Graduate Medical Education Programs Research Articles

Educational video improves dermatology residents' understanding of Mohs micrographic surgery: A survey-based matched cohort study

To the Editor: Dermatology resident experience with Mohs micrographic surgery is highly variable,1Lee E.H. Nehal K.S. Dusza S.W. Hale E.K. Levine V.J. Procedural dermatology training during dermatology residency: a survey of third-year dermatology residents.J Am Acad Dermatol. 2011; 64: 475-483Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar,2Reichel J.L. Peirson R.P. Berg D. Teaching and evaluation of surgical skills in dermatology: results of a survey.Arch Dermatol. 2004; 140: 1365-1369Crossref PubMed Scopus (37) Google Scholar and it has been reported that surgical training is often underemphasized in the course of dermatology training compared with other proceduralists.3Alam M. Dermatologic surgery training during residency: room for improvement.Dermatol Surg. 2001; 27: 508-509PubMed Google Scholar In surgery, especially dermatologic surgery, there is a need to quickly and intuitively transmit complex information to a wide physician audience, and various creative methods have been attempted, including YouTube4Koya K.D. Bhatia K.R. Hsu J.T. Bhatia A.C. YouTube and the expanding role of videos in dermatologic surgery education.Semin Cutan Med Surg. 2012; 31: 163-167Crossref PubMed Scopus (27) Google Scholar and metaphor.5Lee E. Wolverton J.E. SomaniAK A simple, effective analogy to elucidate the Mohs micrographic surgery procedure – the peanut butter cup.JAMA Dermatol. 2017; 153: 743-744Crossref PubMed Scopus (6) Google Scholar We created a mixed live-action and animated video demonstrating an introduction to Mohs micrographic surgery in an effort to improve residents' basic understanding of how, why, and when Mohs micrographic surgery is performed, with additional information on special considerations for Mohs micrographic surgery performed on unique anatomic locations. Although it was never intended to replace any part of a formal Mohs micrographic surgery fellowship, we hoped that residents' confidence with the basic concepts of Mohs micrographic surgery would improve with this approachable educational method. In this survey-based, matched-cohort study, 83 dermatology resident physicians were recruited by contacting Accreditation Council for Graduate Medical Education program coordinators and requesting dispersal within their programs through the Association of Professors of Dermatology LISTSERV (L-Soft International, Bethesda, MD). The residents were asked to complete a preliminary survey to self-rate their comfort level of Mohs micrographic surgery. The survey consisted of 5 basic Mohs competencies, and participants were asked to rate their comfort with each competency as 1 (low) through 5 (high). They were then asked to view 2 short, educational video modules on Mohs micrographic surgery. The first video demonstrates the excision of a sample and its histologic preparation—and how uniquely in Mohs micrographic surgery this allows for evaluation of complete margins with accurate reference to surrounding surface anatomy. The second video demonstrates special anatomic considerations for excising and preparing samples taken from the eyelids, lips, and nails. After viewing the 2 modules, residents reanswered the same survey questions (Fig 1). The combination of premodule and postmodule answers were presented in a cross-tabulation table for each of the 5 questions. Values above the descending diagonal represented higher responses on the postsurvey, and values below this diagonal indicated higher responses on the presurvey. Owing to non-normal distributions for the survey questions, a nonparametric Wilcoxon signed rank test was used to compare the paired responses. This analysis was performed using SAS 9.4 software (SAS Institute Inc, Cary, NC), and a P value of <.05 was considered statistically significant. Our results demonstrated that the video modules significantly improved residents' self-rated comfort in all survey questions (P < .05) (Fig 2). After viewing the video modules, residents assessed themselves as more comfortable with how the layer is taken by the surgeon, how the layer is inked by the surgeon, how the tissue is positioned on the slide, how 100% of the margin is cleared by the surgeon, and unique issues for specific anatomic locations. With wide variation in Mohs micrographic surgery experience among dermatology residents, an approachable medium for resident exposure to Mohs micrographic surgery is needed, and a module conveying 3-dimensional content may fill that need. Our Mohs micrographic surgery video modules improved residents' self-rated confidence with the basics of Mohs micrographic surgery.

Early Impact of the Western Journal of Emergency Medicine CDEM/CORD Special Issue in Educational Research & Practice.

IntroductionIn 2015, with a stated goal of disseminating best teaching practices and developing a community of educational scholars, the Council of Emergency Medicine Directors (CORD) and the Clerkship Directors of Emergency Medicine (CDEM) created an annual Special Issue in Educational Research and Practice (Special Issue) in cooperation with the Western Journal of Emergency Medicine. The intention of this study was to analyze the impact of this effort to date.MethodsBibliometric data was gathered on all four special issues, 2015–2019, from the Web of Science and then verified with the eScholarship website. Authorship, academic affiliation, date published, article type, and format were tabulated for descriptive analysis. Using metrics from Google Scholar, alternative scholarly impact metrics (altmetrics), and the eScholarship website, the authors identified top articles and grouped them into themes.ResultsOf the 136 articles included in the first four years of the Special Issue, 126 represented peer-reviewed publications with an overall acceptance rate of 25.0% (126/505). Authors from this cohort represented 103 of the 182 (56.6%) Accreditation Council for Graduate Medical Education (ACGME) programs in existence at the time of the inaugural issue. Multi-institutional studies represented 34.9% (44/126) of the peer-reviewed publications. Traditional and alternative publication metrics are reported to assess the impact of articles from the Special Issues.ConclusionThe Special Issue is a proven outlet to share best practices, innovations, and research related to education. Additionally, the infrastructure of this process promotes the development of individual faculty and a community of teaching scholars.

Faculty Development in Improvement Science: Building Capacity and Expanding Curricula Across an Academic Health Center.

The ability of health professions faculty to design, teach, evaluate, and improve relevant curricula is vital for teaching improvement science (IS) skills to trainees. We launched a Foundational Improvement Science Curriculum (FISC) to build faculty competence in IS teaching and scholarship, and to develop, expand, and standardize IS curricula across one institution. FISC consisted of 9 full or half-day sessions over 10 months in 2015-2016 and 2016-2017 academic years. Each session required pre-work, including readings, Institute for Healthcare Improvement Open School modules, and personal improvement projects. Sessions included brief didactics, group activities, planning, and feedback on curriculum development. An evaluation strategy was employed, including pre- and post-program self-assessment, competency mapping, evaluations of didactics and overall program, and participant satisfaction. Forty individuals from 23 academic programs voluntarily completed FISC, representing 20% of graduate medical education (GME) programs and 50% of primary GME programs in addition to undergraduate medical education (UME) and nursing programs. Median self-assessed competency scores (mid versus final score; scale 1-9, 9 high; P < .05 for all comparisons) improved over the course for all competencies for knowledge (3 versus 7), application (2 versus 7), curriculum design (2 versus 7), and scholarship (2 versus 5). Eighteen new or revised IS curricula were developed across GME, UME, and nursing programs. FISC offers a feasible model to enhance and support faculty development in IS and IS curriculum design.

What Proportion of Orthopaedic Surgery Residency Programs Have Accessible Parental Leave Policies, and How Generous are They?

Parental leave during graduate medical education is a component of wellness in the workplace. Although every graduate medical education program is required by the Accreditation Council for Graduate Medical Education (ACGME) to have a leave policy, individual programs can create their own policies. The ACGME stipulates that "the sponsoring institution must provide a written policy on resident vacation and other leaves of absence (with or without pay) to include parental and sick leave to all applicants." To our knowledge, a review of parental leave policies of all orthopaedic surgery residency programs has not been performed. QUESTION/PURPOSES: (1) What proportion of orthopaedic surgery residency programs have accessible parental (maternity, paternity, and adoption) leave policies? (2) If a policy exists, what financial support is provided and what allotment of time is allowed? All ACGME-accredited orthopaedic surgery residency programs in 2017 and 2018 were identified. One hundred sixty-six ACGME-accredited allopathic orthopaedic surgery residency programs were identified and reviewed by two observers. Reviewers determined if a program had written parental leave policy, including maternity, paternity, or adoption leave. Ten percent of programs were contacted to verify reviewer findings. The search was sequentially conducted starting with the orthopaedic surgery residency program's website. If the information was not found, the graduate medical education (GME) website was searched. If the information was not found on either website, the program was contacted directly via email and phone. Parental leave policies were classified as to whether they provided dedicated parental leave pay, provided sick leave pay, or deferred to unpaid Family Medical Leave Act (FMLA) policies. The number of weeks of maternity, paternity, and adoption leave allowed was collected. Our results showed that 3% (5 of 166) of orthopaedic surgery residency programs had a clearly stated policy on their program website. Overall, 81% (134 of 166) had policy information on the institution's GME website; 7% (12 of 166) of programs required direct communication with program coordinators to obtain policy information. Further, 9% (15 of 166) of programs were deemed to not have an available written policy as mandated by the ACGME. A total of 21% of programs (35 of 166) offered designated parental leave pay, 29% (48 of 166) compensated through sick leave pay, and 50% (83 of166) deferred to federal law (FMLA) requiring up to 12 weeks of unpaid leave. Although 91% of programs meet the ACGME requirement of written parental leave policies, current parental leave policies in orthopaedic surgery are not easily accessible for prospective residents, and they do not provide clear compensation and length of leave information. Only 3% (5 of 166) of orthopaedic surgery residency programs had a clearly stated leave policy accessible on the program's website. Substantial improvements would be gained if every orthopaedic residency program clearly outlined the parental leave policy on their residency program website, including compensation and length of leave, particularly in light of the 2019 American Board of Orthopaedic Surgery changes allowing time away to be averaged over the 5 years of training. Parental leave policies are increasingly relevant to today's trainees []. Applicants to orthopaedic surgery today value work/life balance including protected parental leave [].

Recommendations for Enhancing Sports Medicine Fellowship Training.

Physical medicine and rehabilitation-trained physicians are increasingly interested in caring for patients with musculoskeletal and sports disorders. Sports medicine fellowships are designed to provide competency in sports medicine and musculoskeletal care. The authors, with endorsement from the Association of Academic Physiatrists, provide a framework and tools that Accreditation Council for Graduate Medical Education accredited sports medicine fellowship programs can use to enhance and meet the Accreditation Council for Graduate Medical Education program requirements. Based on the position statement from the American Medical Society for Sports Medicine, we propose recommendations for Accreditation Council for Graduate Medical Education-accredited sports medicine programs to achieve standards of excellence. We also provide recommendations for research requirements during the course of a sports fellowship. With the proposed recommendations, a sports medicine fellowship program can achieve excellence and enhance fellowship training by increasing proficiency in physical medicine and rehabilitation-based skills relevant to sports and musculoskeletal medicine. Given the multidisciplinary nature of musculoskeletal and sports medicine, it is also key that fellowship programs (regardless of the department that they are accredited through) have faculty members that represents these disciplines and accept applicants with residency training in physical medicine and rehabilitation, internal medicine, family medicine, pediatrics, and emergency medicine.

It Is Time to Prioritize Education and Well-Being Over Workforce Needs in Residency Training.

Residents inhabit an ambiguous world. They are no longer medical students but are still learners. They are not yet attendings but are still paid employees. This ambiguity leads to a misalignment of departmental incentives and trainee expectations. Trainees expect their learning and well-being to be prioritized, while departments are under pressure to meet staffing needs and cut costs. This sets up a fundamental disconnect between the "formal" Accreditation Council for Graduate Medical Education (ACGME) message of well-being and the dominant "hidden" workplace forces that pull in the opposite direction, possibly contributing to the epidemic of burnout in trainees. It is critical that all parties-health systems, graduate medical education (GME) programs, the ACGME, and residents-recognize this disconnect and collaborate to meaningfully implement current ACGME requirements to decompress work intensity and address well-being. Real change will require more than general directives. The ACGME will likely need to take the lead and consider taking a design-thinking approach to structuring regulations governing how and when residents work and how they are supported. It would also be worthwhile to revisit the Institute of Medicine recommendations on GME from 2014 related to funds flow and transformation initiatives. Taking a more comprehensive approach to residents as people, workers, and vital health care professionals is the right thing to do and may well improve retention, reduce burnout, decrease medical errors, and improve care.

A352 Clemens von Pirquet Award Recipient IS IT TIME TO RETHINK THE ALLERGY TRAINING REQUIREMENTS FOR PEDIATRIC RESIDENTS?

Primary care pediatricians (PCPs) play a critical role in the evaluation of childhood allergic disorders, yet, pediatrician-reported comfort in management of allergic conditions remains insufficient. To date, the Accreditation Council for Graduate Medical Education (ACGME) program requirements suggest zero mandatory core or elective rotations in Allergy & Immunology (AI), which limits training opportunities for residents.

Jump-Starting Faculty Development in Quality Improvement and Patient Safety Education: A Team-Based Approach.

Quality improvement (QI) and patient safety (PS) are cornerstones of health care delivery. Accreditation organizations increasingly require that learners engage in QIPS. For many faculty, these are new domains. Additional faculty development is needed for them to teach and mentor trainees. Existing programs, such as the Association of American Medical Colleges Teaching for Quality (Te4Q) program, target individual faculty and thus accommodate only limited participants at a time, which is problematic for institutions that need to train many faculty to support their learners. The authors invited diverse stakeholders from across the University of California, San Francisco (UCSF) School of Medicine and related health systems to participate in a team-based adaptation of the Te4Q program. The teams completed 5 projects based on previously identified priority areas to increase local capacity for QIPS teaching: (1) online modules for faculty new to QIPS, (2) a tool kit for graduate medical education programs, (3) a module for medical school clerkship directors, (4) guidelines for faculty to integrate early learners into QI projects, and (5) a "Teach-for-UCSF" certificate program in teaching QIPS. Thirty-five faculty members participated in the initial Te4Q workshop in January 2015, and by fall 2016, all projects were implemented. These projects led to additional faculty development initiatives and a rapidly expanding number of faculty across campus with expertise in teaching QIPS. Further collaborations between faculty focused on QIPS in care delivery and those focused on QIPS education to promote QIPS teaching have resulted from these initial projects.

Key Considerations for Implementing Group Prenatal Care: Lessons from 60 Practices.

Group prenatal care combines clinical care with peer support and education. Research has indicated neutral or positive results for group care when compared with traditional individual prenatal visits. A national initiative, Strong Start II, was implemented to determine if specific prenatal care interventions such as group prenatal care can reduce the rate of preterm birth, improve health outcomes, and lower costs. This study explored barriers to implementation and sustainability and strategies for overcoming barriers and sustaining the model. Results from prenatal care provider-level qualitative case studies for the independent evaluation of Strong Start were examined. Case studies for sites implementing group prenatal care were based on a total of 313 interviews with 441 Strong Start key informants (eg, prenatal care providers, project staff, and health administrators involved in group care) and 53 focus groups with 428 Strong Start participants from 2013 to 2016. Supplemental interviews with 25 additional stakeholders were also conducted. Case study data were queried using content analysis followed by a grounded theory-based analysis of these findings. Barriers to implementation existed at patient, provider, administrator, system, and funding levels and included inflexible appointment times, lack of childcare, lack of appropriate meeting space, new scheduling and training needs, meeting requirements of graduate medical education programs, prenatal care provider and administrator reluctance to adopt new practices, and Medicaid payment policies. Sites newly implementing group prenatal care had varying degrees of success sustaining their programs. Both new and established sites identified provider champions and opt-out enrollment approaches as critical for maintaining buy-in. Successful implementation of group prenatal care depends on systematic strategies at the practice, payer, provider, patient, and policy levels to implement, reimburse for, and sustain the model. Strategies for overcoming barriers can assist practices in offering this transformative approach, including practices with graduate medical education programs or those serving women with clinical, demographic, or psychosocial risk factors for preterm birth.

1128. Knowledge, Attitudes and Perceptions about Antibiotic Stewardship (AS) Programs among Neonatology Trainees

BackgroundAntibiotic stewardship (AS) is a fundamental aspect of medical training. Neonatal Intensive Care Units (NICU) often have unique stewardship needs as they are ideal settings for the emergence and spread of drug-resistant bacteria. Assessing neonatology fellowship trainees’ knowledge and perceptions will highlight deficits in AS education and inform future curriculum development.MethodsProspective electronic survey study, distributed by Accreditation Council for Graduate Medical Education (ACGME) program directors to neonatology fellows in the United States over 4 months (January to April 2018). The objective was to assess neonatology fellows’ knowledge, attitudes and perceptions about AS to inform sustainable NICU-specific AS programs.ResultsOf 99 programs and 700 fellows, 159 respondents (23%) from 40 neonatology training programs (40%) responded to the survey and 139 (87%) provided complete responses. Respondents were equally spread across all 3 years of trainingSeventy-two percent confirmed an institutional AS program existed, yet, only 33% were able to identify the components of AS programs and 66% either did not or were unsure if they had received AS training during fellowship. Furthermore, only 51% identified the appropriate empiric antibiotic for neonatal meningitis and 12% identified optimal methicillin-susceptible Staphylococcus aureus (MSSA) treatment while answering clinical case study questions. Notably, fellowship training year was not significantly related to the proportion of incorrect responses (P = 0.40).Small group sessions were identified as the best teaching format (35%). This was followed by audit and feedback of individual prescribing behavior and didactic lectures which had an equal proportion of respondents (22%). Seventy-eight percent of respondents preferred a trainee-led AS program targeting necrotizing enterocolitis, antifungal prophylaxis and appropriate surgical prophylaxis.ConclusionAntibiotic stewardship is a critical part of physician training. While most institutions have a stewardship program, a dedicated curriculum incorporating small group sessions and didactics may be beneficial for educating neonatology trainees.Disclosures All authors: No reported disclosures

The Advocacy Journal Club.

To describe a method of educating pathologists about health policy. The Advocacy Journal Club was a series of six conferences. Topics were of those in the news or affecting local practice. Participants reviewed preparatory readings, completed a six- to 10-question pretest, attended an interactive presentation stressing advocacy groups' efforts, and completed a posttest. All were invited to complete a survey after the sessions. Faculty and residents had increased posttest scores following each presentation with a significant difference in four and three sessions, respectively. More than 80% agreed they could discuss the topics with others and understood how regulations affect practice. More than 90% agreed that they gained an understanding of how involvement in organizations' advocacy initiatives affects policy. We present a method for educating pathologists about policy and the role of professional societies that could be implemented by nearly all graduate medical education programs.

Prevalence and Etiology of Burnout in a Community-Based Graduate Medical Education System: A Mixed-Methods Study.

Burnout rates among American physicians and trainees are high. The objectives of this study were: (1) to compare burnout rates among residents and faculty members of the graduate medical education (GME) programs sponsored by the University of Kansas School of Medicine-Wichita (KUSM-W) to previously published data, and (2) to evaluate the physicians' feedback on perceived causes and activities to promote wellness. Between April and May 2017, we surveyed 439 residents and core faculty members from 13 residency programs sponsored by the KUSM-W. The survey included the Abbreviated Maslach Burnout Inventory, two open-ended questions, and demographic questions. The authors used Kruskal-Wallis and Fisher exact tests to analyze the quantitative data, and an immersion-crystallization approach to analyze the open-ended data. Forty-three percent of all respondents met the criteria for burnout, and the overall response rate was 50%. When compared with core faculty members, rates of burnout among residents were higher (51% vs 31%, P&lt;.05). The immersion-crystallization approach revealed five interconnected themes as possible causes of burnout among physicians: work-life imbalance, system issues, poor morale, difficult patient populations, and unrealistic expectations. Promotion of healthy and mindfulness activities; enhanced program leadership; and administration, program, and system modification were identified as activities/resources that can promote wellness among physicians. The findings show that burnout is prevalent among physicians within GME. Wellness and burnout prevention should be addressed at the beginning of medical training and longitudinally. Potential intervention should include activities that allow physicians to thrive in the health care environment.

Realizing a Diverse and Inclusive Workforce: Equal Access for Residents With Disabilities.

Realizing a Diverse and Inclusive Workforce: Equal Access for Residents With Disabilities.

See No Evil, Hear No Evil, Stop No Evil: Institutional-Level Tracking to Combat Mistreatment of Residents and Fellows.

Mistreatment of trainees, including discrimination and harassment, is a problem in graduate medical education. Current tools to assess the prevalence of mistreatment often are not administered institutionally and may not account for multiple sources of mistreatment, limiting an institution's ability to respond and intervene. We describe the utility of a brief questionnaire, embedded within longer institutional program evaluations, measuring the prevalence of different types of trainee mistreatment from multiple sources, including supervisors, team members, colleagues, and patients. In 2018, we administered a modified version of the mistreatment questions in the Association of American Medical Colleges Graduation Questionnaire to investigate the prevalence and sources of mistreatment in graduating residents and fellows. We conducted analyses to determine the prevalence, types, and sources of mistreatment of trainees at the institutional level across graduate medical education programs. A total of 234 graduating trainees (77%) from the University of Minnesota-Twin Cities completed the questions. Patients were cited as the primary source of mistreatment in 5 of 6 categories, including both direct and indirect offensive remarks, microaggressions, sexual harassment, and physical threats (paired t test comparisons from t = 3.92 to t = 9.71, all P < .001). The only category of mistreatment in which patients were not the most significant source was humiliation and shaming. Six questions concerning types and sources of trainee mistreatment, embedded within an institutional survey, generated new information for institutional-, departmental- and program-based future interventions. Patients were the greatest source for all types of mistreatment except humiliation and shaming.

Attrition Rate in Military General Surgery GME and Effect on Quality of Military Programs

The attrition rate in civilian general surgery Graduate Medical Education (GME) is estimated at 20%, while estimates of attrition in military general surgery (MGS) GME programs using the same methodology are nearly twice that. We sought to identify the true attrition rate in MGS GME, identify factors influencing attrition, and examine the relationship between attrition and quality of MGS GME. Deidentified data were collected on categorical general surgery residents matriculating from 2010 to 2013 from all 12 MGS residency programs. Information gathered included gender, medical degree, marital status, location of program, presence of a military-related interruption in training, and age at start of the categorical contract. For those who did not graduate, data on postgraduate year at time of attrition, reasons for attrition, and deficiencies in core competencies were solicited. To assess the effect of true attrition rate on graduate performance, we compared the published 5-year American Board of Surgery qualifying exam/certifying exam first time pass rates between military and civilian programs. One hundred eighty-four categorical residents matriculated from 2010 to 2013. Fifty six (31.5 %) were women, 151 (62.1%) were MD's, 103 (56%) were married, 172 (93.5%) were less than 35 years old, and 33 (17.9%) had a military-related interruption in training. Nineteen individuals left residency prior to graduation (15 resigned, 2 resigned in lieu of termination, 2 terminated) for an overall attrition rate of 10.3%. The most common year for attrition was PGY-3 (31.6%) and most common reason for resignation was changing to a different subspecialty (73.3%). Men and women had equal attrition rates (10.3%), and there was no meaningful difference between MD's and DO's (9.9% vs 12.1%, p = 0.71) or region of training (10.6% East vs 9.1% West, p = 0.73). However, those who were not married, had a militarily mandated interruption in training and started their categorical training over the age of 35 had higher attrition rates (married 5.6%, not married 15%, p = 0.04, interruption 16% vs no interruption 9%, p = 0.1; Age ≥ 35 33.3% vs age < 35 6.7%, p < 0.01). Comparison of American Board of Surgery (ABS) first time pass rates over a similar time period showed that military programs performed statistically discernibly better than civilian programs (82% ± 12 vs 75% ± 13, p = 0.047). Previous used methodology over estimates the attrition rate in MGS GME. The lower rate in MGS programs results in a high level of graduate performance as measured by ABS pass rates. Interruption in training and especially marital status and age ≥ 35 appear to be potential predictors of attrition. Components of MGS GME training and selection processes might inform efforts to reduce attrition and improve performance in civilian surgical GME.

Resident Mental Health: Time for Action.

Resident Mental Health: Time for Action.

High-Value Care Culture Among the Future Physician Workforce in Internal Medicine

Training in high-spending regions correlates with higher spending patterns among practicing physicians. This study aimed to evaluate whether trainees' exposure to a high-value care culture differed based on type of health system in which they trained. In 2016, 517 internal medicine residents at 12 California graduate medical education programs (university, community, and safety-net medical centers) completed a cross-sectional survey assessing perceptions of high-value care culture within their respective training program. The authors used multilevel linear regression to assess the relationship between type of medical center and High-Value Care Culture Survey (HVCCS) scores. The correlation between mean institutional HVCCS and Centers for Medicare and Medicaid Services' Value-Based Purchasing (VBP) scores was calculated using Spearman rank coefficients. Of 517 residents, 306 (59.2%), 83 (16.1%), and 128 (24.8%) trained in university, community, and safety-net programs, respectively. Across all sites, the mean HVCCS score was 51.2 (standard deviation [SD] 11.8) on a 0-100 scale. Residents reported lower mean HVCCS scores if they were from safety-net-based training programs (β = -4.4; 95% confidence interval: -8.2, -0.6) with lower performance in the leadership and health system messaging domain (P < .001). Mean institutional HVCCS scores among university and community sites positively correlated with institutional VBP scores (Spearman r = 0.71; P < .05). Safety-net trainees reported less exposure to aspects of high-value care culture within their training environments. Tactics to improve the training environment to foster high-value care culture include training, increasing access to data, and improving open communication about value.

Hurricane Harvey: Firsthand Perspectives for Disaster Preparedness in Graduate Medical Education.

When disasters strike, hospitals are challenged to continue the delivery of health care, much of which is dependent on trainees. Fortunately, disasters are infrequent; however, that infrequency leads to an absence of training in how to plan and execute a disaster response, and leaves medical professionals and trainees unprepared to handle the burden of a disaster when it strikes. In August 2017, Hurricane Harvey tested the efficacy of the graduate medical education (GME) disaster plan at Corpus Christi Medical Center (CCMC) and provided an opportunity to evaluate residents' performance in a disaster situation in the inpatient setting. In this Invited Commentary, the authors recall their experience at CCMC during Hurricane Harvey and its aftermath. They describe the challenges that resulted from a disaster plan that proved to be inadequate. Based on their own lessons learned, the authors offer several recommendations for more effective disaster planning for GME programs: adequate staffing, adequate resources, optimal team structure, effective communication, safe evacuation, and thorough planning. This evaluation of how the residents prepared for and responded to an actual natural disaster provides perspective into organizational and institutional processes that could benefit from further development and implementation.

The Value of Surgical Graduate Medical Education (GME) Programs Within An Integrated Health Care System

Surgical graduate medical education (GME) programs add both significant cost and complexity to the mission of teaching hospitals. While expenses tied directly to surgical training programs are well tracked, overall cost-benefit accounting has not been performed. In this study, we attempt to better define the costs and benefits of maintaining surgical GME programs within a large integrated health system. We examined the costs, in 2018 US dollars, associated with the surgical training programs within a single health system. Total health system expenses were calculated using actual and estimated direct GME expenses (salary, benefits, supplies, overhead, and teaching expenses) as well as indirect medical education (IME) expenses. IME expenses for each training program were estimated by using both Medicare percentages and the Medicare Payment Advisor Commission study. The projected cost to replace surgical trainees with advanced practitioners or hospitalists was obtained through interviews with program directors and administrators and was validated by our system's business office. A physician lead, integrated, rural health system consisting of 8 hospitals, a medical school and a health insurance company. GME surgical training programs within a single health system's department of surgery. Our health system's department of surgery supports 8 surgical GME programs (2 general surgery residencies along with residencies in otolaryngology, ophthalmology, oral-maxillofacial surgery, urology, pediatric dentistry, and vascular surgery), encompassing 89 trainees. Trainees work an average of 64.4 hours per week. Total health system cost per resident ranged from $249,657 to $516,783 based on specialty as well as method of calculating IME expenses. After averaging program costs and excluding IME and overhead expenses, we estimated the average annual cost per trainee to be $84,171. We projected that replacing our surgical trainees would require hiring 145 additional advanced practitioners at a cost of $166,500 each per year, or 97 hospitalists at a cost of $346,500 each per year. Excluding overhead, teaching and IME expenses, these replacements would cost the health system an estimated additional $16,651,281 or $26,119,281 per year, respectively. Surgical education is an integral part of our health system and ending surgical GME programs would require large expansion of human resources and significant additional fiscal capital.

Validation of Assessing Arthroscopic Skill using the ASSET Evaluation

The Accreditation Council for Graduate Medical Education and the American Board of Orthopaedic Surgery have implemented "milestones" to evaluate residents during their progression in medical education. The purpose of this study was to determine whether a validated evaluation tool correlates with surgical experience, year in training, and progression over time. This was a retrospective study of already collected curriculum assessment data where 2 unbiased, blinded orthopedic surgeons evaluated resident performance on basic diagnostic knee arthroscopy using the Arthroscopic Surgical Skills Evaluation Tool (ASSET) over 3 years. Residents also gained arthroscopy experience through a structured arthroscopy curriculum and clinical experience. The study was conducted at the TRIA Orthopaedic Center (Bloomington, Minnesota, USA), an institutional site for The University of Minnesota orthopedic surgery residency program. Eleven orthopedic surgery residents at postgraduate years 2 to 5 were evaluated using the ASSET. The Pearson's Correlation Coefficient was used to validate both the number of arthroscopic procedures performed by residents (r = 0.946) and their level in training (r = 0.89). Residents who were re-evaluated after undergoing the arthroscopy curriculum throughout the year displayed significant increases in total ASSET scores (p < 0.01). Resident performance on the ASSET correlated with arthroscopic experience based on year-in training. More importantly, performance improved with additional years of training, demonstrating validity over time. The data also demonstrates interobserver reliability. Due to these correlations between exposure to surgery and score on the ASSET, we believe the tool could serve as a suitable means for assessing residents' technical proficiency as required by The Accreditation Council for Graduate Medical Education program guidelines.