Resident Postgraduate Year Research Articles

Impact of Expansion of PGY1 Pharmacy Residency Program From 2 to 4 Residents

Purpose: To evaluate the benefits of postgraduate year 1 (PGY1) pharmacy residency program expansion on clinical outcomes, pharmacy services, educational outreach, costs, and preceptor time at a community teaching hospital. Methods: During academic years 2014 to 2016, two PGY1 resident positions existed, expanding to four PGY1 resident positions during 2016 to 2018. Quantitative analyses comparing the aforementioned periods evaluated clinical interventions, adverse drug events prevented, community and hospital educational programs provided, departmental costs, and documented preceptor hours as a result of program growth. The outcomes were assessed using descriptive statistics. Results: The mean number of documented clinical interventions completed by the resident classes with two residents was 2906 when compared to 5324 with four residents. The mean number of prevented adverse drug events was 56 during the years with two residents and 220 in the years with four residents. The number of community outreach programs increased from 2 to 18 per year. The number of resident lectures provided to allied health professionals increased from 11 to 16 sessions per year. The net economic impact associated with two residents in 2014 was +$4661 USD, while in 2017 the net impact was −$5262 USD. The mean preceptor hours spent per year related to residency activities with two residents was 1005 hours compared to 1109.5 hours with four residents. Conclusion: Through strategic modification, expansion of the PGY1 residency program led to increased documentation of clinical interventions, prevented adverse drug events, and educational programs provided with minimal change in preceptor burden.

A time-sensitive rubric for assessing mastoidectomy proficiency.

To develop a time-sensitive, standardized rubric for cadaveric temporal bone dissection for otolaryngology resident education. This is a five-year prospective cohort study that evaluated otolaryngology resident performance during sequential cadaveric temporal bone dissection courses at a single otolaryngology residency training program. A canal-wall-up mastoidectomy with a facial recess approach was performed adhering to a 30-minute time limit and graded according to a standardized rubric. Main outcome measures included: (1) correct structure identification and (2) injuries sustained to structures as compared by resident post-graduate year (PGY) level. Thirteen residents were evaluated from October 2012 to March 2017. This included 57 individual graded exercises performed over ten dissection courses. The average score for PGY-2 residents was lowest (68.9), and PGY-5 residents achieved the highest average score (87.7). Junior residents correctly identified fewer structures (77.5%) when compared to senior residents (91.3%), p<0.0001. Correct performance of a facial recess approach was achieved by 100% of senior residents, but only 59.3% of junior residents (p=0.0003). The percentage of major injuries, which included the facial nerve, tegmen, labyrinth, and ossicular chain, decreased each PGY-level from a maximum of 17% by PGY-2 residents to a minimum of 5% by PGY-5 residents. Senior residents correctly identify more structures and are able to complete a facial recess approach with higher fidelity when subjected to a time-sensitive graded mastoidectomy rubric.

Development and perception of a multiple-site nontraditional postgraduate year 1 residency program.

To describe the development and perception of a multiple-site nontraditional postgraduate year 1 (PGY1) residency program from the resident and preceptor perspectives. A multiple-site nontraditional residency program was developed within a Florida health system to increase the education level and clinical responsibilities of hospital staff pharmacists. The program provided pharmacists interested in residency training an opportunity to pursue postgraduate credentials while maintaining their current position. The nontraditional residency program was implemented at 1 site and subsequently expanded across multiple affiliated hospital sites due to its success. Pharmacists currently working in the health system's network of hospitals for at least 2 years were eligible to enter into the 24-month program after successfully completing the application, interview, and matching process. The number of nontraditional resident positions available has varied by residency year and site. Offering this opportunity has increased the clinical knowledge of pharmacists, exposed them to a variety of practice areas, and increased their departmental contributions. In response to a request for feedback regarding the multiple-site nontraditional program, both residents and preceptors have reported benefits and challenges. Adequate resources are needed and a number of factors must be considered in developing a multiple-site nontraditional PGY1 residency program. Although there are potential challenges, it is perceived that the benefits justify continuation of the program.

Increasing Internal Medicine Resident Confidence in Leading Inpatient Cardiopulmonary Resuscitations and Improving Patient Outcomes.

Introduction:Residents do not feel confident or competent in leading inpatient resuscitations. This is a crucial part of training future internists. Our objective was to develop a low-cost intervention to improve resident confidence in leading cardiopulmonary resuscitations and patient outcomes.Methods:A “code-conference” including a lecture on a high-yield topic, a low-fidelity simulation, and review of resident-led resuscitations was created at our institution for the 2017-2018 academic year. Patient outcomes were assessed using objective measures of return of spontaneous circulation (ROSC) and survival to discharge (sDC). Confidence was assessed via survey before and after the intervention, with a focus on beginning postgraduate year 2 (PGY-2) residents.Results:In 2017, 8 out of 8 (100%) PGY-2 residents responded, while in 2018, 8 out of 10 (80%) responded. Patient outcomes did not show a statistically significant improvement. There was a trend toward positive outcomes in the resident group alone. Return of spontaneous circulation increased from 63% to 79% (P = .08, total n = 97). Resident confidence was not improved in a statistically significant way, but there was a trend toward improvement and residents agreed it was an important part of their training.Discussion:There was no statistically significant improvement in code-blue outcomes; however, there was a positive trend with increased ROSC and stable sDC for resident-led resuscitations, despite hospital-wide decreases in both. Resident confidence also showed a positive trend with no statistical significant changes. It is possible to institute a low-cost high-yield intervention to improved resident confidence in leading code-blue resuscitations. It may also improve patient outcomes; however, further studies are needed to determine if it can improve patient survival outcomes.

Mental toughness in surgeons: Is there room for improvement?

Mental toughness is crucial to high-level performance in stressful situations. However, there is no formal evaluation or training in mental toughness in surgery. Our objective was to examine differences in mental toughness between staff and resident surgeons, and whether there is an interest in improving this attribute. We distributed a survey containing the Mental Toughness Index (domains of self-belief, attention regulation, emotion regulation, success mindset, context knowledge, buoyancy, optimism and adversity capacity) among general surgery residents and staff at 3 Canadian academic institutions. Responses were recorded on a 7-point Likert scale. Participants were also asked about techniques they used to help them perform under pressure and interest in further developing mental toughness. Eighty-three of 193 surgeons participated: 56/105 (52.8%) residents and 27/87 (31.0%) staff. The average age was 29 (standard deviation 5) years and 42 (standard deviation 8) years, respectively. Residents scored significantly lower than staff in all mental toughness domains. Men scored significantly higher than women in attention regulation and emotion regulation. Age, staff experience and resident postgraduate year were not significantly associated with mental toughness scores. Twenty residents (36%) and 17 staff (63%) reported using specific techniques to deal with stressful situations; 49 (88%) and 15 (56%), respectively, were interested in further developing mental toughness. Staff surgeons scored significantly higher than residents in all mental toughness domains measured. Both groups expressed a desire to improve mental toughness. There are many techniques to improve mental toughness, and further research is needed to assess their effectiveness in surgical training.

A Longitudinal Curriculum In Point-Of-Care Ultrasonography Improves Medical Knowledge And Psychomotor Skills Among Internal Medicine Residents.

PurposeDespite its growing popularity and clinical utility among hospital-based physicians, there are no formal competency requirements nor training standards for United States based Internal Medicine Residencies for learning point-of-care ultrasonography (POCUS). The purpose of this investigation was to study the impact and effectiveness of a novel POCUS curriculum for an Internal Medicine (IM) residency program.Patients and methodsThis was a Single-Group Educational Quasi-Experiment involving Categorical and Preliminary Internal Medicine Residents in Post-Graduate Years 1 through 3 at a single United States academic tertiary center. The study period was from January 1, 2017, through June 30, 2017, during which time the residents participated in monthly modules including didactics and hands-on ultrasound scanning skills with live models. Participants completed a comprehensive knowledge examination at the beginning and end of the six-month period. Participants were also tested regarding hands-on image acquisition and interpretation immediately before and after the hands-on skills labs. The primary outcome measure was performance improvement in a comprehensive medical knowledge assessment.ResultsIn total, 42 residents consented for participation. The residents’ monthly rotations were adjusted in order to accommodate the new educational process. Among 29 participants with complete data sets for analysis, the mean (SD) comprehensive knowledge examination score improved from 60.9% before curriculum to 70.2% after curriculum completion (P<0.001). Subgroup analysis determined that improvement in medical knowledge required attending at least 2 out of the 6 (33%) educational sessions. Attendance at hands-on skills labs correlated significantly with improvement; didactics alone did not.ConclusionA longitudinal POCUS curriculum consisting of both didactic sessions and hands-on skills labs improves knowledge, image acquisition, and interpretation skills of residents. Having this curriculum span at least 6 months provides learners the opportunity to attend multiple classes which strengthens learning through repetition while also providing learners flexibility in schedule.

Identifying opportunities for PharmD curricular reform by surveying oncology pharmacists about career preparedness and exposure

IntroductionThe primary objective of the study was to assess factors that predict pursuit of an oncology post-graduate year 2 (PGY-2) residency. Additional objectives included identifying the role of and exploring opportunities for PharmD curricula to increase student interest in the oncology field. MethodsAn anonymous 15-minute survey was developed and administered to oncology pharmacists and residents. Study participants were included if they were actively practicing as clinical pharmacists in an oncology setting in the US, maintained an active pharmacist license, and >18 years of age. Responses were analyzed using descriptive and inferential statistics. All results are reported in aggregate, with the exception of quotes obtained from open-ended responses. ResultsEighty participants were included in analyses. After controlling for variance due to age, sex, race, years of practice, the number of oncology advanced pharmacy practice experiences (APPEs) correlated with pursuit of a PGY-2 residency in oncology (p = 0.047). Additionally, participants' perceived level of preparedness from didactic oncology training predicted pursuit of an oncology PGY-2 residency (p = 0.002). Emerging themes in pursuing oncology from open-ended items revealed that inclusion of supportive care in the didactic curriculum and having a family member or friend diagnosed with cancer were important factors. Additionally, participants' responses regarding PharmD curricula included recommendations to inform didactic and experiential education. ConclusionsThe results support the need for reevaluation of oncology education in PharmD curricula. Further studies could explore specific aspects of didactic curriculum that impact the level of student preparedness, and which elements encourage a student pharmacist to seek further training in the oncology field.

Evaluation of Gender Differences in Ultrasound Milestone Evaluations During Emergency Medicine Residency Training: A Multicenter Study.

Prior literature has demonstrated incongruities among faculty evaluation of male and female residents' procedural competency during residency training. There are no known studies investigating gender differences in the assessment of procedural skills among emergency medicine (EM) residents, such as those required by ultrasound. The objective of this study was to determine if there are significant gender differences in ultrasound milestone evaluations during EM residency training. We used a stratified, random cluster sample of Accreditation Council for Graduate Medical Education (ACGME) EM residency programs to conduct a longitudinal, retrospective cohort analysis of resident ultrasound milestone evaluation data. Milestone evaluation data were collected from a total of 16 ACGME-accredited EM residency programs representing a 4-year period. We stratified milestone data by resident gender, date of evaluation, resident postgraduate year, and cohort (residents with the same starting date). A total of 2,554 ultrasound milestone evaluations were collected from 1,187 EM residents (750 men [62.8%] and 444 women [37.1%]) by 104 faculty members during the study period. There was no significant overall difference in mean milestone score between female and male residents [mean difference= 0.01 (95% confidence interval {CI}= -0.04 to 0.05)]. There were no significant differences between female and male residents' mean milestone scores at the first (baseline) PGY1 evaluation (mean difference= -0.04 [95% CI= -0.09 to 0.003)] or at the final evaluation during PGY3 (mean difference= 0.02 [95% CI= -0.03 to 0.06)]. Despite prior studies suggesting gender bias in the evaluation of procedural competency during residency training, our study indicates that there were no significant gender-related differences in the ultrasound milestone evaluations among EM residents within training programs throughout the United States.

2644 CREOG 2019 Resident Survey: Obgyn Perception of Surgical Confidence and Competence

Study Objective To measure the residents and program directors perception to their surgical confidence and competence. Design National survey of over 5000 OBGYN residents Setting The Council on Resident Education OBGYN (CREOG) survey is an anonymous voluntary survey taken by residents annually at the time of their CREOG training examination. Patients or Participants All OBGYN residents are available to participating the survey annually. We typically have about a 92% return rate. Interventions This survey was to assess the current perception of OBGYN residents and their program directors regarding the residents' surgical confidence and competence in 5 gynecology and 3 obstetric procedures. Measurements and Main Results Over 5000 residents participated in the 2019 CREOG survey on perceptions of confidence and competence in 5 gynecology and 3 obstetric procedures. Confidence and perceived confidence of the procedures queried were affected by resident post-graduate year (PGY). Additionally, it appears that residents participate in learning of certain procedures at different times during their training. Residents and program directors agree upon the competence of residents for most procedures and some of the most difficult procedures during training are total vaginal hysterectomy, forceps operative vaginal delivery and to a lesser extent robotic laparoscopic surgery. Data will be presented by procedure and level of resident education with comparison between resident perception ad program director perception. Conclusion Continued surveillance of surgical training for OBGYN residents needs to continually assessed. Residents and Program Directors are aligned in their understanding of confidence and competence of resident surgical training. Total vaginal hysterectomy and forceps vaginal operative delivery are two of the most important issues that we need to face in education of OBGYN residents.

Verification of Proficiency in Basic Skills for PGY-1 Surgical Residents: 10-Year Update

The American College of Surgeons and the Association of Program Directors in Surgery developed a curriculum in 2001 that involved instructional modules for 11 basic surgical skills and a standardized Verification of Proficiency (VOP) evaluation instrument. Our institution continues to employ a modified version of this curriculum and the purpose of this study was to provide a 10-year update on our VOP evaluation instrument used to assess postgraduate year 1 (PGY-1) residents on surgical skills. All PGY-1 surgical residents over the past 10 years at our institution have completed the American College of Surgeons/the Association of Program Directors in Surgery-adapted basic surgical skills curriculum and VOP assessment. Retrospective analysis of VOP data for all residents was subjected to statistical analysis for internal validity and level of correlation. Department of Surgery at Southern Illinois University School of Medicine located in Springfield, Illinois. All PGY-1 surgical residents (per year: 4 general surgery, 3 orthopedic surgery, 2 plastic surgery, 2 urology, 2 ENT, 1 vascular surgery, and 1 neurosurgery) over the past 10 years. One hundred and thirty five residents underwent VOP evaluation over 10 years; 92 (68%) failed at least 1 module and 40 (30%) failed at least 2 modules. Residents who failed to demonstrate proficiency were mandated to complete remediation and retested until their scores were considered proficient. Performance on checklist items showed moderate internal consistency (⍺ ≥ 0.50) on 9 of 11 modules. Poor internal consistency (⍺ < 0.30) was noted for overall proficiency across all modules. Combined performance on checklist items and economy of time and motion demonstrated significant positive correlation (p < 0.05) with overall proficiency in every module. The VOP instrument offers an internally valid means of assessing distinct basic skills of PGY-1 residents at basic surgical skills. The instrument provides critical formative and summative feedback on surgical skill performance to trainees.

Are rating scales really better than checklists for measuring increasing levels of expertise?

Background: It is a doctrine that OSCE checklists are not sensitive to increasing levels of expertise whereas rating scales are. This claim is based primarily on a study that used two psychiatry stations and it is not clear to what degree the finding generalizes to other clinical contexts. The purpose of our study was to reexamine the relationship between increasing training and scoring instruments within an OSCE.Approach: A 9-station OSCE progress test was administered to Internal Medicine residents in post-graduate years (PGY) 1–4. Residents were scored using checklists and rating scales. Standard scores from three administrations (27 stations) were analyzed.Findings: Only one station produced a result in which checklist scores did not increase as a function of training level, but the rating scales did. For 13 stations, scores increased as a function of PGY equally for both checklists and rating scales.Conclusion: Checklist scores were as sensitive to the level of training as rating scales for most stations, suggesting that checklists can capture increasing levels of expertise. The choice of which measure is used should be based on the purpose of the examination and not on a belief that one measure can better capture increases in expertise.

The Fuel Gauge: A Simple Tool for Assessing General Surgery Resident Well-Being

Resident well-being is an increasingly relevant issue in medical education; however, there is no consensus on how to best measure well-being. The "fuel gauge," is a simple, easy-to-use tool developed to measure resident well-being and previously applied in an Internal Medicine Residency Program at our institution. The current study sought to evaluate its acceptability and usefulness in a surgery program. Weekly fuel gauge data was retrospectively collected from August 2017 through December 2018 along with resident Postgraduate Year designations. This study was conducted at a single, large general surgery residency program that rotates through a variety of hospitals, including a University hospital, a large county hospital, a Veterans Affairs hospital, and a freestanding Children's hospital. Categorical general surgery residents at every level of training as well as preliminary interns and off service intern rotators from urology, oral and maxillofacial surgery, and otolaryngology were eligible for the study. Fuel gauge submissions which did not denote a score were excluded from analysis. Out of 130 residents, 103 (79.2%) completed at least 1 fuel gauge assessment with a weekly mean response rate of 41.5%. Low scores were submitted by 39.8% of resident participants. Narrative feedback was provided in 6.2% of submissions with increased length associated with decreased fuel gauge score. The fuel gauge was well accepted by a large general surgery program with no decline in participation rates over the study period. The tool provided residents with a direct line of communication with their program's administration, and a feasible way for the program director's office to monitor and identify residents who were struggling with regard to their well-being.

Assessing the Clinical Learning Environment in an Institution in the United Arab Emirates: The Resident Perspective.

A new accreditation model in the United States has increased focus on the clinical learning environment (CLE). There is limited research on trainee perceptions of the CLE in international settings. We surveyed residents to obtain their perspective on the CLE at 1 sponsoring institution in the United Arab Emirates (UAE). We surveyed residents at Tawam Hospital, UAE, a sponsoring institution with 142 trainees, on their perspectives in the 6 focal areas of the US Clinical Learning Environment Review (CLER) to gather baseline information. We administered a 26-item questionnaire to residents through an audience response system in November 2018. Of 100 residents in postgraduate year 2 and above, 72 (72%) responded. The perspective of the majority of respondents was favorable in the areas of reporting patient safety incidents, engaging in quality improvement activities, using a standardized form for care transition, and using professional guidelines for electronic health record documentation. In contrast, only half of the respondents perceived there is honesty in the reporting of duty hours, and only 36% felt the organization supported fatigue management. Other areas for improvement included residents' understanding of the concept of health disparities and activities to address health disparities. Our findings suggest that in key focal areas related to patient safety, health care quality, care transitions, and professionalism, UAE residents have similar perceptions of their CLE as US trainees. Opportunities for improvement include duty hour reporting, fatigue mitigation, and addressing health disparities.

A novel and comprehensive design of mock residency interviews for fourth-professional year doctor of pharmacy students

Background and purposeTo describe a comprehensive design of mock residency interviews intended to closely mimic the environment and variety of interview settings commonly seen in post-graduate year 1 (PGY-1) interviews. Educational activity and settingMock interviews were held during one evening where a total of 24 fourth-professional year doctor of pharmacy students each experienced seven different interview scenarios over the course of nearly three hours. Twenty-seven faculty members and pharmacists and 11 current pharmacy residents participated as interviewers. Students received individual written feedback after the conclusion of the event. FindingsDuquesne University School of Pharmacy has successfully hosted this residency mock interview program for four consecutive years. After establishing a basic template for the interview format, we have been able to include more students, more interviewers, and a greater variety of interview scenarios. SummaryThis comprehensive approach to mock residency interviews has been successfully implemented to help prepare students at Duquesne University School of Pharmacy for PGY-1 residency interviews.

Development of competence in volumetric image interpretation in radiology residents

BackgroundDuring residency, radiology residents learn to interpret volumetric radiological images. The development of their competence for volumetric image interpretation, as opposed to 2D image reading, is not completely understood. The purpose of the present study was to investigate how competence for volumetric image interpretation develops in radiology residents and how this compares with competence development for 2D image interpretation, by studying resident scores on image-based items in digital radiology tests.MethodsWe reviewed resident scores on volumetric and 2D image-based test items in 9 consecutive semi-annual digital radiology tests that were carried out from November 2013 to April 2018. We assessed percentage-correct sum scores for all test items about volumetric images and for all test items about 2D images in each test as well as for all residents across the 9 tests (i.e. 4.5 years of test materials). We used a paired t-test to analyze whether scores differed between volumetric and 2D image-based test items in individual residents in postgraduate year (PGY) 0–5, subdivided in 10 half-year phases (PGY 0–0.5, 0.5–1.0, 1.0–1.5 et cetera).ResultsThe percentage-correct scores on volumetric and 2D image-based items showed a comparable trend of development, increasing in the first half of residency and flattening off in the second half. Chance-corrected scores were generally lower in volumetric than in 2D items (on average 1–5% points). In PGY 1.5–4.5, this score difference was statistically significant (p-values ranging from 0.02 to < 0.001), with the largest difference found in PGY 2.5 (mean: 5% points; 95% CI: -7.3 – -3.4). At the end of training in PGY 5, there was no statistically significant score difference between both item types.ConclusionsThe development of competence in volumetric image interpretation fits a similar curvilinear growth curve during radiology residency as 2D image interpretation competence in digital radiology tests. Although residents performed significantly lower on volumetric than 2D items in PGY 1.5–4.5, we consider the magnitude of this difference as relatively small for our educational setting and we suggest that throughout radiology training there are no relevant differences in the development of both types of competences, as investigated by digital radiology tests.

Trios-OSCE-based simulation course enhances the subcompetency of emergency-stabilization for postgraduate year-1 residents.

For patient safety, this study aims to evaluate the effectiveness of additional objective structured clinical examination (OSCE)-based medical simulation courses to establish the "emergency-stabilization" subcompetency of postgraduate first year (PGY-1) residents. In the simulation course, trainees were randomly divided into three groups: intervention, regular, and control group as Trios-OSCE trainees, Single-OSCE trainees, or OSCE observers (feedback-givers) after attending the pre-OSCE common simulation workshop. Three PGY-1 residents rotated through the Trios OSCE long-station together, while single PGY-1 residents rotated through regular OSCE alone and the control group gave feedback after observation of their peers' OSCE performance. Using Queen's simulation assessment tool, either in Trios-OSCE or Single-OSCE, performance levels were rated as either inferior, novice, competent, advanced or superior in the "therapeutic actions" and "communication" domains. The "overall performances" of all trainees were graded by qualified assessors, experienced facilitators, and standardized senior nurse. The proportion of "overall performance" of trainee's, rated by an experienced facilitator as "above competent level," was significantly higher in intervention group A than in regular group B. After training, the degree of increase in self-efficacy scores was higher among the intervention group than the regular and control groups. In the follow-up stage, a trend of increasing self-efficacy scores was noted in both the interventional and regular groups. For all trainees among the three groups, high postcourse value scores confirm that the new Trios-OSCE model meets the needs of trainees and also motivates the self-directed learning and self-reflection of trainees. Our results provide initial evidence that the new emergency-stabilization-enhanced Trios-OSCE-based medical simulation course including the additional training capacity offered by adding an observer group had positive effects on PGY-1 residents' self-efficacy and clinical transfer.

Internship and Empathy: Variations Across Time and Specialties.

To assess whether any differences exist in Interpersonal Reactivity Index (IRI) scores among postgraduate year 1 (PGY-1) residents across specialties. PGY-1 residents representing 11 specialties at our academic institution were invited to take a Web-based IRI survey at three time points. The specialties were condensed into several binary groups for analysis: internal medicine (IM) versus non-IM; primary care (IM, family medicine) versus nonprimary care; emergency medicine (EM, including the combined IM/EM) versus non-EM; surgical specialties (general surgery, obstetrics and gynecology, otolaryngology, orthopedics, urology) versus nonsurgical specialties (EM, family medicine, IM, neurology, pathology, and psychiatry); men versus women; and age groups. A repeated-measures generalized-estimating equations approach was taken to analyze the effect of specialty and time on each of the four IRI subscales. Of 94 PGY-1 residents invited to participate at each time point, 74 (77.1%) completed the survey at least once. Response rates at each time point were similar (mean 47.9%). When comparing the IM (n=35) and non-IM (n=39) groups, the perspective-taking subscale was found to be significantly lower in the non-IM group (P=0.006). Among male (n=46) versus female residents (n=26), the personal-distress subscale was significantly different overall (P=0.041) but not among time points. No other significant differences were found between groups. The conglomerate subscale scores throughout the year did not show a dramatic change. Our study of IRI subscales in PGY-1 residents showed no major difference among specialties across 1 year except for IM residents, who scored significantly higher (more favorably) in the perspective-taking subscale. Contrary to previous studies, we did not observe a substantial decline in the empathic concern subscale IM residents over their first year.

Internal Medicine Residents' Exposure to and Confidence in Managing Hospital Acute Clinical Events.

Internal Medicine (IM) residency graduates should be able to manage hospital emergencies, but the rare and critical nature of such events poses an educational challenge. IM residents' exposure to inpatient acute clinical events is currently unknown. We developed an instrument to assess IM residents' exposure to and confidence in managing hospital acute clinical events. We administered a survey to all IM residents at our institution assessing their exposure to and confidence in managing 50 inpatient acute clinical events. Exposures assessed included mannequin-based simulation or management of hospital-based events as a part of a team or independently in a leadership role. Confidence was rated on a five-point scale and dichotomized to "confident" versus "not confident." Results were analyzed by multivariable logistic regression to assess the relationship between exposure and confidence accounting for year in training. A total of 140 of 170 IM residents (82%) responded. Postgraduate year 1 (PGY-1) residents had managed 31.3% of acute events independently vs 71.7% of events for PGY-3/4 residents (P < .0001). In multivariable analysis, residents' confidence increased with level of training (PGY-1 residents were confident to manage 24.9% of events vs 72.5% of events for PGY-3/4 residents, P < .0001) and level of exposure, independent of training year (P = .001). Events with the lowest levels of exposure and confidence for graduating residents were identified. IM residents' confidence in managing inpatient acute events correlated with level of training and clinical exposure. We identified events with low levels of resident exposure and confidence that can serve as targets for future curriculum development.

Heart Rate Variability and Acute Stress Among Novice Airway Managers.

The nature of medical emergencies places emergency physicians at risk for high levels of acute psychological stress (APS). Stress-modifying techniques like visualization, breath control, and mental practice may help mitigate APS, but objective markers of stress are difficult to measure in the clinical setting. We explored the relationship between heart rate variability (HRV), a real-time measure of autonomic arousal, and self-reported APS among emergency medicine (EM) residents learning to intubate on actual patients. This was a prospective study of postgraduate year 1 (PGY-1) EM residents at a single academic medical center during their 1-month anesthesia rotation. We obtained repeated measures of HRV immediately before and during the first intubation attempt each day. Participants completed the modified Spielberger State-Trait Anxiety Inventory (STAI-6) before intubation attempts and scored intubation difficulty using the Intubation Difficulty Scale. We analyzed HRV using root mean square of successive differences and analyzed data using clustered data methods and Pearson correlation coefficients. We enrolled eight PGY-1 residents and recorded 64 intubations. Mean HRV in the 2minutes before intubation (17.88 ± 9.22) and during intubation (21.17 ± 13.46) was significantly lower than resting baseline (32.09 ± 15.23; adjusted mean difference [95% CI]=-13.90 [-20.35 to -7.45], p<0.001; and -10.77 [-17.65 to -3.88], p=0.02). Preintubation anxiety was negatively correlated with HRV (r=-0.39 [-0.58 to -0.16], p=0.001). Intubation difficulty was not significantly correlated with HRV (r=-0.12 [-0.36 to 0.13], p=0.35). HRV shows promise as a real-time index of autonomic arousal and may serve as an outcome measure in the evaluation of stress-modifying interventions.

Emergency Undocking Curriculum in Robotic Surgery.

IntroductionTraditional instruction for robotic surgery is typically devoid of training that addresses the delineation of interprofessional roles for operating room personnel. An emergency undocking scenario was developed for robotic surgeons with the objectives of improving time to access the patient, provider knowledge of and confidence in emergency undocking, completion of predetermined critical actions, and delineation of operating room personnel roles.MethodsOver one month, participants joined in three sessions: Session 1 - formative, Session 2 - review, and Session 3 - summative. Embedded standardized participants (ESPs) represented members of the interprofessional team. Prior to entering the operating room for Sessions 1 and 3, trainees were asked to complete a confidence survey and multiple choice questionnaire (MCQ) for knowledge assessment. Participants were randomized to one of two cases and participated in the reciprocal case for the final session four weeks later. Following Session 1, participants underwent an educational intervention, including the proper technique for emergency undocking, emphasis on operating room personnel roles, and hands-on practice. Obstetrics and Gynecology (OBGYN) residents in post-graduate Years 2-4 and attending physicians with robotics privileges at Summa Health Akron Campus or Cleveland Clinic Akron General Medical Center were invited to participate. A total of 21 participants enrolled and finished the study.ResultsAmong the 21 participants, there was a significant increase in the baseline level of knowledge (p-value=0.001) and in the confidence of surgeons when faced with an emergency undocking after the completion of our curriculum (p-value=0.003). Additionally, an improvement in the undocking times (p-value<0.001) and an increase in the critical actions performed (p-value=0.002) were observed.ConclusionThe results of this study demonstrate that incorporating this curriculum into the training programs of robotic surgeons is an effective way to improve the surgical skill of emergency undocking.