Postgraduate Year Research Articles

Entrustable Professional Activities in Endocrine Surgery: A National Pilot Study

The American Association of Endocrine Surgeons drafted Entrustable Professional Activities for Comprehensive Endocrine Surgery to assess trainees in core topics. Fourteen Entrustable Professional Activities were defined. There were 10 "core" Entrustable Professional Activities, with 6 having 3 phases (pre-, intra-, and postoperative) and 4 having a single phase. There were also 4 elective Entrustable Professional Activities, all of which had 3 phases. Beginning in July 2022, 10 institutions collected 3-item microassessments of trainee performance in Entrustable Professional Activities using a web-based platform. Entrustment was measured on a 5-point scale. A total of 698microassessments were submitted between July 2022 and September 2023, with a wide range between programs (3-449, median: 24). Four-hundred ninety-twomicroassessments were completed for endocrine surgery fellows, 6 for chief residents, 6 for postgraduate year 4 students, 166 for postgraduate year 3 students, and 28 for postgraduate year 2 students. Entrustment scores for fellows improved in the second half of the academic year, with 38.2% of microassessments with highest (4/5) entrustment scores in the first 6months of the academic year and 80.1% with highest scores in the second half of the year (P < .001). Intraoperative entrustment scores were lowest in the adrenal category, with only 13 of 117 (11.1%) of microassessments with highest entrustment compared with 85 with 230 (37.0%) in the thyroid category, and 65 of 165 (39.4%) in the parathyroid category (P < .001). Trainees were more likely to achieve highest entrustment in the first 6months for preoperative (36/70, 28.5%) and postoperative (15/28, 53.5%) phases of care, compared with the intraoperative phase of care (79/334, 23.6%) (P < .001). Entrustment scores improved in the second half of the academic year, and trainees were likely to achieve entrustment earlier in nonoperative phases of care.

Family physicians have greater ambiguity tolerance in the clinical context: A nationwide cross‐sectional study

AbstractBackgroundAmbiguity tolerance in the clinical context is increasingly recognized as essential for physicians to work as professionals. However, the relationship between specialty and ambiguity tolerance in the clinical context has been understudied. Here, we investigated the association between specialty and ambiguity tolerance in the clinical context, focusing on differences between family physicians (FPs) and non‐FPs.MethodsWe performed a nationwide cross‐sectional study in Japan. We asked FPs from 14 family medicine residency programs across Japan and non‐FPs from monitors of an internet survey company in Japan to participate in the study. We assessed their tolerance for ambiguity using the Japanese version of the Tolerance for Ambiguity in Medical Students and Doctors (J‐TAMSAD) scale.ResultsIn total, 388 physicians (178 FPs and 210 non‐FPs) completed our anonymous online survey and were included in the analysis. After adjustment for possible confounders (gender and postgraduate years), FPs had higher J‐TAMSAD scale scores than internists/pediatricians, surgeons, and physicians with other specialties, meaning that FPs had greater ambiguity tolerance.ConclusionsThis study reveals that FPs had greater tolerance for ambiguity in the clinical context than non‐FPs. Our findings suggest that there may be a need to increase non‐FP's tolerance for ambiguity specific to the clinical context through educational interventions, since ambiguity is inherent and growing in medicine today. FPs and non‐FPs should work together to complement each other's strengths, rather than simply improving the training of non‐FPs.

Can grit predict well-being?

BackgroundBurnout affects over 50% of surgical residents, and efforts focused on well-being during training are needed. Grit, defined as perseverance toward achieving long-term goals, is a measure of mental fortitude and may be protective against burnout and predictive of well-being.MethodsAn anonymous electronic survey was distributed to surgical and non-surgical resident trainees as well as general surgery faculty. Grit was measured using a 12-question validated Grit Scale and well-being was measured using a 5-question validated WHO-5 Well-Being Index. Linear regression was used to identify associations between post-graduate year (PGY), grit, and well-being. Student’s t-test was used to compare grit and well-being scores among male and female trainees.Results23/38 (60.5%) surgical residents completed the survey. Grit scores ranged from 3 to 4.67 (scale of 1–5) and well-being scores from 24 to 84 (scale of 0–100). There was no correlation between grit and well-being (R2 = 0.01, p < 0.63) or between PGY class and grit (R2 = 0.06, p < 0.27). However, there was a positive correlation between PGY class and well-being (R2 = 0.18, p < 0.05). Female residents trended towards higher grit (4.12 female vs 3.76 male, p < 0.07) and lower well-being (53 vs 60, p < 0.18). Compared with non-surgical residents, there were no significant differences in mean grit or well-being. The pooled trainee group demonstrated a positive correlation between PGY class and well-being (R2 = 0.09). Faculty reported higher grit (4, p < 0.03) and well-being (68.8, p < 0.002) than residents.ConclusionDespite high overall grit, trainees experience relatively low well-being; this effect is exaggerated in females. Grit and well-being trend to increase with PGY years and as faculty. The lack of association between grit and well-being in trainees suggests that intrinsic grit is not enough; well-being is impacted by external factors and encourages future work to identify and modify these factors for a positive impact on trainees.

Digital Flexible Ureteroscope: Evaluating Factors Responsible for Damage and Implementing a Mandatory Certification Program for Usage.

Objective: Digital flexible ureteroscopes (DFUs) play a crucial role in endourological procedures, and scope breakages are often avoidable with proper measures in place. We aimed to evaluate the effect of mandatory training on DFU durability and to assess the influence of various factors on instrument damage. Materials and Methods: Mandatory training involving instructional videos on DFU care was introduced for all processing and operating room staff handling DFUs. Only certified personnel were allowed to handle DFUs, with meticulous usage documentation. The average annual usage of each DFU was compared pre and post program implementation. We examined factors such as patient demographics, procedure details, and operator experience impacting scope life using negative binomial regression. Results: The average usage of DFU increased by 21%, from 6.38 to 7.74 cases. We found that post-graduate year stood out as a significant predictive factor (estimate = 3.28, p = 0.04). Moreover, the streamlined model revealed that previous ureteral-stent use (estimate = 0.94, p < 0.001), struvite stones (estimate = 3.08, p = 0.01), and a higher number of stones (estimate = 0.11, p = 0.04) were associated with an increased number of procedures before DFU breakage, whreas in situ lithotripsy in the lower calyx was associated with a reduced number of procedures before DFU breakage (estimate = -1.11, p = 0.003). Conclusion: Implementing a mandatory training program showed an increase in DFU durability by 21%, suggesting a potential reduction in annual repair and replacement costs by the same percentage. Furthermore, outcomes were more favorable when experienced practitioners conducted treatments, especially in cases involving struvite stones.

Digital supervision in the clinical learning environment: Characterizing teamwork in the electronic health record.

Attending physicians in academic hospitals work in supervisory team structures with medical residents to provide patient care. How attendings utilize the electronic health record (EHR) to support learning through supervision is not well understood. To compare EHR behavior on teaching versus direct care, including evidence of supervisory calibration to learners. Cross-sectional study analysis of EHR metadata from 1721 shifts of hospital medicine faculty at a large, urban academic medical center, January to June 2022. Measures included total EHR time per shift, EHR time outside shift, and time spent on: note-writing, note review/attestation, order entry, and other clinical review. We assessed within physician differences across these service types and used multilevel modeling to determine whether these behaviors varied with resident physicians' experience, accounting for physician-specific signature behavior patterns. Attendings spent substantially less time in the EHR while on teaching service than on direct service (129 vs. 240 min; p < .001) and apportioned their work differently throughout the day. Physicians were less behaviorally consistent and varied more than their peers when on teaching service. Attendings calibrated their supervision to learners. Attendings logged 12.7% less EHR time when paired with more senior residents than postgraduate year 2 (PGY2) residents (137 vs. 120 min, p = .002). PGY1 presence was also associated with reduced EHR time, suggesting some delegation of supervision to senior trainees. EHR behaviors on teaching service are highly variable and differ substantially from direct care; a lack of consistency suggests important opportunities to establish best practices for EHR-based supervision and create an effective clinical learning environment.

It's not that SIMPL—Identifying deficiencies in general surgery trainees' autonomy and competence performing parathyroidectomy and thyroidectomy

BackgroundAlthough many parathyroid and thyroid operations are performed by nonfellowship-trained general surgeons in the United States, there is growing uncertainty of whether graduating residents can perform these procedures competently. This study investigates trends in competency and autonomy among general surgery residents performing parathyroid and thyroid operations using a national survey-based dataset. MethodsA retrospective analysis of the Society for Improving Medical Professional Learning database was performed. Case data from categorical general surgery residents performing parathyroidectomy or thyroidectomy between 2015 and 2023 were included. Competent performance and meaningful autonomy were dichotomized on the basis of faculty surgeon responses. Agreement between resident and faculty evaluations were assessed. Logistic regression was used to examine resident performance and autonomy using postgraduate year level and case complexity as covariates. ResultsThe study included 907 parathyroidectomies and 1,555 thyroidectomies from 724 residents at 77 residency programs. Competent performance was observed in 34.0% of parathyroidectomies and 38.6% of thyroidectomies. Meaningful autonomy was observed in 31.6% of parathyroidectomies and 32.3% of thyroidectomies. Residents and faculty agreed on performance (50.3%) and autonomy (59.1%) in most cases, however when discordant residents often underestimated their performance (44.7%) or autonomy (25.3%). The likelihood of postgraduate year 5 residents demonstrating competent performance or meaningful autonomy was 65.9% and 51.6%, respectively for parathyroidectomy and 77.2% and 58.4%, respectively for thyroidectomy. ConclusionMany graduating residents do not demonstrate competent performance or meaningful autonomy in parathyroidectomy and thyroidectomy. Further initiatives are needed to improve graduating general surgeons' competence for these operations, given access disparities to high-volume endocrine surgeons.

A Case of Painful Visual Loss - Managing Orbital Compartment Syndrome in the Emergency Department.

Emergency medicine (EM) residents. This simulation curriculum may also be utilized for senior medical students conducting EM rotations. Ophthalmologic education represents only a small portion of medical school curriculums and continues to decrease over time, leaving physicians poorly equipped to diagnose and manage eye complaints.1 Of emergency physicians (EPs) surveyed, 72.5% felt that they could diagnose orbital compartment syndrome (OCS), yet only 40.3% felt comfortable performing a necessary lateral canthotomy and cantholysis (LCC).2 These survey results demonstrate the urgent need for improved ophthalmology education in EM residency to help us diagnose and manage potentially vision-threatening pathology. By the end of this simulation, learners will be able to: 1) demonstrate the major components and a systematic approach to the emergency ophthalmologic examination, 2) develop a differential diagnosis of sight-threatening etiologies that could cause eye pain or vision loss, 3) demonstrate proficiency in performing potentially vision-saving procedures within the scope of EM practice. Low-fidelity simulation was conducted using a novel model adapted from that used by Phillips et al. during their ophthalmology day in the Department of Emergency Medicine at Vanderbilt University.3 The simulation case was developed by an interdepartmental team of ophthalmologists and EPs at our institution. To evaluate for statistically significant changes in self-efficacy, knowledge, and performance after an educational intervention. Our primary outcome was defined as a checklist-based performance on a simulated case of orbital compartment syndrome necessitating LCC. We conducted a single-center prospective pre- and post-interventional study evaluating the impact of an educational intervention on EM resident management of a simulated case of OCS. Our two-part study intervention consisted of a lecture on OCS followed by a four and a half hour ophthalmology education day (OED). Residents were evaluated using self-efficacy scales (SES), multiple-choice questions (MCQ), and a performance checklist (developed via a modified Delphi process) at three timepoints: Pre-intervention, immediate post-intervention, and three months post-intervention. Post-graduate year (PGY)-1 through PGY-4 EM residents at an Urban Level 1 Trauma Center participated. Initial recruitment consisted of 18 residents (PGY-1 through PGY-4), and 16 residents (PGY-1 through PGY-3) completed the study. Nine residents participated in the OED and seven residents did not. There were no pre-existing differences in median checklist-based performance, MCQ, or SES scores prior to the intervention. At three months post-OED, the OED attendees scored statistically significantly higher on checklist-based performance than non-attendees (lecture only). Ophthalmology education in physician training is limited, and EP comfort with performing vision-saving procedures is poor. We developed a simulation case involving such a vision-saving procedure as well as an ophthalmology curriculum that increased skill retention surrounding management of ophthalmologic emergencies. Emergency medicine (EM), ophthalmology, orbital compartment syndrome (OCS), retrobulbar hematoma, vision loss, eye pain.

The Educational Benefits of Plastic Surgery Rotations for Off-Service Residents.

With increasing specialization among surgical divisions, a well-rounded education during a surgical residency is often accomplished by rotating among different subspecialties. Inclusion of specific rotations in the resident curriculum can be considered as a cost-benefit calculation balancing the value of exposure to a subspecialty versus the opportunity cost of potential learning from another rotation. We find that often these decisions are based on anecdotal feedback. Our goal is to supplement these reports with a quantifiable metric of learning achieved on the plastic surgery rotation. Our hypothesis in this prospective study was that residents would demonstrate improved performance on a post-rotation test after their 1-month rotation on plastic surgery compared to the pre-rotation test. A question bank was developed to reflect institutional curriculum objectives and clinical scenarios commonly seen on the service. The questions were developed, validated and vetted in collaboration with medical educators and attending plastic surgeons yielding 20 questions available for use. Postgraduate year 1 residents were given a 10-question test before and after their plastic surgery rotation. A one-tailed paired t-test was used to assess improvement between the pre-rotation test and the post-rotation test. A total of 378 tests were administered with 228 (60%) pre- and post-rotation tests completed meeting inclusion criteria. Average percentage of correct answers for the pre-rotation test was 29% and 88% for the post-rotation test showing a differential improvement of 58% (p < 0.001). Surgical trainee time is a limited commodity. Each clinical rotation needs proven consistent benefit for the trainees. We developed a questionnaire that documents the improvement in clinical knowledge after a one-month rotation on plastic surgery relative to before. The test results were consistent even when comparing trainees who did the rotation early versus late in the PGY-1 year. Clinical exposure reinforces and solidifies specialty learning.

Navigating the Discrepancy: How Cost of Living (COL) Adjustments Impact Otolaryngology Residents' Salaries.

To compare differences in otolaryngology residents' salaries in different cities and states before and after adjusting for the cost of living. Cross-sectional analysis. Accreditation Council for Graduate Medical Education (ACGME) otolaryngology residency program websites. US otolaryngology residency programs were identified via the ACGME database in December 2023. Stipends posted by each residency program were compared to the cost of living (COL) for related states and major cities. A baseline value of 100 was used as the mean COL, values over 100 indicate above-mean COL. The weighted salary by state and cities for postgraduate year (PGY) 1 to 5 combined was expressed as mean (SD). Comparisons between salaries before and after adjustment for the COL were assessed using t tests. The mean otolaryngology residency stipend across the nation, by city, was $70,572 (n = 1290, range: $58,100-$93,402; SD = $8370), with a post-COL adjustment mean stipend of $64,055 (range: $39,193-$76,674, SD = $10,094, p < .001). Otolaryngology residents in Manhattan, New York State faced a mean decrease from $89,282 to $39,193 (-56%) post-COL adjustments. Following that were Boston and Los Angeles programs which saw a -$26,402 (-32%) and -$24,761 (-32%) mean decrease after COL adjustments, respectively. Otolaryngology residents in high-cost areas experience significant salary reductions because of COL adjustments, resulting in financial strain. Residents in such regions endure increased financial pressure compared to those in low-cost areas, as current salaries fail to align with living expenses.

Association between physicians’ maldistribution and core clinical competency of resident physicians: a nationwide cross-sectional study

ObjectivesWith physician maldistribution recognised as a global issue, Japan implemented the physician uneven distribution (PUD) index as a strategic measure. Currently, there is a lack of objective assessment of core...

A Whodunit Gamified Flipped Classroom For High Yield Bite Injuries And Envenomation.

Clerkship-level medical students, sub-interns, junior and senior residents, attending physicians. Bite injuries and envenomation are core content found in the model of the clinical practice of emergency medicine.1 However, depending on the geographic location of training or clinical practice, physicians may or may not be exposed to these pathologies. For example, a qualitative analysis conducted in 2022 discovered a significant range in emergency medicine (EM) physician perception of snake antivenom use and level of comfort, noting that experiences with its use ranged from hundreds of cases treated to purely didactic understanding.2 Such discrepancies necessitate supplemental education and activities to bridge the knowledge gap. Ideally, these activities would utilize tenets of experiential learning to allow learner processing comparable to that of clinical experience.3 Flipped classroom and audience participation promote engagement and active learning when compared to the passive learning of lectures.4 In that vein, there is a growing body of gamified resources in medical education which utilize pattern recognition and problem solving skills that can be analogous to clinical practice.5,6. By the end of this activity, learners will be able to: 1) identify and name species responsible for bite/sting/envenomation injuries, 2) recognize associated signs, symptoms, physical exam findings and complications associated with bites/stings/envenomations by certain species, 3) discuss management such as antibiotics, antivenom, and supportive care. We designed a small group activity asking residents to identify, research, and present the "culprits" implicated in environmental exposures to animals and insects, and match them to corresponding clinical scenarios. Participants anonymously answered electronic multiple-choice quizzes before and after completing the activity to gauge its effectiveness in conveying the material. They also completed an additional anonymous, electronic survey regarding their attitudes towards this activity and the possibility of other gamified didactics within the curriculum. Each resident class showed an upward trend in their average multiple-choice score, the greatest of which was seen in the post-graduate year (PGY) 1 class. The residency demonstrated a statistically significant improvement in their ability to answer multiple choice questions (MCQs), with an average pre-activity score of 67.14%, and post-activity score of 87.14%. Participants showed determination and enthusiasm to engage with the material when presented in a gamified format, and 100% of post-activity survey respondents wanted to participate in further gamified activities. Gamified small group activities are a fun and effective method of supplementing residency and medical student education for both common and esoteric clinical presentations that they may not encounter in the clinical environment. Toxicology, bite injury, envenomation, gamification.

Burnout and Well-Being in Trainees: Findings From a National Survey of US Obstetrics and Gynecology Residents.

Background Despite national attention on resident well-being, challenges persist. Effective solutions require greater understanding of personal and program factors. Objective To explore burnout, resilience, self-reported mental health, and perceptions of the learning environment in a national sample of obstetrics and gynecology (OB/GYN) residents. Methods An observational cross-sectional survey of OB/GYN residents taking the January 2022 national in-training examination included an abbreviated 2-item Maslach Burnout Inventory, a short version of the Connor-Davidson Resilience Scale, and subjective experience of other factors. Kruskal-Wallis and chi-square tests explored differences in outcomes and associations between variables. Results Among 5761 residents taking the examination, 3741 (64.9%) participated, with 2425 of 3741 (64.8%) reporting burnout, 2138 (57.2%) depression, 2651 (70.9%) anxiety, and 147 (3.9%) suicidal ideation. Women fared worse than men in terms of burnout (2105 of 3147, 66.9% vs 281 of 496, 56.7%, P<.001), depression (1843 of 3147, 58.6% vs 256 of 496, 51.6%, P=.004), anxiety (2318 of 3147, 73.7% vs 294 of 496, 59.3%, P<.001), and resilience (5.9±2.1 vs 6.2±2.1, P=.006). More nonbinary residents considered leaving residency (17 of 49, 34.7% vs 676 of 3147, 21.5% [women] and 108 of 496, 21.8% [men], P=.008). Race-based differences were seen in depression, suicidal ideation, and thoughts of leaving residency. Increased binge drinking was reported with increasing postgraduate year. Among 614 residents reporting that well-being was not a priority in their program, 539 of 614 (87.8%) reported burnout, 469 of 614 (76.4%) depression, and 508 of 614 (82.7%) anxiety. Conclusions Residents report high rates of mental health concerns, and these are worse among women, gender nonconforming individuals, Black residents, and those who perceive well-being is not a priority in their training program.

Going in Blind: A Common Scenario in an Uncommon Situation.

Medical students, interns, junior resident physicians, senior resident physicians. Power outages have been increasing in frequency in the past few years, therefore becoming an increased threat to healthcare delivery.1 While most studies related to the effects of power outages are focused on outpatient care, such as acute exacerbations of chronic lung conditions and the lack of chargeable equipment, with the increasing number of power outages, hospitals must be prepared for this situation as well.2,3 Although agencies such as the Federal Emergency Management Agency (FEMA) and the US Department of Health and Human Services (HHS) have provided guidelines for the response of hospitals to temporary loss of power,12,13 hospitals generally rely on institutional policies in response to the event of a power outage. Given the relative rarity but increasing frequency of power outages in hospital settings, this medical simulation was created to present a common occurrence in the emergency department (eg, cardiac arrest) in an uncommon setting of a power outage. Simulation has been shown to improve learner self-efficacy, confidence, and leadership skills among resuscitation teams.4,5 The role of simulation also helps learners identify latent safety threats, in this case a power outage.6 The goal of this simulation is to improve the skills of healthcare professionals with regards to managing cardiac arrest and to encourage these practitioners to consider their own hospital guidelines in response to a power outage. By the end of this simulation, learners will be able to (1) evaluate and treat a patient experiencing myocardial infarction and subsequent cardiac arrest during a power outage, (2) describe the local protocols for managing patient care during a power outage, (3) demonstrate the ability to coordinate a medical team during a simulated power outage in an emergency department with limited resources, (4) manage a cardiac arrest patient by following Advanced Cardiac Life Support (ACLS) protocols for bradycardia and ventricular fibrillation, and (5) justify the urgency of transfer to a certified ST segment elevation myocardial infarction center/cardiac intensive care unit, referencing the recommended 120-minute door-to-balloon time. This simulation was conducted with a high-fidelity mannequin. A total of six residents of various post-graduate year (PGY) levels participated in the simulated patient encounter as part of the simulation competition at the Western Regional meeting of the Society for Academic Emergency Medicine. This case was assessed for educational content and piloted by emergency medicine attendings from several institutions prior to running the case for the Western Regional meeting. The efficacy of the content was assessed by oral feedback. The case was well-received by both the attending physicians who evaluated the case prior to running the scenario at the Western Regional meeting and the emergency medicine residents who participated in the case at the Western Regional meeting. Overall, this simulation was well received by both the learners and the debriefers. General feedback was positive, with the perception of increased confidence among learners and reflection upon individual hospital policy in the event of a power outage. Simulation, acute myocardial infarction, cardiac arrest, power outage.

Geographical Distribution and Trends Analysis of Osteopathic General Surgery Residents.

In recent years, the number of Doctor of Osteopathic Medicine (DO) residents entering general surgery has increased. As DOs continue to solidify their role within the surgical domain, understanding their distribution, preferences, and the dynamics of their integration into residency programs becomes crucial for general surgery applicants. Publicly available data were gathered for each DO general surgery resident from residency programs across the nation, including details such as post-graduate year, degrees held, and residency program location. A comprehensive cross-sectional analysis was conducted to determine the geographical distribution and match trends of DO residents in these residency programs. Analysis revealed a significant rise in the number of DOs entering general surgery residencies, from 153 DO trainees beginning their residency training in 2019 to 274 DO trainees beginning their residency training in 2024. This upward trend indicates a growing presence of DOs in surgical practice. Examination of the geographical locations of programs for which DO applicants have matched showed variations nationwide. This analysis allows for a deeper understanding of the evolving match trends for DOs in surgery. It highlights the importance of addressing disparities in access to surgical training opportunities for osteopathic physicians nationwide.

Should I Stay, or Should I Go? Emotional Exhaustion's Association with Intent to Leave in a National Sample of Female Physician Trainees.

Background: Physician burnout disproportionately affects women and contributes to attrition from the workforce, a costly problem that likely begins in training. Female physicians leave the workforce significantly earlier than male counterparts. The association between burnout and attrition intent in women physician trainees is unknown. Methods: This is a cross-sectional analysis of baseline data from a national sample of female physician trainees in a randomized controlled trial testing a well-being program in 2022. Participants completed surveys on burnout and intent to leave. Associations were analyzed using chi-square testing and univariable linear regression. Results: A total of 1,017 trainees responded. The average standard deviation (SD) age was 30.8 (4.0) years, 959 (94.3%) self-identified as a woman, and 540 (53.1%) as White. One-fifth (207, 20.7%) were in postgraduate year (PGY)-1, 198 (19.8%) PGY-2, and 595 (59.5%) ≥ PGY-3. Most scored positively for burnout; 77.5% experienced high emotional exhaustion (EE). One-fifth (20.6%) reported some intent to leave their program before graduation, and 32.7% reported intent to leave their specialty within 2 years. There was a strong association between EE scores and intent to leave: trainees reporting a high likelihood to leave before graduation had a 22.27 higher EE point average than those reporting no likelihood (95% confidence interval [CI]: 7.80, 36.74, p = 0.003). Conclusions: Attrition intent was associated with burnout. Addressing burnout during training will not only benefit trainees but could impact the retention of women physicians.

Impact of Resident and Attending Surgeon Training Level on Free Tissue Transfer Ischemia Time and Complications.

Microsurgical free tissue transfer has become an essential method for reconstruction of complex surgical defects, making the level of training an important factor to consider. There is little published regarding the impact of training level on microsurgical outcomes. This study investigates microsurgical free tissue transfer ischemia time and postoperative complications based on resident and attending surgeon experience level. A retrospective review of all free flaps at a single institution from January 1, 2013, to December 31, 2021 was performed. Linear regression was performed analyzing ischemia time of 497 free flaps and attending surgeon experience defined by years in practice and resident level defined as postgraduate year (PGY). Logistic regression model was used to analyze complications based on attending experience and resident level. The average resident PGY was 3.5 ± 0.8; the average attending has been practicing for 6.4 ± 5.1 years. There was no statistically significant difference in ischemia time or complication rates based on resident PGY or attending surgeon experience level. Lower PGY residents were not found to increase ischemia time or increase complication rates. Lower attending surgeon year was not found to increase ischemia time or increase complication rates compared with surgeons who had been practicing for longer. Microsurgical free tissue transfer is considered a safe procedure in residency training and trainee involvement should be encouraged to improve resident education and enhance technical skills.

Neurosurgical Residency Training at Veterans Affairs Medical Centers, the Resident Perspective.

Department of Veteran's Affairs (VA) Medical Centers play a crucial role in training neurosurgery residents. Although previous studies have examined the impact of VA rotations from the attending perspective, the resident experience remains unexplored. We present a national survey of neurosurgery residents to assess their perceptions of VA rotations, focusing on operative experience, call burden, longitudinal patient care experiences, and overall strengths and limitations. A 33-question survey was distributed by email to all neurosurgery residents who had previously completed a VA rotation within the past 7 years. Responses were received from 77 residents, representing 36 out of 40 neurosurgical residency programs with an active VA rotation. Most residents (79.2%) found their VA rotations adequate in length, having spent a median of 5 months at the VA. Residents completed an average of 11.7 (SD 7.2) cases per month while at the VA, including 8.9 (SD 5.5) spine, 1.7 (SD 2.0) cranial, and 1.4 (SD 1.6) peripheral nerve cases. Many residents reported completing a greater proportion of spine and peripheral nerve cases at the VA compared with their primary clinical sites. Across all postgraduate years, residents felt that the VA offered increased operative autonomy (79.0% agreement) at the expense of total operative volume (98.7% agreement) and complexity (81.9% agreement). Importantly, 94.8% of residents participated in longitudinal patient care experiences, and 59.7% followed all patients longitudinally. The resident experience at the VA varies, presenting both strengths and limitations. Addressing these factors could enhance the overall effectiveness of VA rotations in neurosurgical training programs in the future.

Reliability of a workplace-based assessment for the United States general surgical trainees’ intraoperative performance using multivariate generalizability theory: a psychometric study

The System for Improving and Measuring Procedure Learning (SIMPL), a smartphone-based operative assessment application, was developed to assess the intraoperative performance of surgical residents. This study aims to examine the reliability of the SIMPL assessment and determine the optimal number of procedures for a reliable assessment. In this retrospective observational study, we analyzed data collected between 2015 and 2023 from 4,616 residents across 94 General Surgery Residency programs in the United States that utilized the SIMPL smartphone application. We employed multivariate generalizability theory and initially conducted generalizability studies to estimate the variance components associated with procedures. We then performed decision studies to estimate the reliability coefficient and the minimum number of procedures required for a reproducible assessment. We estimated that the reliability of the assessment of surgical trainees' intraoperative autonomy and performance using SIMPL exceeded 0.70. Additionally, the optimal number of procedures required for a reproducible assessment was 10, 17, 15, and 17 for postgraduate year (PGY) 2, PGY 3, PGY 4, and PGY 5, respectively. Notably, the study highlighted that the assessment of residents in their senior years necessitated a larger number of procedures compared to those in their junior years. The study demonstrated that the SIMPL assessment is reliably effective for evaluating the intraoperative performance of surgical trainees. Adjusting the number of procedures based on the trainees' training stage enhances the assessment process's accuracy and effectiveness.

Gender Differences in Clinical Performance Assessment of Internal Medicine Residents: A Longitudinal Analysis of the Influence of Faculty and Trainee Gender.

Competency-based medical education relies on equitable assessment. This study examined the influence of faculty and trainee gender on assessments of internal medicine (IM) resident performance over time. A longitudinal analysis of clinical performance assessments from 7 U.S. IM residency programs (July 2014-June 2019) was conducted. Core competency scores (patient care [PC], medical knowledge [MK], practice-based learning and improvement [PBLI], systems-based practice [SBP], professionalism [PROF], and interpersonal and communication skills [ICS]) were standardized across programs. Cross-classified mixed-effects linear regression evaluated the relationship between gender and standardized competency scores within training programs, while adjusting for multiple variables including IM In Training Examination percentile rank. Data included 9,346 evaluations by 1,011 faculty (552 [55%] men, 459 [45%] women) for 664 residents (358 [54%] men, 306 [46%] women). Initially, women residents' scores were significantly lower than men's in PC (estimated difference [standard error ] -0.097 [0.033], P = .004), MK (-0.145 [0.034], P < .001), and PBLI -0.090 [0.040], P = .022). PC, MK, PBLI, and SBP scores increased more over time for women residents than men (PC: 0.050 [0.015], P = .001; MK: 0.052 [0.015], P = .001; PBLI: 0.036 [0.018], P = .048; SBP: 0.036 [0.016], P = .027). PROF and ICS scores were comparable across gender. There was a significant interaction between faculty gender and postgraduate year (PGY) across all competencies but none between resident gender, faculty gender, and PGY, indicating that men and women faculty rated residents differently over time but were consistent in how they rated men and women residents. Gender-based assessment differences were variable across competencies and time. Women residents had lower scores initially but greater gains in "hard skill" (MK, PC, and PBLI) than in "soft skill" (ICS and PROF) competencies, suggesting assessment inequities. Efforts to ensure equitable assessment are needed.

Creation of an Automated and Comprehensive Resident Progress System for Residents and to Save Hours of Faculty Time: Mixed Methods Study.

It is vital for residents to have a longitudinal view of their educational progression, and it is crucial for the medical education team to have a clear way to track resident progress over time. Current tools for aggregating resident data are difficult to use and do not provide a comprehensive way to evaluate and display resident educational advancement. This study aims to describe the creation and assessment of a system designed to improve the longitudinal presentation, quality, and synthesis of educational progress for trainees. We created a new system for residency progress management with 3 goals in mind, that are (1) a long-term and centralized location for residency education data, (2) a clear and intuitive interface that is easy to access for both the residents and faculty involved in medical education, and (3) automated data input, transformation, and analysis. We present evaluations regarding whether residents find the system useful, and whether faculty like the system and perceive that it helps them save time with administrative duties. The system was created using a suite of Google Workspace tools including Forms, Sheets, Gmail, and a collection of Apps Scripts triggered at various times and events. To assess whether the system had an effect on the residents, we surveyed and asked them to self-report on how often they accessed the system and interviewed them as to whether they found it useful. To understand what the faculty thought of the system, we conducted a 14-person focus group and asked the faculty to self-report their time spent preparing for residency progress meetings before and after the system debut. The system went live in February 2022 as a quality improvement project, evolving through multiple iterations of feedback. The authors found that the system was accessed differently by different postgraduate years (PGY), with the most usage reported in the PGY1 class (weekly), and the least amount of usage in the PGY3 class (once or twice). However, all of the residents reported finding the system useful, specifically for aggregating all of their evaluations in the same place. Faculty members felt that the system enabled a more high-quality biannual clinical competency committee meeting and they reported a combined time savings of 8 hours in preparation for each clinical competency committee as a result of reviewing resident data through the system. Our study reports on the creation of an automated, instantaneous, and comprehensive resident progress management system. The system has been shown to be well-liked by both residents and faculty. Younger PGY classes reported more frequent system usage than older PGY classes. Faculty reported that it helped facilitate more meaningful discussion of training progression and reduced the administrative burden by 8 hours per biannual session.