Medical Education Common Program Requirements Research Articles

Health Disparities Curricula in General Surgery Residency Programs: A Critical Scoping Review

IntroductionIn 2021, the structural determinants of health (SDOH) were added to the Accreditation Council of Graduate Medical Education common program requirements for all accredited residency programs, including general surgery. In this study, we sought to explore the current scope of, and concepts used in, health disparities curricula for general surgery residents, specifically investigating how general surgery residents learn about health disparities and the SDOH. MethodsWe searched PubMed, EMBASE, Education Research Complete (EBSCOhost), and Web of Science Core Collection using keywords related to health disparities and the SDOH. Inclusion criteria consisted of all studies published after 2005 that discussed health disparities curricula for Accreditation Council of Graduate Medical Education–accredited general surgery residency programs. Five thousand three hundred seventeen articles were screened using a two-phase process. Data extraction and analysis was performed using critical review methods. ResultsSeventeen articles were identified. Within these articles, seven unique health disparities curricula were found. All seven of the identified curricula employed cultural frameworks as methods to mitigate health disparities. Three curricula, all published after 2011, included education on the SDOH. A wide variety of educational methods were utilized; in-person didactics was the most common. ConclusionsIn the current literature, culture continues to play a large role in health disparities training for general surgery residents. Though further efforts are needed to understand the methods used in programs that have not published scholarly work, it is imperative to ensure that residents are provided with the sociopolitical perspective needed to understand the SDOH and serve all patients, including those affected by health disparities.

Stimulating Reflections on This Issue

Back to table of contents Next article EditorialFull AccessStimulating Reflections on This IssueDanielle W. Lowe, M.D., Ph.D.Danielle W. LoweSearch for more papers by this author, M.D., Ph.D.Published Online:1 Mar 2023https://doi.org/10.1176/appi.ajp-rj.2023.180301AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Sometimes a natural theme occurs in an issue of the American Journal of Psychiatry Residents’ Journal (AJP-RJ), and it would be remiss not to reflect on these articles as a group. The issue starts with a literature review of repetitive transcranial magnetic stimulation (rTMS) as a treatment for anorexia nervosa by Jae H. Kim, B.S., and colleagues (1). Although the efficacy data are limited in both number of trials and length of follow up, the possibility of integrating rTMS into a larger multidisciplinary treatment program to help reduce maladaptive processes in the frontolimbic system is appealing. This review is followed by two History of Psychiatry articles that explore the development and science of rTMS. Dallas Hamlin, M.D., and John Garman, M.D., review the roots of neurostimulation by intertwining the discoveries of electricity and magnetism within the field of psychiatry (2). Alexander Levit, M.D., Ph.D., builds on this foundation, discussing some of the technical details of current and emerging protocols (3). Together, these articles help integrate the reader’s understanding of the fundamentals and potential future directions of rTMS, and I hope you enjoy reading them, as I have.It is also exciting that this issue of the AJP-RJ is being released just a few days before the conclusion of our third virtual residency and fellowship match cycles. I encourage you to read Chris Wang, M.D., and colleagues’ discussion of the limitations and benefits of a virtual match from the perspective of having both types of interviews at different stages of professional training (4). Continued dialogue about how to balance equity and affordability while having a meaningful interview experience is critical. We know even less about the effects of the virtual match on well-being and burnout throughout training. Trainee burnout is not a new topic, and the Accreditation Council for Graduate Medical Education common program requirements include the assessment of and support for well-being (5, 6). However, with only two classes of virtually matched trainees matriculated to date, the longer-term effects of virtual interviews on program satisfaction and burnout are yet to be fully realized. How do virtual interviews contribute to the sense of lack of control during training? What effects did in-person interview dinners and applicant interactions have on trainees in the program? What additional burdens do virtual interviews have on trainees? The authors concluded that a curated group of trainees and faculty could provide enough information about an institution and community’s culture for the interviewee’s match list—but how virtual interviews change the larger residency and fellowship experience remains relatively unknown.Dr. Lowe is a fifth-year child and adolescent psychiatry fellow at the University of North Carolina, Chapel Hill. She is also an American Psychiatric Association Foundation Child and Adolescent Psychiatry fellow (2021–2023) and editor-in-chief of the American Journal of Psychiatry Residents’ Journal (2022–2023).

Creating Patient Safety Team Members Through a Simulation-Based Interprofessional Root Cause Analysis Course.

The Accreditation Council for Graduate Medical Education Common Program Requirements require residents to participate in real or simulated interprofessional patient safety activities. Root cause analysis (RCA) is widely used to respond to patient safety events; however, residents may lack knowledge about the process. To improve clinicians' knowledge of the tools used to conduct an RCA and the science behind them, and to describe this course and discuss outcomes and feasibility. A flipped classroom approach was used. Participants completed 5 hours of pre-course work then attended an 8.5-hour program including didactic sessions and small group, facilitator-led RCA simulations. Pre- and post-surveys, as well as a 10-month follow-up on knowledge of and comfort with the RCA process were compared. Statistical significance was evaluated for matched pairs using a repeated measures analysis of variance. Of 162 participants trained, 59 were residents/fellows from 23 graduate medical education programs. Response rates were 96.9% (157 of 162) for pre-course, 92.6% (150 of 162) for post-course, and 81.5% (132 of 162) for 10-month follow-up survey. Most participants had never participated in an RCA (57%, 89 of 157) and had no prior training (87%, 136 of 157). Following the course, participants reported improved confidence in their ability to interview and participate in an RCA (P<.001, 95% CI 4.4-4.6). This persisted 10 months later (P<.001, 95% CI 4.2-4.4), most prominently among residents/fellows who had the highest rate (38.9%, 23 of 59) of participation in real-world RCAs following the training. The course led to a sustained improvement in confidence participating in RCAs, especially among residents and fellows.

Calling Consults: A Workshop to Teach Trainees Using Both Didactic and Small Group-based Learning.

Background: Safe patient care includes effective communication. The Accreditation Council for Graduate Medical Education common program requirements include core requirements for trainees to act in a consultative manner and communicate effectively. However, trainees do not commonly receive formal education on this topic.Objective: We created a 1-hour workshop to teach residents and fellows how to effectively call consults, including how to formulate a cogent and comprehensive consult question.Methods: The workshop, delivered over a 1-hour noon conference, included a didactic portion and interactive small-group case-based learning. We used pre- and postworkshop surveys to assess learners’ prior training, knowledge, and comfort levels in calling consults. Subspecialists answered a separate survey about the quality of consults received from trainees before and 30 days after the workshop.Results: Seventy-three trainees attended the workshop (41.2% of total trainees invited). After the workshop, the percentage of learners who identified as very or somewhat comfortable with calling consults increased from 82% to 91%. Before the workshop, 87% of trainees could identify key elements in a consult, which increased to 100% after the workshop. There was not a statistically significant improvement in subspecialists’ ratings of the overall quality of consults they received 30 days after the workshop.Conclusion: Training learners on the key components and etiquette of calling consults is crucial for the development of effective communication among providers. This training is generally lacking from undergraduate medical education; thus, it is important to provide education in calling consults during residency and fellowship.

Introducing a health information literacy competencies map: connecting the Association of American Medical Colleges Core Entrustable Professional Activities and Accreditation Council for Graduate Medical Education Common Program Requirements to the Association of College & Research Libraries Framework.

Background:Librarians teach evidence-based medicine (EBM) and information-seeking principles in undergraduate, graduate, and post-graduate medical education. These curricula are informed by medical education standards, medical education competencies, information literacy frameworks, and background literature on EBM and teaching. As this multidimensional body of knowledge evolves, librarians must adapt their teaching and involvement with medical education. Identifying explicit connections between the information literacy discipline and the field of medical education requires ongoing attention to multiple guideposts but offers the potential to leverage information literacy skills in the larger health sciences education sphere.Methods:A subgroup of the Association of Academic Health Sciences Libraries Competency-Based Medical Education Task Force cross-referenced medical education documents (Core Entrustable Professional Activities and 2017–2018 Liaison Committee on Medical Education Functions and Structures of a Medical School) with the Association of College & Research Libraries Framework for Information Literacy for Higher Education using nominal group technique.Results:In addition to serving as a vocabulary, the map can also be used to identify gaps between and opportunities for enhancing the scholarly expectations of undergraduate and graduate medical education standards and the building blocks of information literacy education.

Time Allocation and Well-Being in Internal Medicine Residents: A Multi-Institutional Cross-Sectional Survey

Due to work hour limitations set forth in the Accreditation Council for Graduate Medical Education Common Program Requirements, residency programs invest considerable resources examining and managing the time residents spend at work.1 Many proponents of the system assume that by reducing time spent on clinical work, residents may spend more time engaged in activities that mitigate fatigue, stress, and burnout and enhance education. However, reviews of well-being and education following duty hour reforms are inconclusive.

The Implementation of a National Multifaceted Emergency Medicine Resident Wellness Curriculum Is Not Associated With Changes in Burnout.

The Accreditation Council for Graduate Medical Education Common Program Requirements effective 2017 state that programs and sponsoring institutions have the same responsibility to address well-being as they do other aspects of resident competence. The authors sought to determine if the implementation of a multifaceted wellness curriculum improved resident burnout as measured by the Maslach Burnout Inventory (MBI). We performed a multicenter educational interventional trial at 10 emergency medicine (EM) residencies. In February 2017, we administered the MBI at all sites. A year-long wellness curriculum was then introduced at five intervention sites while five control sites agreed not to introduce new wellness initiatives during the study period. The MBI was readministered in August 2017 and February 2018. Of 523 potential respondents, 437 (83.5%) completed at least one MBI assessment. When burnout was assessed as a continuous variable, there was a statistically significant difference in the depersonalization component favoring the control sites at the baseline and final survey administrations. There was also a higher mean personal accomplishment score at the control sites at the second survey administration. However, when assessed as a dichotomous variable, there were no differences in global burnout between the groups at any survey administration and burnout scores did not change over time for either control or intervention sites. In this national study of EM residents, MBI scores remained stable over time and the introduction of a multifaceted wellness curriculum was not associated with changes in global burnout scores.

Optimizing the Learning and Working Environment for Radiology Residents

In the newest revision of the Accreditation Council for Graduate Medical Education Common Program Requirements, substantial changes were made to section VI now entitled "The Learning and Working Environment." The Accreditation Council for Graduate Medical Education expanded section VI to include patient safety, quality improvement, supervision, accountability, well-being, and fatigue mitigation realizing work hours represent only one part of the work environment. These new requirements prompted us to evaluate our current curriculum, including our current tools for meeting program requirements such as the didactic lecture series and tracking resident progress in our Clinical Competency Committee, and identified areas of our curriculum that were lacking or could be improved upon. This assessment leads to incorporation of innovative and novel strategies to not only satisfy the requirements but also to engage our trainees throughout the process. Our model can be used as an example for other residency programs looking for ways to fulfill these new requirements.

Residents' perception of duty hour limits through teaching hospital accreditation status-experience in Taiwan.

Residents' work overload is a rising issue in Taiwan. Duty hours of the residents in the United States have been limited by the Accreditation Council for Graduate Medical Education Common Program Requirements since 2003; similar standards were not implemented in Taiwan until 2013. Taiwanese duty hour standards are the work hour limits adopted as part of the required teaching hospital accreditation status. In January 2015, the Ministry of Health and Welfare conducted a national survey for all house officers in Taiwan. We collected data including those on demographics and perceptions of residents regarding duty hour limits. Most respondents reported positive perceptions of the duty hour standards. They felt that these limits will improve resident education, quality of life, and patient safety. The strong incentive to follow the regulations (through teaching hospital accreditation) could help protect residents (and patients) from unsafe working conditions. However, further studies on the influence of shortened duty hour on professional development are necessary for future improvement.

Resident Designed Intern Orientation to Address the New ACGME Common Program Requirements for Resident Supervision

To design an orientation for surgical interns to meet the new Accreditation Council for Graduate Medical Education Common Program Requirements regarding supervision, to test patient-management competencies, and to assess confidence on skills and tasks pre-orientation and post-orientation. Twenty-seven incoming surgical interns participated in a two-day orientation to clinical duties. Activities included a pre-test, lectures, simulation, oral examination, intern shadowing, and a post-test. Incoming interns were surveyed before and after orientation and two months later for confidence in patient-management and surgical intern skills. Paired t-tests were used to determine if confidence improved pre-orientation and post-orientation, and two months following orientation. The study took place at an academic training hospital. All (n = 27) postgraduate year-1 (PGY-1) surgical residents at our institution, which included the categorical and nondesignated preliminary general surgery, urology, orthopedic surgery, otolaryngology, and neurosurgery programs. All interns passed the oral and written examinations, and were deemed able to be indirectly supervised, with direct supervision immediately available. They reported increased confidence in all areas of patient management addressed during orientation, and this confidence was retained after two months. In surgical and floor-related tasks and skills, interns reported no increase in confidence directly following orientation. However, after two months, they reported a significant increase in confidence, particularly in those tasks that are performed often. New requirements for resident supervision require creative ways of verifying resident competency in basic skills. This type of orientation is an effective way to address the new requirements of supervision and teach interns the tasks and skills that are necessary for internship.

Tackling technical skills competency: A surgical skills rating tool

BackgroundThe Accreditation Council for Graduate Medical Education common program requirements mandate a competency-based assignment of duties. To accomplish this, valid and reliable assessment tools must be developed to evaluate competence. This study evaluated a rating tool to assess competence in basic surgical suturing skills. MethodsA technical skills exercise consisting of the closure of three incisions, 3 cm long, was devised in 2006. The incisions were closed with simple stitches with two-handed knots, vertical mattress stitches with instrument knots, and a running stitch with one-handed knots. Fifteen min were allotted for completion. A rating instrument with 17 competency markers worth 1 point and a global 5-point Likert scale competency score was used to evaluate the performance. Twelve first-week post graduate year 1 surgical residents completed the exercise in 2006, and 16 final-month post graduate year 1 surgical residents completed it in 2011. All tasks were scored on video review by two independent raters. Statistical analysis included descriptive statistics, t-score analysis, rank sum analysis, Cohen's kappa coefficient, and Cronbach's alpha. ResultsThe mean total score (11.8 versus 13.9, P = 0.002) and median global competency rating (1 versus 3, P < 0.001) were lower for the first-week cohort. Cohen's kappa coefficient of inter-rater reliability was 0.77. Cronbach's alpha measure of internal consistency was 0.87. ConclusionThis rating form is a valuable tool to evaluate technical skill competency. Construct validity was demonstrated with improvement in total score and global rating. Excellent internal consistency and inter-rater reliability were also demonstrated. This form may be used to assess technical skill competency in an efficient skills exercise.

Residents and Authorship: Rights, Obligations, and Avoiding the Pitfalls

Residents and Authorship: Rights, Obligations, and Avoiding the Pitfalls

Tracking Outpatient Continuity and Chronic Disease Indicators—A Novel Use of the New Innovations Clinic Module

The Accreditation Council for Graduate Medical Education common program requirements for Practice-based Learning and Improvement in Internal Medicine specify that trainees must "systematically analyze [his/her] practice using quality improvement methods, and implement changes with the goal of practice improvement" and that the training program "must include use of performance data" in the assessment of the resident's practice. Before implementation of an electronic health record at our academic medical center, we found meeting these requirements to be challenging. This prompted us to set up the New Innovations (New Innovations, Inc, Uniontown, OH) Software Suite's Patient Continuity module to permit analysis and tracking of both quality of care indicators and patient continuity. By using the system, our residents were better able to monitor their patient panel sizes and composition and to correlate their practices with quality of care data. Residency programs, which currently utilize New Innovations software but lack an electronic health record, may find the continuity clinic module useful for engaging their house staff in structured practice improvement initiatives and in satisfying the Accreditation Council for Graduate Medical Education's common program requirements for practice-based learning.

Resident fatigue in 2010: Where is the beef?

Background The Accreditation Council for Graduate Medical Education Common Program Requirements for all residency programs (effective July 1, 2011) will limit postgraduate year-1 duty hour length to 16 hours of call. Previous studies have shown some decrement in post-call task performance. We designed a study to evaluate if these decrements still exist in 2010 and to determine specifically when they occur. Methods Fourteen residents were tested on 4 simulator tasks during 5 separate call periods. These tasks were completed serially at 4 different time (T) intervals (T0, T12, T18, and T24) over a 24-hour period. Task performance was measured at each of these intervals. The residents completed a post-call survey. Results Over the 24-hour call there was a trend toward decreased time for the completion of tasks with preservation of accuracy and efficiency. The performance of some residents actually improved and there was minimal correlation between perceived fatigue and performance. Conclusions These data show no decrease in junior or senior resident task performance over a 24-hour call period, and do not support the 2011 Accreditation Council for Graduate Medical Education maximum duty hour length of 16 hours.

Individualized Learning Plans: Basics and Beyond

Self-directed, lifelong learning is an important tenet of medical professionalism because it is integral to maintaining professional competency. 1 ABIM Foundation. American Board of Internal Medicine; ACP-ASIM Foundation. American College of Physicians-American Society of Internal Medicine; European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002; 136: 243-246 Crossref PubMed Scopus (1529) Google Scholar , 2 Medical Professionalism Project. Medical professionalism in the new millennium: a physicians’ charter. Lancet. 2002; 359: 520-522 Abstract Full Text Full Text PDF PubMed Scopus (365) Google Scholar , 3 Fallat M.E. Glover J. Professionalism in pediatrics: statement of principles. Pediatrics. 2007; 120: 895-897 Crossref PubMed Scopus (33) Google Scholar Although patients may assume that physicians with more clinical experience provide better patient care, the relationship between clinical experience and quality of care is not as straightforward as it may seem. Recent graduates may continue to improve their patient care in the first few years of practice as they garner additional clinical experience. However, compared with physicians in practice fewer than 10 years, physicians who have been in practice longer (more than 20 years) have declining knowledge of current medical evidence and practice guidelines and provide lower quality of care to their patients. 4 Choudhry N.K. Fletcher R.H. Soumerai S.B. Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med. 2005; 142: 260-273 Crossref PubMed Scopus (967) Google Scholar Continued lifelong learning could prevent the deterioration of current medical knowledge and the decline in quality of care seen over time. In recognition of this concern, the Liaison Committee on Medical Education, 5 Liaison Committee on Medical Education. Functions and Structure of a Medical School: Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree. June 2010; Available at: http://www.lcme.org/functions2010jun.pdf; Accessed August 23, 2010. Google Scholar the Accreditation Council on Graduate Medical Education (ACGME), 6 Accreditation Council for Graduate Medical Education Common program requirements, effective July 1, 2007. http://www.acgme.org/acWebsite/dutyhours/dh_dutyhourscommonpr07012007.pdf Google Scholar and the American Board of Medical Specialties Maintenance of Certification 7 Miller S.H. American Board of Medical Specialties and repositioning for excellence in lifelong learning: maintenance of certification. J Contin Educ Health Prof. 2005; 25: 151-156 Crossref PubMed Scopus (79) Google Scholar all identify lifelong learning as essential to the continuum of medical education.