Learning Opportunities For Residents Research Articles

Free online otolaryngology educational modules: a pilot study.

Otolaryngology residents need concise, easily accessible modules to expand educational opportunities between surgical cases. These modules should be inexpensive to create and improve learning outcomes. The purpose of this pilot study was to assess whether otolaryngology residents at multiple institutions used online video modules to supplement their studying for the Otolaryngology Training Exam, whether the modules had any effect on their Otolaryngology Training Examination Scores, and to obtain survey feedback about the modules. This randomized trial was conducted in 3 academic departments of otolaryngology in the United States among 37 residents enrolled in 3 otolaryngology residency programs. Residents were randomized into 2 groups, one with access to the educational modules and the other with no access. Otolaryngology training examination scores were obtained from the year prior to the intervention (2012) and the year following module access (2013). Residents with access to the modules were also surveyed to assess use and obtain feedback about the modules. Otolaryngology training examination scores improved significantly from 2012 to 2013 among both residents who had access to the modules and those who did not in the sections of head and neck, laryngology, and sleep medicine. However, scores in the sections of pediatric otolaryngology (8% increase, P = .03), otology (7% increase, P = .02), and facial plastic surgery (10% increase, P = .02) improved from 2012 to 2013 only among residents with access to the modules. All respondents rated the videos as very helpful, with a rating of 4 of 5 on a Likert scale. Online otolaryngology educational modules are an inexpensive way to expand resident learning opportunities. Despite the lack of quantifiable improvement in otolaryngology training examination scores in this study, use of online modules sends a message to otolaryngology residents that their education is a priority; self-study outside the hospital and clinics is necessary and expected; and that instructors are willing to try more nontraditional or progressive forms of education to increase resident knowledge.

The Perceived Effect of Duty Hour Restrictions on Learning Opportunities in the Intensive Care Unit.

Many countries have reduced resident duty hours in an effort to promote patient safety and enhance resident quality of life. There are concerns that reducing duty hours may impact residents' learning opportunities. We (1) evaluated residents' perceptions of their current learning opportunities in a context of reduced duty hours, and (2) explored the perceived change in resident learning opportunities after call length was reduced from 24 continuous hours to 16hours. We conducted an anonymous, cross-sectional online survey of 240 first-, second-, and third-year residents rotating through 3 McGill University-affiliated intensive care units (ICUs) in Montreal, Quebec, Canada, between July 1, 2012, and June 30, 2013. The survey investigated residents' perceptions of learning opportunities in both the 24-hour and 16-hour systems. Of 240 residents, 168 (70%) completed the survey. Of these residents, 63 (38%) had been exposed to both 24-hour and 16-hour call schedules. The majority of respondents (83%) reported that didactic teaching sessions held by ICU staff physicians were useful. However, of the residents trained in both approaches to overnight call, 44% reported a reduction in learner attendance at didactic teaching sessions, 48% reported a reduction in attendance at midday hospital rounds, and 40% reported a perceived reduction in self-directed reading after the implementation of the new call schedule. A substantial proportion of residents perceived a reduction in the attendance of instructor-directed and self-directed reading after the implementation of a 16-hour call schedule in the ICU.

Integrating a Patient Care Development Model to Enhance Community Pharmacy Residency Programs

Purpose: The purpose of this paper is to describe integration of a community-based patient care service development model, Partner for Promotion (PFP), within five community pharmacy residency programs (CPRPs) across the United States and provide insights and examples of methods for optimizing community pharmacy resident experiences, developing new patient care services, and achieving residency accreditation standards.
 Summary: Five community pharmacy residency programs have integrated PFP that affiliated with Midwestern University – Glendale, Northeast Ohio Medical University, Ohio State University, University of Utah, and West Virginia University. Each college and residency program has identified different strategies through which PFP enhances their residency training and service development including completion of training modules, reflections and discussion on application of the PFP service development model to practice, research, and teaching, use of assignments to guide service creation, and mentoring of PFP student-pharmacist teams. All five sites directly link these activities to objectives required in PGY1 CPRP accreditation standards. PFP has resulted in resident-facilitated service development of a variety of patient care programs.
 Conclusion: PFP applied to CPRPs enhances training on service development, builds new services within residency training sites, and assists programs with meeting residency accreditation standards. The experiences of five community pharmacy residency programs across the U.S. that have adopted the program has been positive, with creation of new services and residency sites, integration of novel teaching, practice, research, and learning opportunities for residents, and direct links from the PFP experience to achievement of residency objectives.
 
 Type: Idea Paper

Hemoglobinopathy Education in Canadian Hematology Training Programs: How Much Are Residents Learning?

The number of hemoglobinopathy patients in North America continues to increase, due to high rates of immigration from countries with high prevalence and improved survival. Recent research has led to evidence-based improvements in acute and chronic care of patients with sickle cell disease and thalassemia. Studies have noted gaps in clinicians’ knowledge about management of hemoglobinopathies, with the result that common presentations, such as sickle vaso-occlusive episodes, are often mismanaged. Hematologists completing training in North America require the knowledge and expertise to manage these medically complex patients.To ascertain the extent of hemoglobinopathy teaching and exposure in Canadian Adult and Pediatric Hematology Training Programs, and to assess the perceived importance of hemoglobinopathy knowledge, we administered an online survey to all Training Program Directors (TPDs), and to all residents who were currently enrolled or who had completed training in the previous year. Surveys were available in English and French.The response rate for TPDs was 92% (22/24). Ninety five percent of PDs felt that hemoglobinopathy learning is “important” or “very important” for hematology trainees in their region. Four programs have a mandatory hemoglobinopathy rotation, 14 programs have mandatory hemoglobinopathy clinic participation, and 17 programs have mandatory hemoglobinopathy lab exposure. Laboratory time ranges widely, from “0-2 hours” to “greater than 20 hours”. All programs covered laboratory aspects of hemoglobinopathy, outpatient care of sickle cell disease and inpatient care of sickle cell disease, and all but one program covered outpatient care of thalassemias. In 1/2 to 2/3 of adult training programs, these topics were covered at only a basic level. All pediatric programs covered outpatient and inpatient care of sickle cell disease “in-depth”, with 90% and 40% of programs covering outpatient thalassemia care and laboratory diagnostics “in-depth”, respectively. All 22 programs had academic half-days with teaching devoted to hemoglobinopathy. Seventy-seven percent of programs had faculty member(s) with an interest in hemoglobinopathy.The response rate for residents was 45% (70/156). The majority of respondents were senior residents, with 88% currently in post-graduate year five, or above. Among residents in adult hematology programs, 61% had completed a rotation or elective with a focus on hemoglobinopathy versus 25% in the pediatric programs. Total numbers of hemoglobinopathy patients seen ranged from “0” to “more than 50”, and laboratory exposure varied from “none” to “in-depth”. Most residents with clinical hemoglobinopathy experience had seen patients with both sickle cell disease and thalassemia major or intermedia. Of residents who responded, 83% felt that hemoglobinopathy knowledge was “important” or “very important” to their future practice.All TPDs and 90% of residents felt that online hemoglobinopathy learning modules could be beneficial for resident learning.There appears to be wide variability in depth and breadth of clinical and laboratory hemoglobinopathy learning in Hematology training programs across Canada. TPDs and residents place high importance on hemoglobinopathy learning, but some centres have small patient numbers, or lack faculty with interest in hemoglobinoapthies. Online learning modules could provide added learning opportunities for residents. DisclosuresNo relevant conflicts of interest to declare.

Using a resident discharge clinic for resident education and patient care: a feasibility study.

Many patients in internal medicine resident continuity clinics experience difficulty accessing care, making posthospitalization ambulatory follow-up challenging. Experiential learning in care transitions is also lacking for residents. We sought to assess the feasibility and impact of a weekly Resident Discharge Clinic (RDC) in increasing access to early posthospitalization follow-up and providing learning opportunities for residents. We staffed the RDC with an ambulatory block resident, an internal medicine preceptor, and a clinical pharmacist. We assessed time to posthospitalization follow-up, readmission rates, and resident perceptions of postdischarge care for resident-clinic patients, comparing data before and after RDC implementation. There were 636 discharges in the baseline group, 662 during the intervention period, and 56 in the RDC group. Six months after RDC implementation, the percentage of discharged resident-clinic patients with follow-up within 7days improved from 6.6% at baseline to 9.7% (P = .04). The mean interval to the posthospitalization follow-up appointment in the RDC group was 7.4days compared with 33.9days in the baseline group (P < .001). The percentage of surveyed residents (n = 72) who agreed that early follow-up was easy to arrange increased from 21% to 77% (P < .001). There was no significant decrease in the 30-day readmission rate for patients in the RDC group (18.1% versus 12.5%, P = .29). The RDC was easily implemented, increased access to timely posthospitalization follow-up, and provided a platform for resident learning about care transitions.

Necessity Is the Mother of Invention

The traditional apprenticeship model for training doctors requires ample opportunities in the clinic for trainees to learn core procedures under the supervision of skilled doctors. In this issue, Kyser and colleagues document that the learning opportunities for residents to master certain core procedures, such as forceps and vacuum deliveries, are insufficient in many teaching hospitals. To address this serious problem, this author argues that learning techniques (i.e., deliberate practice and simulator use) from other domains of expertise, such as chess, music, and sports, must be adapted for use in medicine. For example, medical procedures should be videotaped and indexed for access over the Internet. Trainees then could view recordings of rare emergency procedures and complications and practice their decision-making skills. Evidence suggests that training outside the constraints of the clinic could be more effective in improving performance because trainees are able to engage in deliberate practice and focus on their individual weaknesses in executing procedures and making decisions. For example, with video and simulator training, trainees have the opportunity to repeatedly perform only the parts of a procedure that they find challenging until they have attained a level of acceptable speed and control. More generally, training could be structured around the particular needs of individual learners and scheduled when the learners are rested and able to concentrate fully on learning. Training also should include opportunities for learners to practice repeatedly with different patient descriptions requiring the same or different, yet related, procedures to teach trainees effective discrimination and execution.

Who pays for orthodontic education?

Who should pay for orthodontic education? A couple of years ago, I would have told you that I knew the answer, absolutely and without a doubt. Now, I'm not so sure. You may think this is an easy question. If you do, your answer likely depends on in which country you live, what your experience was when you were in school, and maybe what type of school you attended, public or private.Higher education throughout the world is either funded publically, by way of taxation, or privately, by collecting tuition. In many cases there are combinations, with some proportion of central support being augmented by fees paid by the students enrolled. In the US, there is a wide range of educational financial options available from the orthodontic resident's perspective, between being paid $160,000 to actually paying $240,000 over the duration of a residency program.1 If I were an applicant, it would seem obvious that I would opt for a graduate program that paid me a stipend or at least one that didn't charge, if that were possible. Yet, just two days ago, I was contacted by a prospective student by email asking me what she would “miss out on” by attending a program that paid a stipend rather than choosing a school charging a hefty tuition. I can understand her confusion.As far as I can tell, the main difference between programs that charge tuition and those that pay a stipend is the financial model under which they operate and that's it. There are differences among programs in teaching, research, and clinical balance and philosophy but these are not necessarily correlated with the amount of tuition they charge. Every program has good and bad characteristics depending on your perspective and it's up to the programs and the applicants to sort that out so that they match up appropriately.Dental education is very expensive to deliver. In post-graduate dentistry and in orthodontics in particular, however, there is an opportunity to generate financial support for education through the treatment that residents provide to patients. Where I am, we have been able to sustain a favorable balance financially by running an efficient orthodontic treatment practice as part of the orthodontic post-graduate program. Though the details of how the resources generated are distributed have varied over time depending on the higher administrations' policies, patient treatment revenues have been sufficient to cover the cost of running the orthodontic program. The model works well because having financial responsibility provides incentive for all the parties involved to make it successful. The residents themselves enjoy the experience because the environment required for the program to meet its expenses mimics what they will need to do in their future practices. Also, it means that the residents don't have to pay tuition, actually receive a small stipend, and even get an allowance for travel to scientific conferences and meetings.However, it is not always an easy task to meet a program's financial needs. An orthodontic graduate program with a clinical component that runs like a private practice experiences the same ups and downs of any orthodontic practice. When economic times are good, profits come easy. When the economy is tight, it is more important to watch where the money is spent. The staff members still need to be paid, the facility still needs to be upgraded to attract new patients, the residents still need resources to complete their research requirements. The challenges posed in hard economic times like the current one provide a learning opportunity for residents, faculty, and administrators alike. In some ways, it is actually instructive for the residents to experience the administrative pain of planning out how the practice (and hence the program) will meet its financial obligations.So, who pays for orthodontic education? I believe it is just too easy to say “let's raise tuition to cover our increased costs.” With residents graduating from programs in the US with an average debt approaching $200,000,2,3 it is irresponsible to keep raising tuition without considering the burden this places on the residents themselves, but also on the specialty and its future. Yet, not every program has the opportunity or ability to sustain its own financial health by managing an efficient treatment facility successfully. It is a question that is difficult to answer and yet is becoming a more critical problem than ever to solve.

Resident training in the psychiatric emergency service: duty hours tell only part of the story.

Psychiatry residents in North America are generally required to work on-call on the psychiatric emergency service (PES) during training. Resident discontent with the long hours, onerous case loads, and lack of on-call teaching has been reported as a barrier to PES training. Given that the PES is a longitudinal and important experience, we sought to develop a better understanding of this service from the resident perspective and identify factors that affect residents as they work and train in this area. In this grounded theory qualitative study, we collected data from focus groups with psychiatry residents. We analyzed data according to grounded theory methodology to develop an enhanced understanding of the resident experience on the PES. THREE MAJOR THEMES EMERGED FROM DATA ANALYSIS: (1) challenges residents face in the PES are complex and attributable to more than simply long duty hours, (2) the PES offers unique learning opportunities for residents, and (3) resident satisfaction with the PES depends on a good relationship with the team. This study highlights important topics for any residency programs that require residents to work on a PES team. Although much attention has been paid to addressing challenges inherent to the on-call experience, such as limiting the amount of on-call hours and call frequency, equal attention should be paid to team dynamics. Like prior work on physician contentment and multidisciplinary team functioning, our study found that physicians will tolerate stressful workplace factors, so long as there is a supportive and healthy team dynamic. It is important for program directors to identify problems with team dynamics in the PES in light of their potential impact on residents.

Recession Imposes New Challenges on Psychiatric Care

Recession Imposes New Challenges on Psychiatric Care

Linking Process to Outcome: Are We Training Pediatricians to Meet Evolving Health Care Needs?

The Residency Review and Redesign in Pediatrics (R(3)P) Project began in 2005 and will have been completed in 2009. The purpose was to conduct a comprehensive reassessment of general pediatric residency education. The project convened 3 major colloquia supplemented by numerous meetings of an R(3)P committee and by surveys of residents, subspecialty fellows, and generalist and subspecialty practitioners. A principal conclusion was that resident learning opportunities should be more flexibly directed toward the variety of career choices available to pediatricians. Another conclusion was that reasonable expectations for residency education are most likely if learning is regarded as an integrated continuum, beginning in medical school and continuing throughout a career in practice. The R(3)P Committee declined to create a list of recommendations for immediate changes in residency education; instead, it recommends that changes be based on evidence of education outcomes that are important to improving the health of children, adolescents, and young adults.

Attending Anesthesiologist Responses to Resident Challenge: The Two-Challenge Rule

Introduction: In aviation, the “two-challenge rule” is a principle where a subordinate is obligated to challenge a superior when it’s believed an unsafe action has been taken. If there is no answer, or a nonsensical answer, the subordinate is empowered to escalate the challenge and ultimately take control of the aircraft. A modified two-challenge rule for healthcare has been advocated in patient safety literature where “taking over” is replaced by “calling for help.” In a prior simulation-based study, anesthesiology residents were reluctant to challenge questionable practices of an attending anesthesiologist. This follow-up study examines the responses of attending anesthesiologists to challenges made by residents. Methods: In a simulated operating room, scripted residents challenge decisions made by an attending anesthesiologist (subject). The scenario is an elderly patient (70s) having an elective repair of a humerus fracture under interscalene block and general anesthesia. Relevant past medical history includes hypertension treated with hydrochlorothiazide. While the subject watches from a remote location, a confederate anesthesia team comprised of a simulator faculty attending and resident induce general anesthesia. There is disagreement about proceeding with the operation following discovery that the patient had a small amount of orange juice in the waiting area. After an uneventful rapid sequence induction, the attending is called to another room. The departing attending requests that the subject anesthesiologist supervise the resident described as “difficult to work with.” The patient goes into rapid atrial fibrillation (HR ∼ 150; SBP ∼ 75). Using a structured technique based on the aviation two-challenge rule, the resident challenges medical decisions made by the subject. Videotapes from ten scenarios were reviewed by a single investigator (RHB). Number and type of subject actions and subject response to the resident’s challenge were noted. Subject response was coded to note if the challenge was acknowledged and whether an explanation was given. Acknowledgments were coded as “none,” a “simple” verbal response, or “complex,” meaning the subject acknowledged their management was being challenged. Additionally, the quality of an explanation for the action, or for rejecting the challenge, was coded as adequate or inadequate. The absence of an explanation was coded as inadequate. Results: Of 10 cases evaluated, 45 challenges were identified (average 4.5 per case; range 2–8). Subjects’ choice of therapy for atrial fibrillation was: medical 28/45 (62%), electrical 7/45 (16%), and other 10/45 (22%). 5/10 (50%) of the subjects requested and received help from another attending anesthesiologist. Subject responses to the resident challenges were: none 5/45 (11%), simple 30/45 (67%), and complex 10/45 (22%). The subjects’ explanation to the resident was judged adequate 21/45 (47%) and inadequate 24/45 (53%). Conclusions/Discussion: Anesthesiologists’ responses to resident challenge demonstrated that over half of the challenges were not accompanied by an adequate explanation of the rationale behind the attending’s decision-making. In the authors’ opinions, these are lost learning opportunities for residents. Of greater concern is risk to patient safety when the resident suggestions are ignored or suppressed due to the position of authority of the attending. Conflict of Interest: Authors indicated they have nothing to disclose.

Utilizing a JCAHO review in the education of clinical pastoral education CPE residents.

Reflects on how a pastoral care department utilized a Joint Commission review in the education of five pastoral care residents enrolled in their third unit of Clinical Pastoral Education in a medical center. Outlines how residents prepared for the review, the learning opportunities for residents and medical staff, the outcomes, and the recommendations.

Failed appointments in residency practices: who misses them and what providers are most affected?

Missed appointments can affect patient health, disrupt schedules, and result in poor utilization of resources, increased workload for staff and physicians, and lost learning opportunities for residents in training programs. The setting was an established community-hospital-based family practice residency practice averaging 25,000 outpatient visits per year in a small northern New England town. Data from a computer-scheduling system and hospital mainframe, as well as demographic and other information contained in billing records and patient schedules, were abstracted for patients who scheduled 3962 appointments on 36 sampled days during 1995. The missed appointment rate during the study period was 6.7 percent. Characteristics associated with missed appointments were younger patient age (17 to 30 years), Medicaid coverage or lack of health insurance, and appointments scheduled with first-year residents or medical students. Attention should be given to those patients most likely to miss appointments and, in training programs, to patients seeing first-year residents and medical students. It is possible that our relatively low missed appointment rate overall resulted from the nature of the practice and its environment.

The Behavioral Medicine Service: An administrative model for biopsychosocial medical care, teaching, and research

The biopsychosocial model has been promoted for its advantages in many important health problems. However, the lack of administrative practice models specifically designed to develop and promote the model hinder the development of systematic clinical applications. This article describes a successful clinical teaching and research practice, The Behavioral Medicine Service, that was conceptualized and developed based on the biopsychosocial model. Systematic planning enabled the service to take advantage of clinical, research, and teaching opportunities and to reduce the constraints imposed on development from within psychiatry and the institution. Advantages of the organizational model include multidisciplinary treatment teams, a systematic method of biopsychosocial assessment and management planning, and continuity of care between several settings: the medical-surgical wards of a general hospital; a behavioral medicine inpatient unit; and outpatient subspecialty clinics for chronic pain, chronic medical illness, anxiety and stress-related disorders, and drug and alcohol abuse. The Human Behavioral Pharmacology Laboratory forms the research arm of the service. Referrals of a diversity of medical and psychiatric problems create a unique learning opportunity for residents. Billing for multimodal team treatment, training residents, establishing clinical research, and managing a plethora of referrals were developmental challenges addressed by the service.