Learning Opportunities For Residents Research Articles

Impact of an Interprofessional HIV Quality Improvement Team on Patient Care and Resident Learning Opportunities.

Although human immunodeficiency virus (HIV) care is a recommended competency for family medicine training, many programs report a lack of HIV expertise among faculty. After the departure of faculty with HIV care experience, an interprofessional HIV quality improvement team (HIV-QIT) of physicians and pharmacists aimed to maintain on-site HIV care and retain learning opportunities for residents, using process improvement and panel reviews with a remote HIV specialist faculty member. This study reports on a multicycle quality improvement pilot project with pre- and postintervention chart reviews between December 2019 and May 2021. All patients received primary care and HIV-QIT chart reviews on-site. We compared patients with integrated HIV care on-site to those receiving external HIV specialty care. Primary outcomes included virologic suppression, CD4 count ≥200 cells/mm3, and adherence to guideline-recommended HIV care. In cycle 1 (January-June 2020), the HIV-QIT reviewed patient charts and sent guideline-based recommendations to physicians. In cycle 2 (July 2020-May 2021), the HIV-QIT implemented several HIV-specific processes, including decision support updates, note templates, order sets, and reference materials. Sustained process improvements included HIV panel chart audits every 3 to 6 months and subsequent provider education. Of 29 patients, more than half (55%, n=16) received integrated HIV care at the primary care site. We found no significant difference in care quality measures between primary and specialty care. Barriers to care completion included missed or canceled follow-up visits, on-site phlebotomy service closures, and declined HIV services. The HIV-QIT maintained on-site HIV treatment and retained experiential learning opportunities through process improvement and specialist-supported care recommendations to primary care physicians.

Residents' Report of COVID-19 Associated Training Disruptions, Stressors, and Opportunities During the Pandemic-The Singapore Experience.

The COVID-19 pandemic has disrupted residency training. Several studies have been performed to investigate the impact of the pandemic on residency training in Accreditation Council for Graduate Medical Education-International (ACGME-I)-accredited institutions. However, these were either limited to certain specialties or failed to consider possible opportunities from the pandemic. To determine the stressors on residents as well as the opportunities that arose from the COVID-19 pandemic across multiple specialities in Singapore. A cross-sectional survey among SingHealth residents was conducted between July and September 2020. The survey assessed the balance between service and training during hospital postings, the pandemic's influence on examination and teaching, the psychological impact of the pandemic, the level of burnout, and the effect on morale of residents during the pandemic. The response rate was 27.1% (253 of 934). Out of the 253 residents, 136 (53.8%) felt stressed during the pandemic. Concerns about family's health and safety pertaining to potential COVID-19 infection, progression in training, and completion of examinations were the top 3 stressors. One-hundred and three residents (40.7%) had their training disrupted either by being placed in an interim posting not part of their residency requirements or being deployed to care for patients with COVID-19. Although administrative support and information for virtual teaching were sufficient, only 108 (42.7%) agreed it had the same value as face-to-face sessions. Despite the challenges, 179 (70.8%) thought that experiencing this crisis provided more meaning in their career. The COVID-19 pandemic has brought about challenges and learning opportunities for residents.

Teaching Potential of Multidisciplinary Tumor Board Meetings for Orthopedic Residents: Insights From a French Sarcoma Reference Center.

Multidisciplinary tumor boardmeetings (MTBMs) have been established in oncology to improve patient care. While their benefits for patients have been well-documented, there are no previous studies on the teaching opportunities they provide for residents and medical students. This study aimed to examine the teaching provided to residents during MTBM and identify areas for improvement. The study hypothesized that although the primary objective of MTBM is not teaching, they could still contribute to residents' learning. The study focused on the tumors board meeting for bone metastasis and musculoskeletal tumors/sarcoma in a French reference center for musculoskeletal oncology. The composition of the MTBM included specialists from various disciplines, and it convened on a weekly basis to discuss cases. The orthopedic oncology residents (OORs) actively participated in the MTBM as part of their training. A questionnaire was distributed to OORs who had served between 2014 and 2021, and their responses were analyzed. The results showed that the OOR perceived MTBM as interesting, beneficial for their training, and challenging. While opinions were divided on whether MTBM was a suitable place for education, the majority believed it improved their knowledge of different specialties and provided valuable elements applicable to daily practice. They also felt it facilitated future access to MTBs if needed. OORs recommended the rotation as an orthopedic oncology resident to younger residents. Recommendations for improvement included incorporating more dedicated teaching time, active involvement of residents in the learning process, availability of learning materials, and post-MTBM debriefing sessions. The study highlighted the importance of case presentations, public speaking skills, interdisciplinary collaboration, and clinical reasoning observed during MTBM. In conclusion, while not primarily designed for teaching, MTBM offers valuable learning opportunities for residents. Enhancing the teaching experience through dedicated debriefing sessions, resident involvement, and improved support can further optimize their educational impact. Future evaluations are needed to assess the effectiveness of these improvements. This study provides insights into the teaching potential within MTBM and can guide educational initiatives in the field of oncology.

Learning in a real-life escape room: an explorative study on the supervisory relationship in GP residency during the COVID-19 pandemic

BackgroundThe relationship between supervisors and residents plays a prominent role in the professional development of general practice (GP) residents. When disruptions occur in the normal course of healthcare, due to effects of e.g. war or emerging epidemics, we need to consider how this may affect the training of the next generation of general practitioners. As both supervisors and residents face new and unprecedented challenges that impact overall quality of the training. In this study, we examined the characteristics of the supervisory relationship in GP training during the disruptions early on during COVID-19. Our aim was to understand better how resident learning is affected in these circumstances, which is a first step in enabling supervisors, residents and faculty to anticipate disruptive situations better in the future.MethodsWe conducted a qualitative case study with a constructivist approach. Seven GP residents at the start of their second placement, and their 10 supervisors participated in this study. Participants came from a University Medical Centre in the Netherlands. Semi-structured interviews were held between September 2020 and February 2021. The subjects were (1) interviewed individually about what they had learned regarding COVID-19, and (2) they were interviewed in supervisory pairs about how they had learned. Data were iteratively analysed; thematic analysis for (1) and template analysis in (2).ResultsWe identified notable changes in the supervisor-resident relationship attributable to COVID-19. Supervisors and residents were confronted with an all-encompassing uncertainty in the workplace, and disruptive changes in patient care and learning opportunities for residents. Supervisors and residents addressed these emerging workplace challenges through three types of collaboration, (1) getting the job done; (2) residents’ learning; and (3) collective learning. Each type had a different focus and distinctive characteristics of the supervisory relationship.ConclusionWith the outbreak of COVID-19, supervisors and residents were faced with disruptive uncertainty. In these circumstances, learning occurred not only between residents and their supervisors, but also with non-supervising GPs and assistants in collective learning. We propose to complement collective learning in the workplace with reflection between residents and supervisors at the training institution.

Case Cards: A Novel Learner-Centered Initiative to Improve Resident Education in the Pediatric Emergency Room.

The pediatric emergency department (PED) provides a wealth of learning opportunities for residents. However,delivering dedicated educationcan be a significant challenge due to considerable variability inday-to-dayschedules, volume, cases, time, and resource availability. Case-based and learner-centered teaching models are well suited for ambulatory settings like the emergency department. Using the Kern model, we designed an educational intervention titled "Case Cards" to facilitate active learning conversations in pediatric emergency medicine (PEM). Our goal was to improve clinical teaching in the PED to demonstrate self-reported satisfaction, knowledge acquisition, confidence, and commitment among residents rotating in this fast-paced, challenging clinical environment. After general and targeted needs assessments, we developed a compendium of 30high-yield case cards to facilitate case-based learning conversations between learners and preceptors. Case topicsmirror the American Board of Pediatrics Content Outline of Emergent Conditions. The "Learner Card" presents a PEM case for the learner to read and hold, while the "Teacher Card" contains evidence-based teaching prompts following established learner-centered clinical teaching models to guide and facilitate the case.Post-implementation surveys queried Kirkpatrick New World educational outcomes in a retrospectiveformat. We collected data from 24 pediatric and emergency medicine residents between July 2021 and January 2022. All respondentsagreed or strongly agreed that case cards are enjoyable, educational, applicable to clinical practice, enhanced confidence, and would be recommended to others. Case cards for learner-centered teaching in the pediatric emergency setting are well-received and demonstrate resident self-reported satisfaction, knowledge, and confidence in core PEM conditions. Having established and readily available teaching topics, such as case cards, can enhance the clinical experience in the PED and other challenging settings and augment clinical exposure to core content. Educators may wish to expand and explore evolving technologies to facilitate learner-centered clinical teaching.

The Resident Learning Journey in the Medical Intensive Care Unit.

The medical intensive care unit (MICU) offers rich resident learning opportunities, but traditional teaching strategies can be difficult to employ in this fast-paced, high-acuity environment. Resident perspectives of learning within this environment may improve our understanding of the common challenges residents face and inform novel approaches to transform the MICU educational experience. We conducted a qualitative study of internal medicine residents to better understand their approach to learning the critical care activities that they are entrusted to perform in the MICU. Using a thematic analysis approach, we conducted six focus group interviews with 15 internal medicine residents, separated by postgraduate year. A trained investigator led each interview, which was audio-recorded and transcribed verbatim for analysis. Our diverse research team, representing different career stages across the continuum of learning to minimize interpretive bias, identified codes and subsequent themes inductively. We refined these themes through group discussion and sensitizing social learning theory concepts using Wenger's community of practice and organized them to create learner archetypes and a conceptual framework of resident learning in the MICU. We identified three thematic resident learning categories: learning goals and motivation, clinical engagement, and interprofessional collaboration. We distinguished three learner archetypes, the novice, experiential learner, and practicing member, to describe progressive resident development within the interprofessional MICU team, the challenges they frequently encounter, and potential teaching strategies to facilitate learning. We developed a conceptual framework that describes the resident's journey to becoming a trusted, collaborating member of the interprofessional MICU team. We identified common developmental challenges residents face and offer educational strategies that may support their progress. These findings should inform future efforts to develop novel teaching strategies to promote resident learning in the MICU.

Digital communication platforms in cardiothoracic surgery during COVID-19 pandemic: keeping us connected or isolated?

During the COVID-19 pandemic, performing a surgeon’s duties has become challenging while adhering to social distancing mandates. To aid in the continuity of healthcare services, rapid implementation of digital communication tools became a necessity. This is an account of experiences using digital communication platforms, namely Microsoft Teams and Zoom, for clinical and educative purposes in the field of Cardiothoracic Surgery in the UK. While enabling ongoing virtual clinical meetings, conferences and learning opportunities for residents with little face-to-face contact, are these digital communication platforms keeping us connected or isolated?

Attitudes of Canadian Plastic Surgeons on Temporal Artery Biopsy in Giant Cell Arteritis Management

Background:Temporal artery biopsies (TAB) rarely impact management of patients with suspected giant cell arteritis and carry complications. We sought plastic surgeons’ perspectives on this procedure’s risks and benefits.Methods:An email survey was designed, piloted, and refined to elicit Canadian Society of Plastic Surgeons (CSPS) members about TAB’s diagnostic contribution, complications, usefulness as a resident education tool, and surgeons’ insight into emerging diagnostic modalities like ultrasound. Text comments were sought at each question. A reminder was emailed one week later. Data was compared and analyzed using the chi-squared test and student t-test.Results:An estimated 83 responses were received from 435 surgeons (19%). Of the surgeons, 20% voiced uncertainty regarding TAB indications; 40% were unsure if TAB results changed steroid duration and dose; 83% did not see patients postoperatively. Surgeons recalled 29 cases of hematoma and three facial nerve injuries from TAB. In total, 80% felt TAB was a valuable learning opportunity for residents, although residents were involved in only 21% of cases; 65% of surgeons supported a changeover to ultrasound as primary diagnostic modality. Analysis of text comments revealed a sense of futility from TAB and disdain toward being mere technicians. Several participants wished for stakeholders to collaborate and potentially endorse noninvasive diagnostic modalities.Conclusions:This survey demonstrated varying attitudes to TAB. Generally, plastic surgeons were uncertain of TAB’s contribution to treatment, tended not to follow-up on results or patients, and recognized a number of complications. Conversations are desired regarding switching from scalpel to probe to evaluate the temporal artery.

Mentorship: A Millennia-Old Remedy for Learner Success Amidst the COVID-19 Pandemic

Mentorship: A Millennia-Old Remedy for Learner Success Amidst the COVID-19 Pandemic

Multi-Institutional Collaborative Resident Education in the Era of COVID-19.

The 2019-2020 coronavirus pandemic has had a significant impact on all aspects of health care. Decrease in clinical and operative volume and limitations for conferences has drastically decreased educational opportunities for resident trainees. We describe the formation and initial success of the Collaborative Online Video Didactics lecture series, a multi-institutional online video didactics collaboration. Zoom data extraction and postlecture evaluation surveys were used to collect data on the impact of the pandemic on local educational activities as well as feedback about the lecture series. Lectures are being given by faculty from 35 institutions. The twice daily, hour-long webinar averages more than 470 live viewers per session with an average of 33.5 questions per session and has over 7,000 YouTube views of the recordings after the first 2 weeks. Viewers reported significant decreases in outpatient (75.2%), inpatient (64.9%) and operating room (77.7%) volumes at local programs, and only half (52.7%) of the survey responders indicated an increase in didactics locally. The lectures have been well-received, with over 90% of respondents giving the lecturers and series above average or excellent ratings. A significant majority of responders indicated that the lecture series has allowed for ongoing education opportunities during the pandemic (95.0%), helped to access faculty experts from other institutions (92.3%) and provided a sense of community connectedness during this period of social isolation (81.7%). We strongly encourage other institutions and trainees to participate in the didactic series and hope that this series can continue to evolve and be of benefit beyond the pandemic.

Pandemic brings unique clinical experiences.

When Jill Starykowicz looks at the COVID-19 pandemic from her perspective as director of a postgraduate year 2 residency program in critical care, she finds teachable moments. “This is . . . a great learning opportunity for residents—to learn how to handle a variety of different cases . . . and to manage a variety of drug shortage issues and alternative strategies,” she said. “I’m fortunate to have residents’ help with many services.” Starykowicz is a medical and cardiac intensive care unit (ICU) pharmacist at Advocate Lutheran General Hospital in Park Ridge, IL. She said in mid-April that she’s tried to give her residents autonomy and independence while also being available to discuss clinical questions that arise each day. The format of patient rounds has changed in response to the pandemic. Instead of having several medical and pharmacy residents donning personal protective equipment and visiting each patient, a single resident will enter the room and present the patient case.

Strategies to overcome limitations in Otolaryngology residency training during the COVID-19 pandemic.

PurposeThe COVID-19 pandemic has produced an unequaled human crisis forcing a radical reorganization in the healthcare system. Otolaryngologists are at high risk of exposure, and changes in medical and surgical activities have reduced the learning opportunity for residents and fellows. We believe that even during COVID-19 crisis it is mandatory to guarantee an optimal training, and here, we propose some strategies, based on our experience, to further increase our trainees’ learning curve.MethodsWe asked our trainees to fill out an electronic survey about several aspect of their training: a first section focused on the reduction of clinical activities and the perceived impact of the pandemic on residents’ skills; the second part outlined the type of attended training activity and the perceived benefit.ResultsSurgical training has been reported by our residents as the activity perceived to be the most contracted during the pandemic. According to residents’ opinion the most useful activities were dissection (n = 8, 53.4% residents) and online journal clubs/webinars (n = 7, 46.6% of residents). Residents’ suggestions included actively participating to tracheostomy procedures on SARS-CoV-2 positive patients, attending lessons held by senior consultants on basic ENT topics and promoting collegial discussion of inpatient clinical cases.ConclusionBuilding on this dramatic experience, we must be ready for a global restructuring of the residency program to provide an adequate trainee education for the future surgeons.

Access to Learning Opportunities for Residents in Care Homes: Reviewing the challenges and possibilities

International, national and regional policy documents and key reports espouse the benefits of lifelong learning and people’s rights to it, yet little attention has been given to the learning needs of frail older people in nursing (care) homes. People living in care have frequently been cited as a forgotten sector of the community and this is apparent in the provision of learning opportunities. It appears that the learning needs of this population are largely ignored. This paper suggests that when the door of the care home is opened, the door to learning closes. The aim of this paper is to add to a small but growing body of literature on meeting the learning needs of people in long-term care. To investigate the topic, a scoping review of the literature (2002-2020) and a search of policy and key papers (1990-2020) were conducted. The results show a paucity of literature on the topic, which leads to the conclusion that many residents in nursing (care) homes are marginalised when it comes to furthering their learning requirements. This can be ascribed to limited resources in the care home sector but also suggests a form of ageism. The results show four themes that may contribute to designing a learning culture in care: Culture of learning vs culture of care; Learning vs recreational activity; Surviving vs thriving in care; and Outside vs care home communities. The paper concludes by recommending that links to community learning opportunities are vital for people in care to have their learning needs met.

Maximizing Patient Coverage Through Optimal Allocation of Residents and Scribes to Shifts in an Emergency Department.

Residents and scribes in an Emergency Department (ED) work closely with an attending physician. Residents care for patients under the supervision of the attending physician, whereas scribes assist physicians with documentation contemporaneously with the patient encounter. Optimal allocation of these roles to shifts is crucial to improve patient care, physician productivity, and to increase learning opportunities for residents. Since resident and scribe availability varies on a monthly basis, the allocation of these roles into different shifts within a pre-designed ED physician shift template must be dynamically adjusted. Using historical patient flow timestamp data as well as information about the patient-coverage capacity of an ED care team, a data-driven model was developed for optimally determining which shifts must be staffed by residents and scribes to maximize patient coverage and to calculate the relative importance of a shift. This relative importance metric aids decision-making in adjusting the allocation of residents and scribes to various shifts as their availability fluctuates. Since the model uses historical timestamp data, which all EDs are mandated to collect, the approach is generalizable to all EDs.

A Qualitative Analysis of Attending Physicians' Use of Shared Decision-Making: Implications for Resident Education.

Physicians need to rapidly and effectively facilitate patient-centered, shared decision-making (SDM) conversations, but little is known about how residents or attending physicians acquire this skill. We explored emergency medicine (EM) attending physicians' use of SDM in the context of their experience as former residents and current educators and assessed the implications of these findings on learning opportunities for residents. We used semistructured interviews with a purposeful sample of EM physicians. Interviews were transcribed verbatim, and 3 research team members performed iterative, open coding of transcripts, building a provisional codebook as work progressed. We analyzed the data with a focus on participants' acquisition and use of skills required for SDM and their use of SDM in the context of resident education. Fifteen EM physicians from academic and community practices were interviewed. All reported using SDM techniques to some degree. Multiple themes noted had negative implications for resident acquisition of this skill: (1) the complex relationships among patients, residents, and attending physicians; (2) residents' skill levels; (3) the setting of busy emergency departments; and (4) individual attending factors. One theme was noted to facilitate resident education: the changing culture-with a cultural shift toward patient-centered care. A constellation of factors may diminish opportunities for residents to acquire and practice SDM skills. Further research should explore residents' perspectives, address the modifiable obstacles identified, and examine whether these issues generalize to other specialties.

Flipped classroom model for learning evidence-based medicine.

Journal club (JC), as a pedagogical strategy, has long been used in graduate medical education (GME). As evidence-based medicine (EBM) becomes a mainstay in GME, traditional models of JC present a number of insufficiencies and call for novel models of instruction. A flipped classroom model appears to be an ideal strategy to meet the demands to connect evidence to practice while creating engaged, culturally competent, and technologically literate physicians. In this article, we describe a novel model of flipped classroom in JC. We present the flow of learning activities during the online and face-to-face instruction, and then we highlight specific considerations for implementing a flipped classroom model. We show that implementing a flipped classroom model to teach EBM in a residency program not only is possible but also may constitute improved learning opportunity for residents. Follow-up work is needed to evaluate the effectiveness of this model on both learning and clinical practice.

Development of a pharmacy resident rotation to expand decentralized clinical pharmacy services.

The development of a pharmacy resident rotation to expand decentralized clinical pharmacy services is described. In an effort to align with the initiatives proposed within the ASHP Practice Advancement Initiative, the department of pharmacy at Cleveland Clinic, a 1,400-bed academic, tertiary acute care medical center in Cleveland, Ohio, established a goal to provide decentralized clinical pharmacy services for 100% of patient care units within the hospital. Patient care units that previously had no decentralized pharmacy services were evaluated to identify opportunities for expansion. Metrics analyzed included number of medication orders verified per hour, number of pharmacy dosing consultations, and number of patient discharge counseling sessions. A pilot study was conducted to assess the feasibility of this service and potential resident learning opportunities. A learning experience description was drafted, and feedback was solicited regarding the development of educational components utilized throughout the rotation. Pharmacists who were providing services to similar patient populations were identified to serve as preceptors. Staff pharmacists were deployed to previously uncovered patient care units, with pharmacy residents providing decentralized services on previously covered areas. A rotating preceptor schedule was developed based on geographic proximity and clinical expertise. An initial postimplementation assessment of this resident-driven service revealed that pharmacy residents provided a comparable level of pharmacy services to that of staff pharmacists. Feedback collected from nurses, physicians, and pharmacy staff also supported residents' ability to operate sufficiently in this role to optimize patient care. A learning experience developed for pharmacy residents in a large medical center enabled the expansion of decentralized clinical services without requiring additional pharmacist full-time equivalents.

Is Orthopedic Department Teaching Status Associated With Adverse Outcomes Of Primary Total Hip Arthroplasty?

BackgroundAlthough resident physicians play a vital role in the US health care system, they are believed to create inefficiencies in the delivery of care. Under the regional component of the Comprehensive Care for Joint Replacement model, teaching hospitals are forced to compete on efficiency and outcomes with nonteaching hospitals. MethodsWe identified 86,021 patients undergoing elective primary total hip arthroplasty in New York State between January 1, 2009, and September 30, 2014. Outcomes included length and cost of the index admission, disposition, and 90-day readmission. Mixed-effects regression models compared teaching vs nonteaching orthopedic hospitals after adjusting for patient demographics, comorbidities, hospital, surgeon, and year of surgery. ResultsPatients undergoing surgery at teaching hospitals had longer lengths of stay (β = 3.2%; P < .001) and higher costs of admission (β = 13.6%; P < .001). There were no differences in disposition status (odds ratio = 1.03; P = .779). The risk of 90-day readmission was lower for teaching hospitals (odds ratio = 0.89; P = .001). ConclusionPrimary total hip arthroplasty at teaching orthopedic hospitals is characterized by greater utilization of health care resources during the index admission. This suggests that teaching hospitals may be adversely affected by reimbursement tied to competition on economic and clinical metrics. Although a certain level of inefficiency is inherent during the learning process, these policies may hinder learning opportunities for residents in the clinical setting.

Clinic First: 6 Actions to Transform Ambulatory Residency Training.

Clinic First: 6 Actions to Transform Ambulatory Residency Training.

Automated Case Cancellation Review System Improves Systems-Based Practice.

Accreditation Council for Graduate Medical Education (ACGME) core competencies of systems-based practice and practice-based learning and improvement are difficult to assess, as they are often not directly measurable or observable. Reviewing day-of-surgery cancellations could provide resident learning opportunities in these areas. An automated system to facilitate anesthesiology resident review of cancelled cases was implemented on the Preoperative Evaluation Clinic (PEC) rotation at the authors' institution. This study aims to evaluate its impact on resident education. Residents on the PEC rotation during the 6 months preceding (n = 22) and following (n = 13) implementation in 2014 were surveyed about their experience performing cancelled case reviews in order to ascertain the effect of the intervention on their training. Significant changes were reported in the number of cases reviewed by each resident (p < 0.0001), perceived importance of review (p = 0.03), and ease of review (p = 0.03) after system implementation. There was also an increase in the proportion of cancelled cases reviewed from 17.3% (34 of 196) to 95.6% (194 of 203) (p < 0.0001). Non-significant trends were seen in perceived rotation effect on ACGME competencies, including systems-based practice. Several specific improvements to our clinical practice, including the creation of standardized guidelines, arose from these case reviews. Implementation of automated systems can improve compliance with educational goals by clarifying priorities and simplifying workflow. This system increased the number of cases reviewed by residents and the perceived importance of this review as a part of their educational experience.