonsurgeons did not score differently (P= 0.46, analysis of variance). Technical skills of neurosurgery residents recorded during craniotomy can be measured with high interrater reliability. Surgeons and nonsurgeons alike readily distinguish different skill levels. This type of assessment could be used to coach residents, to track performance over time, and potentially to compare skill levels. Developing an objective tool to evaluate surgical performance would be useful in several areas of neurosurgery education.

A Randomized Trial of a Supplemental Alarm for Critically Low Systolic Blood Pressure.

Intraoperative hypotension is associated with complications that might be ameliorated by earlier intervention. We therefore tested the primary hypothesis that a supplemental decision support alert for critically low systolic blood pressure (SBP) decreases the duration of intraoperative hypotension. We enrolled adults having surgery and anesthetized by attending anesthesiologists or nurse anesthetists under attending supervision. When invasive SBP <80 mmHg was detected for 3 consecutive minutes or any oscillometric SBP <80 mmHg, patients were randomly assigned to routine management or a visual alert and pager notification. Clinicians who received alerts were free to act on the alert or not. The primary outcome was time to return to SBP ≥ 80 mmHg. Secondary outcomes were time until SBP remained ≥ 80 mmHg for at least 10 minutes and the duration of hospitalization. One thousand five hundred ninety-eight patients were randomly assigned to the hypotension alerts and 1567 to no alerts. Randomized groups did not differ on time to return to SBP ≥ 80 mmHg after the first alert, with estimated adjusted hazard ratio of 0.99 (95% confidence interval, 0.92-1.06; P = 0.69). The median time [quartiles] to return to SBP ≥ 80 mmHg was 1 [0, 3] minutes in each group and 1 [0, 3] minutes in the nonalert group (P = 0.69). Hospital length of stay was also similar, with the median [quartiles] lengths of stay being 2 [1, 4] days in the alert group and 2 [1,5] in the nonalert group (P = 0.35). An additional warning for severe hypotension did not reduce the duration of hypotension or hospitalization. Decision support alerts may be more useful for more complicated situations.

Comparing resident cataract surgery outcomes under novice versus experienced attending supervision.

PurposeTo determine whether supervision by an attending who is new to surgical teaching, or an experienced attending measurably influences intraoperative complications rates or outcomes in phacoemulsification performed by ophthalmology residents.SettingSingle tertiary hospital.DesignRetrospective cohort study.MethodsResident-performed phacoemulsification cases supervised by one novice attending (N=189) and experienced attending (N=172) over 1 year were included. Data included: resident year, patient age, sex, preoperative risk factors (4+ on the four point scale for dense/white/brunescent cataracts, Flomax, zonular dialysis, pseudoexfoliation, glaucoma risk, post-vitrectomy), intraoperative risk factors (Trypan blue, iris hooks), and intraoperative complications (capsule tears, vitreous loss, zonular dialysis, zonular dehiscence, burns, nuclear fragment loss, Descemet’s tear). Experienced attending data were compared against those of the novice attending.ResultsRegarding preoperative risks, experienced attending cases more likely involved 4+ cataract (P=0.005), Flomax (P<0.001), or glaucoma risk (P=0.001). For intraoperative risks, novice attending cases more likely involved Trypan blue (P<0.001). Regarding complications, novice attending cases were associated with vitreous loss (P=0.002) and anterior capsule tears (P<0.001). When comparing total complications, the novice attending was more likely to have both increased number of cases with complications and total complications than the experienced attending. The novice attending’s overall complication rate trended downward (rate from 28% in first 25 cases to 6.67% in last 15).ConclusionEarly cases for the novice attending were accompanied by greater complications (vitreous loss and anterior capsule tear), likely due to a learning curve. Surgical judgment in the operating room likely develops with experience. Training programs may focus on these specific areas to aid new instructors.

Operating in a contemporary safety net.

Operating in a Contemporary Safety Net Jason D. Keune It is summer, and I have just started my fourth year of general surgery residency, having just returned from two years in the lab. My “lab years” were spent as a Scholar–in–Residence of the American College of Surgeons. The scholarship that I engaged in included obtaining an MBA and a Graduate Certificate in Professional Ethics. The ethics component was self–designed with help from an advisor, and was made up of graduate courses in political theory, healthcare financing law and bioethics. To say that I was reflective as I returned to the clinical rotations of the fourth year of residency would be understated. During this two–year period, I did not operate. I did do some clinical work during this time, but there wasn’t anyone in town willing to hire a partially–trained surgeon to do anything operative. I ended my third year of residency very happy with my technical skills, and was not sure just how these skills would survive a two–year hiatus. The challenge, as I thought of it then, would be to return to clinical rotations with this insecurity in mind and try to gain insight into just how rusty my skills were in a short period of time, and rectify them. I was in for a surprise. I felt a chill of trepidation when I discovered that the rotation that had been selected for me to return to was one in which I would be assigned to operate on and care for a low–income population of uninsured or underinsured patients with surgical problems—with minimal attending supervision. The patients were referred from the Federally Qualified Health Centers in town. The rotation had arisen from altruistic roots. The surgical service, provided at a large, academic urban hospital, was established when the city’s last remaining public hospital closed its doors for surgical patients. The service was an upright attempt to provide surgical continuity for this population. As I started the rotation and performed my first surgeries in two years with very minimal supervision, I realized that I would be participatory in what sums to a thoroughly unjust healthcare system. I would be caught in a swirl of humanitarian justice celebrated and a focus on a justice that seemed to fall short of a mark. The indigent hospital itself managed the clinic with a full complement of staff befitting a contemporary surgical clinic, albeit with a rather rudimentary computer system. The recordkeeping mechanism in our surgical office, however, was done without administrative assistance. We occupied a small room amongst the academic surgical offices at our home institution. The chief resident sat at a large [End Page 12] desk, the intern at a smaller desk, and the medical student had a chair and a laptop. The recordkeeping mechanism tracking who needed surgery, who had had surgery, and who needed follow–up on pathology was maintained by all members of the team. It involved one labyrinthine Excel spreadsheet, with multiple tabs, and a complex color–coordinated scheme of organization. The team would scan the entire thing on a daily basis to make sure nothing would be missed. When it came time to schedule a patient for the operating room, it was my responsibility as a chief resident to get an attending to “cover the case”, which amounted to finding an attending who agreed, at the bare minimum, to be present for the “critical portion” of the case. If the case was complex or very difficult, an attending surgeon would have to be sought who would scrub in and help perform the procedure. Not every attending would cover a charity case—the reasons why were not forthcoming. One surgeon would scrub every case he was asked to cover, stating that he felt every patient should have the same chance at the best treatment. Another would come to the room, but sit along the wall and review manuscripts as we operated, there to grant reassurance, and answer questions, but not, presumably, to direct the overall decision–making. All patients with breast cancer were seen, and operated on by one very dedicated breast surgeon with a humanitarian bent. I...

Deliberate practice for achieving and maintaining expertise in anesthesiology.

For the dedicated anesthesiologist, a high level of expertise is needed to deliver good care to patients and to provide excellent service to surgeons, anesthesia colleagues, and others. Expertise helps the anesthesiologist recover from difficult situations and generally makes the practice run more effectively. Expertise also contributes to quality of life through higher self-esteem and long-term career satisfaction. We begin by reviewing the attributes that characterize expert performance and discussing how a specific training format, known as deliberate practice, contributes to acquisition and maintenance of expertise. Deliberate practice involves rehearsal of specific tasks to mastery, ideally under the eye of a mentor to provide feedback. This amounts to an orchestrated effort to improve that enables trainees to progress to expert levels of performance. With few exceptions, people who become recognized experts have pursued deliberate practice on the order of 4 hours per day for 10 to 15 years. In contrast, those who practice their profession in a rote manner see their skills plateau well below the level of top performers. Anesthesiology instruction with attending supervision provides all of the necessary components for deliberate practice, and it can be effective in anesthesia. Using deliberate practice in teaching requires organization in selecting training topics, effort in challenging students to excel, and skill in providing feedback. In this article, we discuss how educational programs can implement deliberate practice in anesthesiology training, review resources for instructors, and suggest how anesthesiologists can continue the practice after residency.

Diagnosis of appendicitis by bedside ultrasound in the ED

BackgroundComputed tomography (CT) has largely become standard of care for diagnosing appendicitis at the expense of increased patient radiation exposure, cost, and time to surgical intervention. To date, there are very limited data on the accuracy of bedside ultrasound (BUS) for the diagnosis of appendicitis in adults. ObjectiveThe objective of this study is to evaluate test characteristics of BUS for diagnosis of acute appendicitis in the emergency department. MethodsData were prospectively collected on 97 cases of suspected appendicitis, which had BUS performed by trained residents with attending supervision between August 2011 and November 2013. All BUS interpretation and additional diagnostic imaging were left to the discretion of the physician or surgical consultants. A blinded ultrasound fellowship-trained physician reviewed all images after clinical treatment. Bedside ultrasound findings and patient outcomes were reported. ResultsA total of 97 adult cases underwent diagnostic ultrasound scans for suspected appendicitis. Of 97 cases, 34 had acute appendicitis by surgery/pathology report. Twenty-four BUS were positive for acute appendicitis and 11 were nondiagnostic. Of 24 positive ultrasounds, 23 had appendicitis on pathology report. There was 1 false-positive result, yielding a sensitivity of 67.65% (95% confidence limits, 49.5%-82.6%) and a specificity of 98.41% (95% confidence limits, 91.4%-99.7%). Of 23 positive BUS, 12 cases went to the Operating Room without an abdominal CT yielding a 12% reduction in CT utilization. If all positive BUS went to the OR without a CT scan, this would yield a 24% reduction in CT utilization. ConclusionsBedside ultrasound may be an appropriate initial test to evaluate patients with suspected acute appendicitis in the emergency department.

Long-term Outcomes of Resident- Versus Attending-Performed Primary Trabeculectomy With Mitomycin C in a United States Residency Program

To evaluate long-term outcomes of primary trabeculectomy with mitomycin C performed by ophthalmology residents. Cohort study and case-matched comparison. setting: Residency program. population/intervention: A cohort of glaucoma patients at a Veterans Administration hospital (VAH) and private patients of attending physicians ("attendings") who underwent primary trabeculectomy between 2003 and 2012 with ≥6 months of postoperative follow-up. Qualified surgical success was defined as intraocular pressure (IOP) ≤15 and >5 mm Hg (± glaucoma medications) without complications or additional glaucoma surgery. A subgroup of VAH patients with resident-performed trabeculectomy was case-matched to private patients with attending-performed trabeculectomy. outcome measures: Success rate, IOP, glaucoma medication number, visual acuity, complications, and additional glaucoma surgery. Eighty-five eyes (85 patients) underwent resident-performed primary trabeculectomy at the VAH with mean follow-up duration of 45.2 ± 28.1 months. Cumulative survival rates were 69.0% ± 5.6% at 3 years and 65.0% ± 6.5% at 5 years of follow-up. The complication rate was 9.4%. Patients in the resident group had more severe preoperative visual field defects, poorer long-term postoperative visual acuity, and a lower rate of cataract surgery performed after trabeculectomy than those in the attending group. Glaucoma patients at a VAH with primary trabeculectomy performed by residents under attending supervision had similar success and complication rates as patients who underwent attending-performed trabeculectomies. However, the visual outcomes of patients with trabeculectomy performed by residents were worse in the long term, which might be attributable to a more advanced glaucoma disease stage or a lower rate of cataract surgery performed in the VAH patients.

Simulator Training Enhances Resident Performance in Transesophageal Echocardiography

Standardized training via simulation as an educational adjunct may lead to a more rapid and complete skill achievement. The authors hypothesized that simulation training will also enhance performance in transesophageal echocardiography image acquisition among anesthesia residents. A total of 42 clinical anesthesia residents were randomized to one of two groups: a control group, which received traditional didactic training, and a simulator group, whose training used a transesophageal echocardiography-mannequin simulator. Each participating resident was directed to obtain 10 commonly used standard views on an anesthetized patient under attending supervision. Each of the 10 selected echocardiographic views were evaluated on a grading scale of 0 to 10, according to predetermined criteria. The effect of the intervention was assessed by using a linear mixed model implemented in SAS 9.3 (SAS Institute Inc., Cary, NC). Residents in the simulation group obtained significantly higher-quality images with a mean total image quality score of 83 (95% CI, 74 to 92) versus the control group score of 67 (95% CI, 58 to 76); P = 0.016. On average, 71% (95% CI, 58 to 85) of images acquired by each resident in the simulator group were acceptable for clinical use compared with 48% (95% CI, 35 to 62) in the control; P = 0.021. Additionally, the mean difference in score between training groups was the greatest for the clinical anesthesia-1 residents (difference 24; P = 0.031; n = 7 per group) and for those with no previous transesophageal echocardiography experience (difference 26; P = 0.005; simulator n = 13; control n = 11). Simulation-based transesophageal echocardiography education enhances image acquisition skills in anesthesiology residents.

Preserving the Educational Value of Call in a Diagnostic Radiology Residency Program

Our study was designed to determine residents' opinions of the advantages, disadvantages and educational value of a traditional "Tandem Call" (TC) model as compared to night float (NF). Because TC is more representative of adult learning principles and constructivist theory, we hypothesized that resident satisfaction and educational outcomes would demonstrate a preference for, and the educational efficacy of, the TC model. We surveyed all residents in a university-based radiology residency on their opinions of TC and its educational value. Aggregate data from annual Graduate Medical Education Committee institutional surveys (2008-2012) and annual radiology alumni surveys (2009-2012) were reviewed as measures of satisfaction with TC. Performance on the ABR oral exam was a proxy for educational outcome. Quality data for the year of study and prior years in which TC was in effect were reviewed as a measure of patient safety. The great majority of respondents attributed confidence/competence on call and added value to their education directly to TC. A majority believed that teamwork required for TC facilitated more positive relationships among residents and more peer teaching. Most said that they would not prefer NF. Almost all believed indirect supervision with attending backup aided in developing confidence in performance. Quality data confirmed a low number of discrepancies between preliminary resident and final attending reads. TC provides a more consistent call experience throughout residency than NF. TC is valued by residents, facilitates retrieval-based learning and development of independence and efficiency, andparallels essential elements of team-based learning. Quality data suggests that lack of 24-hour attending supervision is not detrimental to patient safety.

Evaluation of cytopathology fellow performance for rapid on-site evaluations of fine-needle aspirates over a 6-year period

Rapid on-site evaluation (ROSE) of fine-needle aspirates is an invaluable teaching tool for a cytopathology (CyP) fellowship. The ability of fellows to accurately perform ROSEs without direct attending supervision is not well documented in the literature. This study reviewed ROSEs performed independently by CyP fellows and focused on diagnostic discrepancies with managerial implications. All fine-needle aspirates with ROSE documentation performed at the University of Virginia from October 1, 2007 to March 31, 2013 were reviewed and compared with the final diagnosis. Cases were only included if a CyP fellow performed the ROSE. Discrepancy between ROSE and final diagnosis was categorized according to the change. Numbers of false positive (FP) and false negative diagnoses, organ site, and recurrent interpretative pitfalls were noted. CyP fellows performed 6815 ROSEs in 6 years. An attending cytopathologist was present 8% of the time. Of ROSEs without direct attending supervision (6224 fine-needle aspirates), the preliminary and final diagnoses were identical in 95% of cases. FP rate was 1.06%. The most frequent categorical change occurred from ROSE of "atypical" to final diagnosis of "malignant." The most common sites involved in FP diagnoses were pancreas/biliary tract, lung, and lymph node. Experience gained over the fellowship year did not significantly affect the FP rate. Errors encountered are known interpretative challenges. This is the largest study addressing discrepancies between ROSE and final diagnosis and the first study examining CyP fellow performance. Our results affirm that fellows perform extremely well when performing ROSEs independently.

Capsule Commentary on Tukey et al., The Impact of a Medical Procedure Service on Patient Safety, Procedure Quality and Resident Training Opportunities

Medical procedure services (MPS) were developed to achieve several aims: 1) train residents in the performance of bedside procedures, 2) routinely provide attending supervision, 3) improve procedural success while reducing complications, and 4) offset resident workload in the era of duty hours restrictions.1–3 The study by Tukey et al.4 examines the impact of a MPS on trainee engagement and procedural safety. They found that resident participation in procedures did not differ when performed by the MPS versus the primary team. Procedures performed by the MPS were more likely to use ultrasound guidance, be supervised by an attending, and were more likely to be completed successfully. However, there was no difference in the primary outcome of overall or individual procedure complication rates. This is not the first study that has failed to show a difference in complications.3 Similar to previous studies, the inability to measure differences in patient outcomes may be the result of selection bias: more procedural referrals to the MPS from inexperienced residents or referrals for more complex procedures that in other hands may have resulted in complications. What does it mean that, when studied rigorously, a MPS does not achieve all desired aims? Perhaps we can draw an analogy between MPS and Rapid Response Teams (RRTs). Both are resource-rich innovations that provide valuable support to hospital providers, but have not yet consistently demonstrated benefits in patient outcomes.5 Like RRTs, hospitals may decide the benefits of a MPS—namely, enhanced resident experience and comfort, improved educational outcomes, and low rates of complications1–3—offset the as yet unproven outcome improvements. The truth is that alternatives are lacking. It is no longer practical or feasible to ensure all Internal Medicine (IM) residents are competent to perform procedures during training. Fewer IM faculty feel comfortable training residents in bedside procedures; they have neither the opportunity nor demand to maintain their skills. The need for safe and timely bedside procedures, however, still exists. MPS offer dedicated experience and training for IM residents, while providing safe and successful procedures for residents and other attendings, who often lack the time and expertise for procedures.

AMA to Clarify Status of Fellows for Sunshine Act

Residents are exempted from reporting requirements of the Physician Payment Sunshine Act, but recent statements from CMS indicate that fellows may not be exempt.

Patient Understanding of the Role of the Orthopedic Resident

Patients have identified the knowledge of a physician's level of training as important. Previous studies show equally poor patient's understanding of the medical education hierarchy. Given the importance to the patient and the possible effect on patient satisfaction, it is critical to evaluate patient's understanding of the orthopedic educational hierarchy. The specific aim of this study is to evaluate patient's understanding of the role of an orthopedic resident as it pertains to their orthopedic care. Adult, English-speaking patients presenting to an outpatient academic orthopedic practice completed surveys similar to those utilized in prior research on this topic. Each questionnaire compiled demographics, questions assessing knowledge of the role of the resident in patient care, and questions to assess the patient's preferences regarding resident physician's role in their care. The knowledge section of the questionnaire was scored with 1 point given to each correct answer. The individual questions with the worst scores from the entire patient population were further evaluated to find demographic predictors of success. In addition to percent correct responses for the entire population, a linear regression model was used to evaluate the effect of age, gender, level of education, ethnicity, and number of academic visits on the knowledge section score. One hundred seventy-four (n = 174) patients completed the survey. Among them, 40% were male, 27% had a high school education or less, 82% were Caucasian, and for 18% it was their first visit to an academic hospital. The average score for the knowledge section was 10.2 (standard deviation±4.0) out of a possible of 16. Linear regression controlling for noted demographic variables revealed higher level of education to be predictive of a better score (coefficient 3.2; 95% confidence interval 1.9-4.7). The 3 worst scoring questions were regarding knowledge of (1) residents having completed medical school, (2) residents performing surgery with attending supervision, and (3) whether or not residents were actually doctors. For these questions higher level of education correlated with more correct answers (p = 0.005, p = 0.001, p = 0.000, respectively). Among the patients, 90% agreed that it was important for them to know the level of training of their physicians and 76% felt it was okay for residents to "learn" on them as long as they were supervised. Patient's knowledge of the role the resident physician provides, in their care, is variable. Higher levels of education appear predictive of better understanding. Patients have difficulty discerning where residents fit in the medical hierarchy. Despite this misunderstanding, patients find it very important that they know the physician's level of training. Given the patient's high priority of knowing the level of training of the doctors who care for them and their frequent misunderstanding of the medical hierarchy, steps should be taken to better educate patients as to who is caring for them. Besides being important for patient's informed consent, it may improve patient satisfaction.

The Unspoken Tyranny of Regulatory Agencies: A Commentary on The ACGME Resident Survey

Residency training directors dread various moments— for instance, when the Residency Review Committee (RRC) reviews their program, or Match Day. Another such moment of anxiety is when residents answer the Accreditation Council for Graduate Medical Education (ACGME) Resident Survey. This survey asks residents about their compliance with duty hours and their opinions of faculty, the feedback they receive, the educational content of the teaching, their program’s resources, and, finally, their overall experience. These are seemingly fair, important questions. Why would anyone dread seeing the answers? What would be wrong with a survey asking this information about the program? Why would anybody think that this is not a good and useful survey? In my opinion, at least four cardinal problems with the ACGME Resident Survey may trigger training director anxiety and dread. The first problem is the validity and comprehensibility of the survey questions. Fahy and colleagues (1) suggested that the responses obtained on the ACGME Survey might inaccurately reflect the magnitude of noncompliance found in certain areas, and they proposed that this discrepancy might be due to the limited range of responses available on the survey. Sticca and colleagues (2) reported that 14% of residents admitted to not answering the questions truthfully, and 37% of residents felt that the survey did not provide an accurate evaluation of their work-hours. These authors felt that a tool in which 1 in 7 responders admits to answering questions falsely and 1 in 5 responders had difficulty interpreting the questions may not be a valid evaluation tool. In contrast, Holt and colleagues (3) found that the ACGME Survey demonstrated a high degree of internal reliability and thus felt that this survey was a reliable, valid, and useful tool for evaluating residency programs. Holt and colleagues (3) also reported that programs having resident-identified duty-hour issues were more likely than those without such issues to have received duty-hour citations from residency review committees (sic). These are contradictory results. Some might question the first two studies (1, 2) because they were conducted by surgeons who have been unhappy with the implementation of the 80 duty-hour limit. Othersmay question the third study (3) because it was conducted by the main stakeholder and creator of this survey: the ACGME itself. Unfortunately, these studies, as well as many critics of this survey, focus on just one part of the survey—duty-hours —which is probably the most objective part of the ACGME Resident Survey. I have a harder time with the interpretation of some questions in the other parts of the survey. For instance: “How sufficient is the supervision you receive from faculty and staff in your program?” (Possible answers: Extremely, Very, Somewhat, Slightly, Not At All); “Thinking about the faculty and staff in your program overall, how interested are they in your residency education?” (same answers); or “Thinking about the faculty and staff in your program overall, how effective are they in creating an environment of scholarship and inquiry?” (same answers) are all very subjective questions. Their interpretation could vary profoundly from resident to resident. Similarly, the question “In your opinion, howoften do your rotations and other major assignments provide an appropriate balance between your residency education and other clinical demands?” sounds ambiguous. What constitutes an appropriate balance is a matter of opinion, and this question raises further questions: What is considered education? Is seeing patients under attending supervision “clinical demand”or “education”? Is classroom teaching the only form of education? Or consider another question—“Howoften do youwork in interdisciplinary teams to care for patients?” What does the answer “Somewhat/Sometimes” mean? Are we expecting that residents work always in interdisciplinary teams? If they see patients in individual therapy (i.e., no interdisciplinary team), does it mean “noncompliance”? I could discuss Received April 6, 2011; revised June 28, November 2, 2011; accepted November 2, 2011. Send correspondence to Richard Balon, M.D., Wayne State Univ., Univ. Psychiatric Center; e-mail: rbalon@wayne.edu Copyright © 2012 Academic Psychiatry

"Page Me if You Need Me": The Hidden Curriculum of Attending-Resident Communication.

Discrepancies exist between what resident and attending physicians perceive as adequate supervision. We documented current practices in a university-based, categoric, internal medicine residency to characterize these discrepancies and the types of mixed messages that are communicated to residents, as well as to assess their potential effect on resident supervision and patient safety. We surveyed residents and attending physicians separately about their current attitudes and behaviors regarding resident supervision. Both groups responded to 2 different measures of resident supervision: (1) 6 clinical vignettes that involved patient safety concerns, and (2) 9 frequently reported phrases communicated by attending physicians to residents before leaving the hospital during on-call admission days. There were clear and substantial differences between the perceptions of resident and attending physicians about when the supervising attending physician should be notified in each of the 6 vignettes. For example, 85% of attending physicians reported they wanted to be notified of an unexpected pneumothorax that required chest tube placement, but only 31% of resident physicians said they would call their attending physician during those circumstances. Common phrases, such as "page me if you need me," resulted in approximately 50% of residents reporting they would "rarely" or "never" call and another 41% reporting they would only "sometimes" call their attending physicians. Our study found that attending physicians reported they would want more frequent communication and closer supervision than routinely perceived by resident physicians. Although this discrepancy exists, commonly used phrases, such as "page me if you need me," rarely resulted in a change in resident behavior, and attending physicians appeared to be aware of the ineffectiveness of these statements. These mixed messages may increase the difficulty of balancing the dual goals of appropriate attending supervision and progressive independence during residency training.

Closed claim review from a single carrier in New York: the real costs of malpractice in surgery and factors that determine outcomes

IntroductionWe postulated that a closed claim review of surgical cases would identify not only the quality of care elements but also factors that will predict successful legal outcomes. MethodsOne hundred eighty-seven closed surgical cases from a single carrier, which insured physicians practicing in 4 university hospitals in New York State, were reviewed, cataloged, and analyzed. ResultsMost suits occurred during midcareer and routine operations. Seventy-three percent of cases were won. The average payment and expenses per case were $220,846 ± $38,984 and $40,175 ± $4,204, respectively. Poor communication was identified in 24% of cases and was a predictor of a negative outcome (41% lost, P < .05), as was inadequate attending supervision (46% lost, P < .05). Expert reviews incriminated or exculpated physician defendants in 85 cases, which affected the outcome and cost. The quality of the physician defendant as a witness also affected the outcome. ConclusionsMost surgical malpractice claims are won. Although supervision, communication, and aggressive risk management are important, the use of quality experts and establishing credibility of the physician defendant are critical for successful legal outcome.