Current Training Paradigm Research Articles

Real-time dynamic polygenic prediction for streaming data.

Polygenic risk scores (PRSs) are promising tools for advancing precision medicine. However, existing PRS construction methods rely on static summary statistics derived from genome-wide association studies (GWASs), which are often updated at lengthy intervals. As genetic data and health outcomes are continuously being generated at an ever-increasing pace, the current PRS training and deployment paradigm is suboptimal in maximizing the prediction accuracy of PRSs for incoming patients in healthcare settings. Here, we introduce real-time PRS-CS (rtPRS-CS), which enables online, dynamic refinement and calibration of PRS as each new sample is collected, without the need to perform intermediate GWASs. Through extensive simulation studies, we evaluate the performance of rtPRS-CS across various genetic architectures and training sample sizes. Leveraging quantitative traits from the Mass General Brigham Biobank and UK Biobank, we show that rtPRS-CS can integrate massive streaming data to enhance PRS prediction over time. We further apply rtPRS-CS to 22 schizophrenia cohorts in 7 Asian regions, demonstrating the clinical utility of rtPRS-CS in dynamically predicting and stratifying disease risk across diverse genetic ancestries.

107 A pragmatic approach to portable neuroimaging utilized in clinical research

OBJECTIVES/GOALS: The aim of thispaper is to raise awareness of the limitations of the current pMRI training paradigm and to recommend a standardization of skills to expand diversity among field-based neuroimaging technicians. METHODS/STUDY POPULATION: Currently, there are seven international brain research initiatives. The goal is to establish and understand the cultural values a society holds and how the outcomes of research may be adopted into societal practice. We must also consider the benefits of early detection amongst minoritized communities in neuroscience research. Neuroimaging in remote settings can allow patients to advocate more accurately for timely medical care which can lead to better health outcomes. According to the Journal of Neurological Sciences, neuroscience accounts for 9% of total medical publications. RESULTS/ANTICIPATED RESULTS: Neuroimaging research continues to evolve in terms of resolution and portability. T By harnessing diverse data, we are able to utilize advanced neuroimaging techniques and software technology to recognize trends amongst subgroups of individuals who were previously considered geographically inaccessible. DISCUSSION/SIGNIFICANCE: Despite the excitement and promise of portable neuroimaging devices, there is a fundamental need to establish standardized training procedures that can be accessed by individuals of all socioeconomic backgrounds.

The Leaders in Epidemiology, Antimicrobial Stewardship, and Public Health (LEAP) Fellowship, a Novel Training Program in Public Health for Infectious Diseases Physicians.

The severe acute respiratory syndrome coronavirus 2 pandemic demonstrated a critical need for partnerships between practicing infectious diseases (ID) physicians and public health departments. The soon-to-launch combined ID and Epidemic Intelligence Service fellowship can only address a fraction of this need, and otherwise US ID training lacks development pathways for physicians aiming to make careers working with public health departments. The Leaders in Epidemiology, Antimicrobial Stewardship, and Public Health (LEAP) fellowship is a model compatible with the current training paradigm with a proven track record of developing careers of long-term collaboration. Established in 2017 by the ID Society of America, Society for Healthcare Epidemiology of America, Pediatric ID Society, and supported by the Centers for Disease Control and Prevention, LEAP is a single-year in-place, structured training for senior trainees and early career ID physicians. In this viewpoint, we describe the LEAP fellowship, its outcomes, and how it could be adapted into ID training.

현장 경찰관 사격훈련의 개선방향에 관한 연구

This study is aim to explore the improvement direction and derive a plan so that police education and training such as tasers and pistols can be used in the field. To this end, opinions on the direction of improvement of shooting training were collected and analyzed by qualitative research from seven field police officers. As a result of the analysis, it was confirmed that the training situation should be created similar to reality based on realistic scenarios, and that conditions for many police officers to train should be prepared by distributing simulation training systems using virtual reality. In addition, the current training paradigm is basically assumed to shoot, and it is confirmed that the shooting technique of accurately shooting at the target is improved, which should be changed. In fact, the dispatched police officer is considering whether to fire or not to fire at the target or subdue it with other low-risk means, but the decision-making training for this part is still in its infancy. Accordingly, it was suggested to develop a scenario based on the actual case of the physical force use report, and to distribute a simulation system using VR so that all police officers can actually participate in the training. Also, I tried to draw a training system that quickly and accurately recognizes various elements of the dispatch site and decides whether to shoot or not through the cases of developed countries such as the United States and Australia. In addition, the framework of complex scenarios to develop the ability to grasp the characteristics of victims, context such as relationships with the persons concerned, and physical specificity of the field was derived from the research participants' presentation and scenarios in developed countries.

Training to proficiency in surgery using simulation: is there a moral obligation?

A deontological approach to surgical ethics advocates that patients have the right to receive the best care that can be provided. The ‘learning curve’ in surgical skill is an observable...

Training Experiences of American Society of Transplant Surgeons Fellows in Deceased Donor Organ Procurement.

Training Experiences of American Society of Transplant Surgeons Fellows in Deceased Donor Organ Procurement.

Impact of Trainee Involvement on Video-Assisted Thoracoscopic Lobectomy for Cancer

Previous literature in other surgical disciplines regarding the impact of resident and fellow involvement on operative time and outcomes has yielded mixed results. The impact of trainee involvement on minimally invasive thoracic surgery is unknown. This study compared risk-adjusted differences in operative time and outcomes of video-assisted thoracoscopic lobectomy for cancer between cases performed with and without residents and fellows involved. All patients undergoing elective video-assisted thoracoscopic lobectomy for cancer between 2008 and 2018 were identified in the Veterans Affairs Surgical Quality Improvement Program database. Patients were stratified into 2 cohorts: cases with residents and fellows involved, and cases performed only by attending surgeons. Primary outcomes included operative time, postoperative hospital length of stay, and composite 30-day morbidity and mortality. Secondary outcomes included factors associated with high and low trainee operative autonomy. A total of 3678 patients met study inclusion criteria. In all, 1780 cases were performed with residents and fellows involved (median postgraduate year, 5; interquartile range, 4-7). Multivariate analysis showed that operative time was significantly shorter in resident- and fellow-involved cases compared with attending-only cases (mean [SD], 3.6 [1.4] versus 3.8 [1.6] hours; P < .001). There were no significant differences in composite 30-day morbidity and mortality (16.0% versus 17.1%; adjusted odds ratio= 0.93; 95% confidence interval, 0.77-1.11; P= .40) or length of stay. Substratification of trainees by postgraduate year resulted in similar findings. Cases performed in July through October and those in the Northeastern United States were associated with low autonomy. Current training paradigms in thoracic surgery are safe, and the involvement of motivated and skilled trainees with appropriate supervision may benefit operative duration.

National Early Career Transplant Hepatologist Survey: Compensation, Burnout, and Job Satisfaction.

Despite the growth of transplant hepatology as a subspecialty over the past decade, data on professional roles and compensation models remain lacking. Furthermore, the prevalence of physician burnout and job satisfaction are unknown in this profession. We aimed to conduct a comprehensive assessment of early career transplant hepatologists to fill these voids in knowledge and to inform current and future transplant hepatologists. An online survey designed to quantify clinical and nonclinical roles, compensation and structure, job satisfaction, and burnout was sent to 256 early career transplant hepatologists. Respondents were divided into three practice settings: university hospital clinical (n = 79), non–university hospital clinical (n = 35), and research (n = 25). The median age of respondents was 38 (interquartile range [IQR] 36‐40) years, and 44% were women. The median half‐days/week spent in clinic was 4 (IQR 3‐6) and in endoscopy was 1 (IQR 1‐2). Most of the respondents provided inpatient care (88%) for a median of 9 (IQR 6.5‐10) weeks/year. The median base compensation was $300,000 (IQR US $263,750‐$326,250), and most (76%) had salary‐based compensation. Although only 8% of respondents were dissatisfied with their position, the prevalence of burnout was high at 35%. Conclusion: This survey is a comprehensive assessment focusing on early career transplant hepatologists, is reflective of the current training paradigm and practice of transplant hepatology, and provides transparency to guide professional negotiations and empower both trainees pursuing careers in transplant hepatology and early career transplant hepatologists.

Combat thoracic surgery in Iraq and Afghanistan: 2002-2016.

Thoracic surgery constitutes 2.5% of surgical procedures performed in theater, but the skills required are increasingly foreign to military surgeons. This study examines thoracic surgical workload in Iraq and Afghanistan to help define surgical training gaps. Retrospective analysis of Department of Defense Trauma Registry for all role 2 (R2) (forward surgical) and role 3 (R3) (theater) military facilities, from January 2002 to May 2016. The 95 thoracic surgical International Classification of Diseases-9th Rev.-Clinical Modification procedure codes were grouped into 10 categories based on anatomy or endoscopy. Select groups were further stratified by type of definitive procedure. Procedure groupings were determined and adjudicated by surgeon subject matter experts. Data analysis used Stata Version 15 (College Station, TX). Of the total procedures, 5,301 were classified as thoracic surgical procedures and were included in the present study. The majority of thoracic surgical procedures (4,645 [87.6%]) were recorded as being performed at R3 medical treatment facilities (MTFs). The thoracic surgical procedures groups with the largest proportions were: bronchoscopy (39.1%), thoracotomy (16.9%), diaphragm (15.6%), and lung (11.4%). The most common lung procedure subgroup, aside from not otherwise specified, was segmentectomy (28.8%). The R3 MTFs recorded nearly five times the number of lung procedures compared with R2 MTFs; with R3 MTFs recording more than eight times the number of lobectomies compared with R2 MTFs. Thoracic workload was variable over the 15-year study period. Thoracic surgical skills are necessary in the deployed environment to manage combat-related injuries. Given the current trends in training and specialization, development and sustainment of thoracic surgical skills is challenging in the deployed US trauma system and likely for other nations, and humanitarian surgical care as well. Current training and practice paradigms pose both training and sustainment challenges for surgeons who deploy to a combat zone. Therapeutic/Care Management IV.

“This above all: to thine own self be true…” the effects of the COVID-19 pandemic on surgical residency training and education

COVID-19 has drastically affected the current surgical training paradigm. Fellows anticipate a 10-25% decrease in procedural volumes for this year because of the pandemic. With a reduction in elective cases, surgical programs have transitioned to resident coverage cutbacks and/or reassigning trainees to non-surgical wards to assist with pandemic relief.

Attitudes of Trainees in Obstetrics and Gynecology Regarding the Structure of Residency Training

To measure future and current resident perspectives on obstetrics and gynecology residency training structure and possible future models. Medical students invited for obstetrics and gynecology residency interviews and residents (postgraduate year [PGY]-1-4) at the University of Colorado, the University of Washington, the University of California San Francisco, Loyola University, Saint Joseph's Hospital, and Texas A&M in 2017-2018 received a voluntary, electronic survey regarding possible models for restructuring residency training. Student and resident responses were compared using χ test for categorical and two-sample t-test for continuous items. Applicants (63%, 280/444) and residents (66%, 101/153) had similar response rates (overall response rate 64%). Applicants (24%) and residents (29%) reported having concerns about the current structure of residency training. The ideal residency duration was reported as 4 years by 72% of applicants and 85% of residents. Lack of gynecologic surgical volume was the most frequently reported concern among applicants (75%) and residents (72%). Fourth-year tracking (focusing on training aligned with postgraduation career path) was preferred by 90% of applicants and 77% of residents (P=.002) and 92% among respondents planning fellowship. Most applicants (68%) and residents (75%) preferred not starting fellowship training after the 3rd year of residency. The majority of learners surveyed support a 4-year training structure but likewise support individualizing training in PGY-4. It is imperative that obstetrics and gynecology leadership consider this and other feedback from learners when considering modifications to the current training paradigm.

Surgical Informatics: Defining the Role of Informatics in the Current Surgical Training Paradigm

Clinical Informatics is a large part of the current surgical practice, yet, there is no formal curriculum to teach residents about informatics. The purpose of this article is to describe the field of clinical informatics, describe the potential of informatics to improve surgical care, and propose a framework to train surgical informaticians. This is a perspective summarizing the role of clinical informatics in current surgical training. The manuscript concisely discusses the potential impact of novel technologies and information systems on surgical care delivery. We demonstrate the importance of informatics training for surgeons and describe the relatively new fellowship program as well as the various pathways to obtain board certification in clinical informatics.

Poisson Probability of Failing to Meet Minimum Case Volumes in Pediatric Surgery Fellowships.

With the expansion of pediatric surgery fellowships from 2008 to 2018, there is concern for the dilution of training experience, especially for rare index cases. The Accreditation Council for Graduate Medical Education (ACGME) established required minimum case numbers by case type, but this is a program requirement rather than an individual trainee requirement. The American Board of Surgery (ABS) is considering instituting minimum case requirements across 5 broad categories for individuals to be board-eligible in pediatric surgery. The ACGME National Data Report summary case logs were obtained for graduating fellows in pediatric surgery from 2008 to 2018. Median case volumes were compared to minimum ACGME case numbers and proposed ABS individual requirements. Using Poisson distributions, probabilities of individual fellows failing to meet minimum case numbers were calculated. The average annual probability that a median program would fail to meet minimum ACGME case numbers in at least 1 category was estimated at 16.6%. Using the proposed ABS system, the probability of failure was estimated at 44.1%. No temporal trend was found in the annual probability of failure in either the ACGME or the proposed ABS system. There is significant risk of a fellow failing to meet case minimums in the ACGME system and the proposed ABS system. This probability is increased for the half of programs below median. If the ABS institutes case minimums as a requirement for certification in pediatric surgery, the current training paradigm may be impacted at some programs.

Share-n-Learn

Wearable sensors utilize machine learning algorithms to infer important events such as the behavioral routine and health status of their end users from time-series sensor data. A major obstacle in large-scale utilization of these systems is that the machine learning algorithms cannot be shared among users or reused in contexts different from the setting in which the training data are collected. As a result, the algorithms need to be retrained from scratch in new sensor contexts, such as when the on-body location of the wearable sensor changes or when the system is utilized by a new user. The retraining process places significant burden on end users and system designers to collect and label large amounts of training sensor data. In this article, we challenge the current algorithm training paradigm and introduce Share-n-Learn to automatically detect and learn physical sensor contexts from a repository of shared expert models without collecting any new labeled training data. Share-n-Learn enables system designers and end users to seamlessly share and reuse machine learning algorithms that are trained under different contexts and data collection settings. We develop algorithms to autonomously identify sensor contexts and propose a gating function to automatically activate the most accurate machine learning model among the set of shared expert models. We assess the performance of Share-n-Learn for activity recognition when a dynamic sensor constantly migrates from one body location to another. Our analysis based on real data collected with human subjects on three datasets demonstrates that Share-n-Learn achieves, on average, 68.4% accuracy in detecting physical activities with context-varying wearables. This accuracy performance is about 19% more than ‘majority voting,’ 10% more than the state-of-the-art transfer learning, and only 8% less than the experimental upper bound.

Proving the Effectiveness of the Fundamentals of Robotic Surgery (FRS) Skills Curriculum: A Single-blinded, Multispecialty, Multi-institutional Randomized Control Trial.

To demonstrate the noninferiority of the fundamentals of robotic surgery (FRS) skills curriculum over current training paradigms and identify an ideal training platform. There is currently no validated, uniformly accepted curriculum for training in robotic surgery skills. Single-blinded parallel-group randomized trial at 12 international American College of Surgeons (ACS) Accredited Education Institutes (AEI). Thirty-three robotic surgery experts and 123 inexperienced surgical trainees were enrolled between April 2015 and November 2016. Benchmarks (proficiency levels) on the 7 FRS Dome tasks were established based on expert performance. Participants were then randomly assigned to 4 training groups: Dome (n = 29), dV-Trainer (n = 30), and DVSS (n = 32) that trained to benchmarks and control (n = 32) that trained using locally available robotic skills curricula. The primary outcome was participant performance after training based on task errors and duration on 5 basic robotic tasks (knot tying, continuous suturing, cutting, dissection, and vessel coagulation) using an avian tissue model (transfer-test). Secondary outcomes included cognitive test scores, GEARS ratings, and robot familiarity checklist scores. All groups demonstrated significant performance improvement after skills training (P < 0.01). Participating residents and fellows performed tasks faster (DOME and DVSS groups) and with fewer errors than controls (DOME group; P < 0.01). Inter-rater reliability was high for the checklist scores (0.82-0.97) but moderate for GEARS ratings (0.40-0.67). We provide evidence of effectiveness for the FRS curriculum by demonstrating better performance of those trained following FRS compared with controls on a transfer test. We therefore argue for its implementation across training programs before surgeons apply these skills clinically.

Surgeons' Perceptions Toward Providing Care for Diverse Patients: The Need for Cultural Dexterity Training.

We sought to understand the experiences of surgical residents and faculty with treating culturally diverse patients, and identify recommendations for establishing and implementing structured cultural competency training. Cultural competency training for medical professionals could reduce healthcare disparities, yet is currently not a standard part of surgical residency training. Few studies have explored the perspectives of surgical residents and faculty on the skills needed to provide cross-cultural care. A purposeful sample of surgical residents and faculty from 4 academic institutions was recruited for semistructured qualitative interviews. We developed an in-depth interview guide and performed interviews to thematic saturation. Interviews were audio-recorded, transcribed, and analyzed using grounded theory methodology. We interviewed 16 attending surgeons and 15 surgical residents. Participant demographics were: male (51.6%), White (58.1%), Black (9.7%), Asian (22.5%), and Hispanic (9.7%). Four main themes emerged from the data: 1) aspects of culture that can inform patient care; 2) specific cultural challenges related to surgical care, including informed consent, pain management, difficult diagnoses and refusal of treatment, emergency situations, and end-of-life issues; 3) need for culturally competent care in surgery to navigate cultural differences; 4) perceived challenges and facilitators to incorporating cultural competency into the current training paradigm. Surgeons identified the need to provide better cross-cultural care and proposed tenets for training. Based on these findings, we suggest the development and dissemination of a cultural dexterity training program that will provide surgeons with specific knowledge and skills to care for patients from diverse sociocultural backgrounds.

Enhancing Confidence in Graduating General Surgery Residents: Establishing a Chief Surgery Resident Service at an Independent Academic Medical Center

Providing opportunities for autonomy to enhance the development of independence and confidence during surgery residency remains among the greatest challenges of the current training paradigm. The objective of this study was to evaluate the implementation and outcomes of a chief resident service (CRS). A CRS was designed with operative, call and office responsibilities. Supervision and evaluation were consistent with institutional guidelines. CRS operative logs from 2011 to 2014 were compared with logs from the participants' first year in practice. Select procedures were compared and evaluations were reviewed. Residency graduates' satisfaction with the CRS was evaluated. Independent academic medical center. Nine general surgery residency graduates with one complete year in practice. Nine residents completed CRS rotations and submitted case logs. Median total case volume was 1101 (994-1311) during the 5-year residency, 92 (20-149) during CRS and 299 (99-784) during the first year in practice. Median case volumes for selected procedures for the entire 5-year residency, CRS, and first year of practice were: 93 (66-97), 7 (3-16), and 9 (1-26) laparoscopic appendectomies; 146 (120-157), 24 (3-32), and 34 (15-112) laparoscopic cholecystectomies; 81 (51-94), 1 (1-4), and 3 (0-8) ileocolectomies; 57 (35-86), 4 (0-9), and 8 (2-34) ventral/incisional hernia repairs; 102 (87-137), 12 (3-16), and 13 (3-86) inguinal hernia repairs. Graduates reported that the CRS experience was very beneficial to their current practice. Annual program reviews emphasized the CRS as a major strength of our residency. Creation of a CRS to increase resident autonomy and provide continuity of patient care with appropriate faculty supervision was successful. Case mix and volumes provided an opportunity for independent operative and clinical experience during residency which realistically paralleled graduates' first year of practice.

The Fourth Year of Medical School: Time for Reassessment: AOA Critical Issues.

Most U.S. medical schools follow the 4-year model, consisting of 2 preclinical years, core clinical experience, and a fourth year intended to permit students to increase clinical competency, to explore specialty areas, and to transition to residency. Although the design and delivery of Years 1 through 3 have evolved to meet new challenges and expectations, the structure of Year 4 remains largely unchanged. For most students considering a career in orthopaedics, Year 4 is a series of elective rotations in which educational objectives become secondary to interviewing for residency programs. Most accreditation bodies recognize the importance of attainment of competency over the duration of medical school as the goal of educating physicians, and thus, there is a growing interest in reexamining the traditional medical school curriculum with the goal of integrating the final phases of undergraduate education and the first phases of postgraduate education.A literature search was undertaken to identify publications on the duration of medical education. Pilot approaches to competency-based integration of undergraduate medical school and postgraduate training in orthopaedic surgery were reviewed.There have been few data suggesting that 4 years of medical education is superior to shorter-duration programs. Three approaches to competency-based integration of undergraduate medical school and postgraduate training are presented. Their goal is to use student and faculty time more effectively. Each approach offers the opportunity to lower the cost and to decrease the time required for Board Certification in Orthopaedic Surgery. Two approaches shorten the entire duration of medical school and graduate training by using various proportions of the fourth year to begin residency, and one approach expands the duration of orthopaedic training by starting in the fourth year of medical school and including training equivalent to a fellowship program into the residency experience.The effectiveness of such programs will form the basis for revisions to the current orthopaedic training paradigm, resulting in a more effective, efficient, and integrated orthopaedic training curriculum.

Design of a cost-effective, hemodynamically adjustable model for resuscitative endovascular balloon occlusion of the aorta (REBOA) simulation.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an adjunct technique for salvaging patients with noncompressible torso hemorrhage. Current REBOA training paradigms require large animals, virtual reality simulators, or human cadavers for acquisition of skills. These training strategies are expensive and resource intensive, which may prevent widespread dissemination of REBOA. We have developed a low-cost, near-physiologic, pulsatile REBOA simulator by connecting an anatomic vascular circuit constructed out of latex and polyvinyl chloride tubing to a commercially available pump. This pulsatile simulator is capable of generating cardiac outputs ranging from 1.7 to 6.8 L/min with corresponding arterial blood pressures of 54 to 226/14 to 121 mmHg. The simulator accommodates a 12 French introducer sheath and a CODA balloon catheter. Upon balloon inflation, the arterial waveform distal to the occlusion flattens, distal pulsation within the simulator is lost, and systolic blood pressures proximal to the balloon catheter increase by up to 62 mmHg. Further development and validation of this simulator will allow for refinement, reduction, and replacement of large animal models, costly virtual reality simulators, and perfused cadavers for training purposes. This will ultimately facilitate the low-cost, high-fidelity REBOA simulation needed for the widespread dissemination of this life-saving technique.

Specificity of children’s arithmetic learning

Among adults, arithmetic training–transfer studies have documented a high degree of learning specificity. Provided that there is a delay of at least 1day between training and testing, performance gains do not transfer to untrained problems, nor do they transfer to complement operation-inverted problems (e.g., gains for 4+7=__ do not transfer to the complement subtraction problem, 11−4=__, or vice versa). Here we demonstrate the same degree of learning specificity among 6- to 11-year-old children. These results appear to rule out, for the current training paradigm, operation-level procedural learning as well as any variant of complement problem mediation that would predict transfer. Results are consistent with either or both of two types of learning: (a) item-level procedural learning and (b) a shift to memory-based performance as predicted by the elemental elements model. These results suggest a developmental pattern such that specificity of learning among children is similar to that among adults. Educational implications are noted.