Graduate Medical Education Programs Research Articles

A Call to Action: Students Establish a Culture of Bystander Intervention Early in Medical Training.

To the Editor: Discrimination, harassment, unrecognized biases, and mistreatment are all forces that negatively influence health care work environments and outcomes. As the United States confronts social inequity nationwide, it is imperative that providers and leaders in medicine are keenly aware of how biases shape our profession and overall health care climate. An effective health care culture must uphold values, maintain accountability, and work to reduce barriers that prevent transparency, communication, advocacy, and growth. It is critical that all health care professionals are empowered with skills to intervene when mistreatment occurs and to lead teams to prevent and recognize mistreatment. However, little time is dedicated to such needs. We created a novel 4-session, student-led, prevention-focused, small group Culture Change in Medicine curriculum as an action-based advocacy project targeted at immediate cultural change at our institution. Sessions are near peer-led where senior medical students facilitate small groups of junior students. Four sessions total are completed by all medical students at key transition points of training: Session 1: Bystander Intervention, Preclerkship Session 2: Response to Discrimination and Bias, Transition to Clerkship Session 3: Advocacy, Postclerkship Session 4: Leadership in Action, Senior Practicum Peer leaders facilitate case-based discussions and deliberate possible interventional or protective strategies for victims or bystanders, empowering students with tools to prevent or address mistreatment. Peer educators undergo faculty development training sessions via live webinars and receive educator guides, facilitator tips, and supplemental resources. A faculty advisor oversees the content development and execution of the training. To date, 2 classes of medical students completed sessions of this training, resulting in 510 person-hours of instruction. Feedback submitted through 97 anonymous postsession surveys is largely positive. Eighty-five students (87%) reported that the curriculum had important topics to cover during medical school and 92 students (95%) reported that their peer educators were knowledgeable on the topics delivered in the curriculum. Near peer leaders promoted buy-in and motivation from students, allowing for broader and more honest conversations about these sensitive topics, and provided a stronger sense of security and confidentiality without the presence of authority figures (faculty/staff). Next steps include widening participation to other key groups such as clinical faculty, graduate medical education programs, and other health professions learners and faculty. We hope that our work can also translate to other institutions and provide a foundation for further dialogue and improvement in medical training culture, building new skills to confront the societal norms that lead to bias, discrimination, and mistreatment. Acknowledgments: The authors thank the leadership of the Uniformed Services University School of Medicine for supporting student leadership in this endeavor. Additionally, this curriculum would not be possible without the time investment, professionalism, and passion of the many student peer educators. Finally, the authors thank Military Primary Care Research Network staff for their ongoing assistance in the development of curricular evaluation methods.

What Behaviors Define a Good Physician? Assessing and Communicating About Noncognitive Skills.

Once medical students attain a certain level of medical knowledge, success in residency often depends on noncognitive attributes, such as conscientiousness, empathy, and grit. These traits are significantly more difficult to assess than cognitive performance, creating a potential gap in measurement. Despite its promise, competency-based medical education (CBME) has yet to bridge this gap, partly due to a lack of well-defined noncognitive observable behaviors that assessors and educators can use in formative and summative assessment. As a result, typical undergraduate to graduate medical education handovers stress standardized test scores, and program directors trust little of the remaining information they receive, sometimes turning to third-party companies to better describe potential residency candidates. The authors have created a list of noncognitive attributes, with associated definitions and noncognitive skills-called observable practice activities (OPAs)-written for learners across the continuum to help educators collect assessment data that can be turned into valuable information. OPAs are discrete work-based assessment elements collected over time and mapped to larger structures, such as milestones, entrustable professional activities, or competencies, to create learning trajectories for formative and summative decisions. Medical schools and graduate medical education programs could adapt these OPAs or determine ways to create new ones specific to their own contexts. Once OPAs are created, programs will have to find effective ways to assess them, interpret the data, determine consequence validity, and communicate information to learners and institutions. The authors discuss the need for culture change surrounding assessment-even for the adoption of behavior-based tools such as OPAs-including grounding the work in a growth mindset and the broad underpinnings of CBME. Ultimately, improving assessment of noncognitive capacity should benefit learners, schools, programs, and most importantly, patients.

Ongoing Self-review and Continuous Quality Improvement Among Family Medicine Residencies.

Graduate medical education (GME) occurs during and is a crucial step of the transition between medical school and clinical practice. Residency program graduates' abilities to provide optimal patient care, act as role models, and demonstrate excellence, compassion, professionalism, and scholarship are key elements and outcomes of successful GME programs. In order to create and maintain the training environment that leads to such outcomes, programs must continually review and revise their patient care and educational activities. Currently, compliance with accreditation standards as determined by individual specialties such as family medicine serves as a common and significant marker for program quality. Compliance with these requirements is necessary but not sufficient if faculty and residents want to achieve the goal of residency training in terms continually improving and optimizing the care they provide to their patients and communities. For overall program improvement to truly occur, the patient care, scholarship, and community activities of current residents and graduates must be assessed and used in program improvement activities. Appropriately applied to programs and using these assessments, quality improvement principles and tools have the potential to improve outcomes of patient care in residents' current and future practice and improve programs in educating residents.

Using a Delphi Technique to Define a Feedback Culture in Graduate Medical Education.

Experts in medical education hypothesize that programs with a robust culture of feedback foster learning and growth for learners and educators, yet the literature shows no consensus for what defines a feedback culture in graduate medical education. Using a two-round, modified Delphi technique in summer and fall of 2019, the authors asked a panel of experts to identify essential elements to a feedback culture. The research team compiled a list of experts and a list of 29 descriptors of a highly functioning feedback culture. Experts rated the items as an essential, compatible, or not important aspect of a highly functioning culture of feedback. Researchers set a minimum threshold of 80% agreement and used comments from panelists to revise elements that did not meet agreement during round one. Experts then rerated the elements using information on their initial ratings, aggregate panelist ratings, and comments from all panelists. The response rates from our panel of experts were 68% (17/25) for round one and 88% (15/17) for round two. Seventeen elements were rated as essential to a feedback culture. An expert panel endorsed essential elements that can be used to assess feedback culture in graduate medical education programs.

Medicare Support for Dental and Podiatry Graduate Medical Education Programs

Oral health care faces ongoing workforce challenges that affect patient access and outcomes. While the Medicare program provides an estimated $14.6 billion annually in graduate medical education (GME) payments to teaching hospitals, including explicit support for dental and podiatry programs, little is known about the level or distribution of this public investment in the oral health and podiatry workforce. To examine Medicare GME payments to teaching hospitals for dental and podiatry residents from 1998 to 2018, as well as the distribution of federal support among states, territories, and the District of Columbia. This cross-sectional study was conducted using data from 1252 US teaching hospitals. Data were analyzed from May through August 2020. Dental and podiatry residency training. Medicare dental and podiatry GME payments were examined. Among 1252 teaching hospitals, Medicare provided nearly $730 million in dental and podiatry GME payments in 2018. From 1998 to 2018, the number of residents supported more than doubled, increasing from 2340 residents to 4856 residents, for a 2.1-fold increase, while Medicare payments for dental and podiatry GME increased from $279 950 531 to $729 277 090, for a 2.6-fold increase. In 2018, an estimated 3504 of 4856 supported positions (72.2%) were dental. Medicare GME payments varied widely among states, territories, and the District of Columbia, with per capita payments by state, territory, and district population ranging from $0.05 in Puerto Rico to $14.24 in New York, while 6 states received no support for dental or podiatry residency programs. These findings suggest that dental and podiatry GME represents a substantial public investment, and deliberate policy decisions are needed to target this nearly $730 million and growing investment to address the nation's priority oral and podiatry health needs.

A Call for LGBTQ Content in Graduate Medical Education Program Requirements.

A well-developed body of literature demonstrates that lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals experience poorer health outcomes and report worse health care experiences than straight/cisgender individuals. Many reforms since 2010 have addressed the LGBTQ-related education of future health care professionals at the undergraduate medical education (UME) level; however, reforms at the graduate medical education (GME) level are lagging, and new literature suggests that didactic education at the UME level is not enough to prepare future physicians to properly and compassionately care for LGBTQ patients. Recently, the Accreditation Council for Graduate Medical Education (ACGME) implemented a major revision of its Common Program Requirements that requires residents to demonstrate, as a competence, respect and responsiveness to diverse populations. Given these revisions and the ongoing failure of many GME training programs to adequately prepare future physicians to care for LGBTQ patients, the authors argue that now is the time for the ACGME to develop and implement LGBTQ health-related residency requirements. In addition, the authors outline a path by which the academic medical community may develop and implement these requirements.

Love at First Click: Surgery Residency Websites in the Virtual Era

Frequently, a residency program's website is the first interaction students interested in surgery have with the program. In the setting of virtual interviews for residency in 2020, the online availability of program information is of heightened importance. We sought to assess how academic versus community-based general surgery residency programs compared with respect to certain details on their websites. A total of n = 268 surgery residency programs were investigated. Our database of website characteristics included: direct link to residency website from the American Council on Graduate Medical Education (ACGME) program page, resident research requirement, listing of residents' publications, availability of residents' demographic information, program alumni information, board pass rates, attrition rate, detail of educational/academic activities, residents' evaluation methods, diversity, and mentorship. Inter-group analyses between academic and community-based programs were performed using Pearson's Chi-squared test. Academic and community-based general surgery residency program websites were compared based on twelve (12) different parameters. Statistically significant differences were observed for eight of these comparisons: direct website access from ACGME (p = 0.007), research highlighted (p < 0.001), resident research requirement (p = 0.002), resident demographic information available (p=0.004), alumni information (p = 0.005), resident evaluation methods (p = 0.016), diversity (p < 0.001), and mentorship (p = 0.012). Across these domains, academic programs had more information available on their websites than the community programs did. The program websites did not differ significantly based on the frequency of mentioning resident publications, board pass rate, attrition rate, or resident education. Many general surgery programs are lacking detailed information on their websites. The amount of website information available on general surgery residency programs differs when comparing academic and community-based programs.

From Beginning to End: A Single Radiology Residency Program's Experience with Web-Based Resident Recruitment during COVID-19 and a Review of the Literature

COVID-19 disrupted the practice of in-person visits for the 2020-2021 recruitment cycle. This past year, Graduate Medical Education (GME) programs converted to online interviews and virtual visits for all applicants. Given the unpredictable nature of this pandemic, it remains unclear when or if conventional travel for residency interviews will resume. Therefore, it is important to reflect on this past season and look ahead to our next recruitment and interview cycle. Here, we review prior publications studying faculty and applicant experiences with web-based interviewing strategies, and we describe our own residency program's recruitment strategy for a virtual interview season, including survey results of reactions by both interviewers and candidates following our first season in this new era of virtual meetings and interviews. Web-based recruitment and interviews are feasible and can be done well with careful planning and preparation of those involved. Concerns persist primarily among applicants that virtual visits to a training program are inadequate for providing sufficient information prior to ranking. Regardless of future travel restrictions, GME programs will likely benefit all stakeholders by offering web-based recruitment and interviews, while also providing opportunities for optional in-person visits.

Preventive Medicine for Rural America: Why More Training Programs Must Be Here.

While there is a well-recognized national shortage of Preventive Medicine (PM) physicians, there is also a marked maldistribution. Since 47.5% of physicians were active in the state where they completed their most Graduate Medical Education (GME), one approach to address the disparity in PM specialists in practice within rural regions such as Appalachia is by supporting a greater number of GME programs based within these regions. Currently, of the 64 accredited civilian PM residency programs, only 4 are located in rural areas. The only PM residency programs based in the entire Appalachian region are based at West Virginia University. Several threats to the establishment and sustainability of rural-based PM GME programs have been identified, including challenges in securing support through competitive national grants, the limited number of board-certified community preceptors, and difficulty in recruiting and retaining both core program faculty and trainees. Targeted efforts to promote and support GME programs that are based in rural areas of need, such as the Health Resources and Services Administration's Rural Residency Planning and Development Program, will help address this disparity.

Rebuilding Graduate Medical Education After a Crisis: Perspectives of Medical Residents in the United Arab Emirates.

Pandemics create unprecedented public health challenges that require comprehensive and coordinated responses from health care systems and can, thereby, cause substantial and prolonged disruption to residency training. The coronavirus 2019 (COVID-19) pandemic has impacted medical education worldwide. Currently, there is a gap in the literature from the trainee’s perspective, and little advice on resuming post-pandemic operations. As internal medicine residents serving on the frontlines of a COVID-19 designated government hospital in the United Arab Emirates, we also faced significant challenges and uncertainties during the pandemic. We are fortunate to have overcome the initial surges and have spent the past 6 months navigating a new reality. We believe that the COVID-19 crisis provides an opportunity for graduate medical education programs worldwide to implement targeted changes that can lead to sustainable improvements in the system. In supporting learning during these times, our residency program has adopted flexible scheduling, focused on frequent and transparent communication, incorporated different strategies to build community and promote psychological wellbeing, and advanced virtual teaching modalities. The aim of this article is to share the strategies that have helped us to move forward in the aftermath of the first phases of the pandemic, whilst we prepare for the uncertainty of the future. We hope that the lessons we have learned can help inform other programs as they react and adapt to the global after-effects of this crisis.

Current Milestones Assessment Practices, Needs, and Challenges of Program Directors: A Collective Case Study in a Pediatric Hospital Setting.

IntroductionAccreditation Council for Graduate Medical Education's (ACGME's) Milestones assessment requirement has placed new demands on Program Directors (PDs), especially those with limited knowledge of assessment and evaluation activities. There is a lack of clarity on how Program Director (PDs)/Associate PDs (APDs) are effectively implementing milestones assessment and evaluation practices in the Graduate Medical Education programs. The purpose of this study was to investigate current assessment practices, needs, and challenges of PDs in implementing milestones assessment within their residency and fellowship programs in a pediatric hospital setting.MethodsThis study used a collective case study approach to obtain information from PDs, APDs, and Clinical Competency Committee (CCC) Chairs in 19 graduate programs at a pediatric hospital. We used structured meetings with planned agendas and a pre-formatted template to itemize program needs/difficulties/challenges in the milestone assessment. We used cross-case thematic content anal­ysis to identify categories and themes to compare differences and commonalities across programs.ResultsA total of 38 PDs, APDs, and CCC Chairs from 19 different specialties/subspe­cialties participated in this study. Thirteen types of assessment and evaluation tools were consistently used across programs. Three categories emerged in relation to those assessment and evaluation types (direct, indirect, and multi-source). Rotation evaluation (84.2%), direct observation (73.2%), and 360-degree assessment (68.4%) were primarily used for measuring patient care among the six core competencies. Programs’ needs varied from curriculum and assessment tool development to alignment of milestones items, and to creating a sys­tematic assessment management plan. The most common challenges were difficulties related to logistics and tracking of evaluation in the survey management system (52.6%), challenges with time management (47.3%), and difficulty in determining and interpret­ing the milestones’ numbers and levels (31.5%).ConclusionsMilestones assessment and evaluation in medical education can be a challenge, but a priority for many training programs. Our study indicated that milestones assessment and evaluation in medical education are far more com­plex than we expect. Multiple assessment methods must be utilized to evaluate all essential competencies for accurate measurement of trainees’ performance abilities. Our study uncovered several issues PDs faced during the implementation of milestones assessment and needs and challenges.

An Examination of the Intersection of Climate Change, the Physician Specialty Workforce, and Graduate Medical Education in the U.S.

Issue As U.S. healthcare systems plan for future physician workforce needs, the systemic impacts of climate change, a worldwide environmental and health crisis, have not been factored in. The current focus on increasing the number of trained physicians and optimizing efficiencies in healthcare delivery may be insufficient. Graduate medical education (GME) priorities and training should be considered in order to prepare a climate-educated physician workforce. Evidence: We used a holistic lens to explore the available literature regarding the intersection of future physician workforce needs, GME program priorities, and resident education within the larger context of climate change. Our interinstitutional, transdisciplinary team brought perspectives from their own fields, including climate science, climate and health research, and medical education to provide recommendations for building a climate-educated physician workforce. Implications: Acknowledging and preparing for the effects of climate change on the physician workforce will require identification of workforce gaps, changes to GME program priorities, and education of trainees on the health and societal impacts of climate change. Alignment of GME training with workforce considerations and climate action and adaptation initiatives will be critical in ensuring the U.S. has a climate-educated physician workforce capable of addressing health and healthcare system challenges. This article offers a number of recommendations for physician workforce priorities, resident education, and system-level changes to better prepare for the health and health system impacts of climate change.

From Crisis to Growth: A Guiding, Pragmatic Model During a Global Pandemic

We draw on articles about adaptive leadership during a sustained crisis, 8 and on theories for promoting a growth mindset for leaders, faculty, and trainees At the individual level, adopting a growth mindset is important to prepare leaders, faculty, and trainees for ongoing work and future crises - Kurt Lewin 1 T he COVID-19 pandemic has changed individuals and health care institutions and is testing the graduate medical education (GME) community's collective adaptability and potential for growth under adversity and uncertainty Woodson Scott Jones, MD Ingrid Philibert, PhD, MA, MBA Lyuba Konopasek, MD Frederic W Hafferty, PhD There is nothing as practical as a good theory [Extracted from the article] Copyright of Journal of Graduate Medical Education is the property of Accreditation Council for Graduate Medical Education and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission However, users may print, download, or email articles for individual use This abstract may be abridged No warranty is given about the accuracy of the copy Users should refer to the original published version of the material for the full abstract (Copyright applies to all Abstracts )

Cultivating Healthy Governance in Rural Programs.

Cultivating Healthy Governance in Rural Programs.

The Importance of Competency-Based Programmatic Assessment in Graduate Medical Education.

The Importance of Competency-Based Programmatic Assessment in Graduate Medical Education.

Navigating Academic Law in Competency Decisions.

Navigating Academic Law in Competency Decisions.

In Seas of Change, a Call to Action: 2021 American Board of Medical Specialties Policy on Parental, Caregiver, and Medical Leave During Training

Institutional graduate medical education (GME) programs are guided by architecture built by the Accreditation Council for Graduate Medical Education (ACGME), the American Board of Medical Specialties (ABMS) and, as radiology programs, the American Board of Radiology (ABR). At its core, GME is dynamic and progressive, committed to enhancing resident education and improving the patient care that residents deliver. In 2019 and 2020, new ACGME program requirements and the expanded second edition of ACGME Radiology Milestones added new guidelines affecting all accredited radiology residencies (1,2).

In Reply to Bowe et al.

We thank Bowe and colleagues for their comments regarding our article on a framework for inclusive graduate medical education (GME) recruitment strategies. The authors acknowledge there is evidence that non-White race is an independent predictor of lower likelihood for interview selection and matriculation in surgery residency, 1 which substantiates the concerns for bias in selection and matriculation we highlighted in our article. In addition, Bowe and colleagues raise concerns about the need for data to support initiatives to diversify training programs. We agree that data are an important driver of change and that changes to recruitment strategies are necessary nationwide to improve workforce diversity and inclusion. Our article was meant to provide a framework for inclusive recruitment strategies for individual GME programs, and in-depth program-level analysis is one way to assess individual programs and institutions for progress and opportunities for improvement. 1 However, Bowe and colleagues highlight that residency programs and the Accreditation Council for Graduate Medical Education have difficulty assessing progress in diversifying efforts on a larger scale. Some data exist to aide in specialty-specific analyses via the Association of American Medical Colleges (AAMC). For example, one of us (C.M.O.) coauthored a study using data from the AAMC GME Track survey 2 to investigate race disparities in nephrology fellowship training, highlighting trends in the racial makeup of medical student graduates, internal medicine trainees, and nephrology fellows. 3 However, using only the AAMC and GME track data that are currently available has its limitations, particularly in the applicant-to-matriculant stage, such as “Withdrew” and “No Rank List” categories, from the National Resident Matching Program (NRMP), as Bowe and colleagues have mentioned. Bowe and colleagues also bring to our attention that the currently available NRMP data show disparities in non-U.S. graduate Match rates. It is plausible that other disparities (e.g., ethnic, gender, and disability) exist in the Match, the Supplemental Offer and Acceptance Program, and matriculation rates. For instance, some ethnic minority groups are also disproportionately represented in the category of non-U.S. medical school graduates. It is unclear why the NRMP has limited its collection and reporting to “applicant-type.” Collection, analysis, and sharing of NRMP sociodemographic data, such as race, ethnicity, gender, disability, and geographic location, in collaboration with the currently available NRMP, AAMC, and GME Track data, is necessary as it enables programs, institutions, specialties, and organizations, such as the ACGME, to track trends and increase accountability for workforce diversity and inclusion efforts. Acknowledgments: The authors acknowledge Dr. James Appiah-Pippim for contributions to their framework and support.

How Long Will It Take to Reach Gender Parity in Orthopaedic Surgery in the United States? An Analysis of the National Provider Identifier Registry.

Although previous studies have evaluated how the proportion of women in orthopaedic surgery has changed over time, these analyses have been limited by small sample sizes, have primarily used data on residents, and have not included information on growth across subspecialties and geographic regions. We used the National Provider Identifier registry to ask: How have the (1) overall, (2) regional, and (3) subspecialty percentages of women among all currently practicing orthopaedic providers changed over time in the United States? The National Provider Identifier Registry of the Centers for Medicare and Medicaid Services (CMS) was queried for all active providers with taxonomy codes pertaining to orthopaedic subspecialties as of April 2020. Women orthopaedic surgeons were identified among all physicians with subspecialty taxonomy codes. As all providers are required to provide a gender when applying for an NPI, all providers with queried taxonomy codes additionally had gender classification. Our final cohort consisted of 31,296 practicing orthopaedic surgeons, of whom 8% (2363 of 31,296) were women. A total of 11,714 (37%) surgeons possessed taxonomy codes corresponding with a specific orthopaedic subspecialty. A univariate linear regression analysis was used to analyze trends in the annual proportions of women who are active orthopaedic surgeons based on NPI enumeration dates. Specifically, annual proportions were defined using cross-sections of the NPI registry on December 31 of each year. Linear regression was similarly used to evaluate changes in the annual proportion of women orthopaedic surgeons across United States Census regions and divisions, as well as orthopaedic subspecialties. The national growth rate was then projected forward to determine the year at which the representation of women orthopaedic surgeons would achieve parity with the proportion of all women physicians (36.3% or 340,018 of 936,254, as determined by the 2019 American Medical Association Physician Masterfile) and the proportion of all women in the United States (50.8% or 166,650,550 of 328,239,523 as determined by 2019 American Community Survey from the United States Census Bureau). Gender parity projections along with corresponding 95% confidence intervals were calculated using the Holt-Winters forecasting algorithm. The proportions of women physicians and women in the United States were assumed to remain fixed at 2019 values of 36.3% and 50.8%, respectively. There was a national increase in the proportion of women orthopaedic surgeons between 2010 and 2019 (r2 = 0.98; p < 0.001) at a compound annual growth rate of 2%. Specifically, the national proportion of orthopaedic surgeons who were women increased from 6% (1670 of 26,186) to 8% (2350 of 30,647). Assuming constant growth at this rate following 2019, the time to achieve gender parity with the overall medical profession (that is, to achieve 36.3% women in orthopaedic surgery) is projected to be 217 years, or by the year 2236. Likewise, the time to achieve gender parity with the overall US population (which is 50.8% women) is projected to be 326 years, or by the year 2354. During our study period, there were increases in the proportion of women orthopaedic surgeons across US Census regions. The lowest growth was in the West (17%) and the South (19%). Similar growth was demonstrated across census divisions. In each orthopaedic subspecialty, we found increases in the proportion of women surgeons throughout the study period. Adult reconstruction (0%) and spine surgery (1%) had the lowest growth. We calculate that at the current rate of change, it will take more than 200 years for orthopaedic surgery to achieve gender parity with the overall medical profession. Although some regions and subspecialties have grown at comparably higher rates, collectively, there has been minimal growth across all domains. Given this meager growth, we believe that substantive changes must be made across all levels of orthopaedic education and leadership to steepen the current curve. These include mandating that all medical school curricula include dedicated exposure to orthopaedic surgery to increase the number of women coming through the orthopaedic pipeline. Additionally, we believe the Accreditation Council for Graduate Medical Education and individual programs should require specific benchmarks for the proportion of orthopaedic faculty and fellowship program directors, as well as for the proportion of incoming trainees, who are women. Furthermore, we believe there should be a national effort led by American Academy of Orthopaedic Surgeons and orthopaedic subspecialty societies to foster the academic development of women in orthopaedic surgery while recruiting more women into leadership positions. Future analyses should evaluate the efficacy of diversity efforts among other surgical specialties that have achieved or made greater strides toward gender parity, as well as how these programs can be implemented into orthopaedic surgery.

The RCA ReCAst: A Root Cause Analysis Simulation for the Interprofessional Clinical Learning Environment.

The Accreditation Council for Graduate Medical Education calls for resident participation in real or simulated interprofessional analysis of a patient safety event. There are far more residents who must participate in these investigations than available institutional root cause analyses (RCAs) to accommodate them. To correct this imbalance, the authors developed an institutionally sponsored, interprofessional RCA simulation program and implemented it across all graduate medical education (GME) residency programs at the Hospital of the University of Pennsylvania. The authors developed RCA simulations based upon authentic adverse events experienced at their institution. To provide relevance to all GME programs, RCA simulation cases varied widely and included examples of errors involving high-risk medications, communication, invasive procedures, and specimen labeling. Each simulation included residents and other health care professionals such as nurses or pharmacists whose disciplines were involved in the actual event. Participants adopted the role of RCA investigation team, and in small groups systematically progressed through the RCA process. A total of 289 individuals from 18 residency programs participated in an RCA simulation in 2019-2020. This included 84 interns (29%), 123 residents (43%), 20 attending physicians (7%), and 62 (21%) other health care professionals. There was an increase in ability of GME trainees to correctly identify factors required for an RCA investigation (62% pre vs 80% post, P = .02) and an increase in intent to "always report" for each adverse event category (3% pre vs 37% post, P < .001) following the simulation. The authors plan to expand the RCA simulation program to other GME clinical sites while striving to involve all GME learners in this educational experience at least once during training. Additionally, by collaborating with health system patient safety leaders, they will annually review all new RCAs to identify cases suitable for simulation adaptation.