Years Of Postgraduate Training Research Articles

Resident Education Versus Fellowship Training—Conflict or Synergy?

The fundamental mission of graduate medical education is to train young professionals to become future practitioners and academicians. Orthopaedic surgery training programs are primarily directed toward resident education. The subspecialty training of fellows, however, is arguably equally important. Thus, two constituencies that may compete for educational experience, attention, and resources are inherent to many training programs. We developed a survey to explore this issue prior to a symposium on this topic presented at the American Orthopaedic Association (AOA) meeting in June of 2009. Questions concerning the relationship between resident and fellowship education were distributed to orthopaedic residents in their fourth postgraduate year (PGY-4) of training who attended the Resident Leadership Forum at the 2009 AOA meeting. Responses were obtained from seventy-seven resident participants, a number that represents 12% of the total PGY-4 orthopaedic residents in 2009. The same survey was distributed to orthopaedic surgery department chairs, program directors, and fellowship directors across the United States. One hundred sixty-nine of this “faculty” group responded, a number that was 41.6% of the possible total. In the nineteenth century, surgeons generally were self-trained or learned by way of an apprenticeship1. No formal system was in place and few surgeons spent more than one or two years in a hospital setting. In 1889, with the founding of The Johns Hopkins Hospital, Dr. William Halsted transformed surgical training from its loosely organized structure to a university-sponsored, hospital-based model with graduated responsibility that culminated in a period of near autonomy. Formalization of the qualifications requisite of surgical subspecialties soon followed, largely to assure the public of a specialist’s preparation and skill2. The American Board of Orthopaedic Surgery (ABOS) was incorporated on February 4, 1934, and gave its first certification examination in 19353. Oversight of board certification implied the need for …

Pediatric Residents’ Knowledge, Use, and Comfort With Expedited Partner Therapy for STIs

We examined California pediatric residents' knowledge, practices, and comfort of providing expedited partner therapy (EPT) for sexually transmitted infections, by postgraduate year of training and presence of an adolescent medicine fellowship. We hypothesized that few residents are aware of EPT, and fewer are comfortable providing it; knowledge, practices, and comfort increase during residency; and presence of an adolescent medicine fellowship increases knowledge, practices, and comfort. Online anonymous questionnaires were completed by pediatric residents from 14 California programs. Two hundred eighty-nine pediatric residents (41% response; mean age, 29.4 ± 2.7 years; 78% female) responded. Twenty-two percent reported being moderately or very familiar with EPT. Most correctly identified several EPT methods. Incorrectly identified as EPT included patient (55%), health department (42%), and provider (37%) referrals. Only 8% were aware of California's legal status regarding EPT. Sixty-nine percent knew that California law allows EPT for chlamydia and gonorrhea, but 38% incorrectly stated that EPT can be used to treat trichomoniasis. Fifty-two percent reported ever providing EPT, but 30% of them were uncomfortable doing so. Postgraduate year 1 residents were significantly more likely to report lack of experience as a barrier to prescribing EPT. Residents in programs with the presence of an adolescent medicine fellowship had significantly higher global knowledge scores and were more likely to practice EPT with fewer concerns. California pediatric residents have knowledge gaps and discomfort providing EPT, and the presence of adolescent medicine fellowship is associated with increased EPT knowledge, use, and comfort among residents. Our findings demonstrate a need to improve EPT education in pediatric residencies.

Specialist training in forensic psychiatry: The UK experience

Training pathways and structures in forensic psychiatry differ between European Union countries, and perspective may differ between trainees and trainers. To describe the context of forensic psychiatry training in the UK, with a particular emphasis on England and Wales, as well as some details of core psychiatry and specialist forensic training. Forensic psychiatry in the UK takes place in the context of general medical training guidance and regulation. In the last decade, it has changed to be in line with the European working directive and to take account of opinions from outside medicine. The specialist component is typically during the last 3 years of post-graduate training and is based on an apprenticeship/competency model.

An Operative Performance Rating System for Urology Residents

An operative performance rating system for urology residents was developed for 6 sentinel urological procedures. We tested the reliability, validity and feasibility of the operative performance rating system for urology residents. The operative performance rating system of each procedure contained a 3-point case difficulty scale, 4 to 6 procedure specific items, 3 general items and an overall performance item. A Likert scale of 1 to 5 was used for each item. A single video/audio record of each procedure was evaluated by the faculty. Single item interrater agreement was measured by comparing the observed variance and random measurement error variance. Resident operative performance evaluations were completed on line. Internal consistency reliability was measured using Cronbach α. Overall scale scores by resident training postgraduate year level were compared using 1-way ANOVA. Faculty evaluation of video/audio records showed an interrater agreement range of 0.71 to 0.92. Faculty evaluations of resident operative performance demonstrated an internal consistency reliability range of 0.91 to 0.95. Significant differences in overall scale scores between postgraduate year levels were noted for 3 of the 6 procedures (p ≤0.0016). An operative performance rating system for urology residents is feasible using an Internet based resident management system. Interrater agreement and internal consistency reliability meet threshold limits for checklist evaluation instruments. The operative performance rating system can discriminate among postgraduate year levels of resident training. A validated operative performance rating system can offer residents immediate, objective feedback on surgical performance and enable program directors to monitor progress in resident operative performance.

Video-laryngoscopy versus direct laryngoscopy in critically ill patients: a pilot randomized trial

Endotracheal intubation in critically ill patients is associated with a high risk of complications that tend to increase with multiple attempts at laryngoscopy. In this pilot study, we compared direct laryngoscopy (DL) with video-laryngoscopy (VL) with regard to the number of attempts and other clinical parameters during endotracheal intubation of critically ill patients performed by novice providers. Patients were randomized to either VL or DL for endotracheal intubation. Exclusion criteria for the study included: requirement for immediate endotracheal intubation, cervical spine precautions, anticipated difficult intubation, oxygen saturation < 90%, or systolic blood pressure < 80 mmHg despite resuscitation. The providers, predominantly non-anesthesiology residents in their first three years of postgraduate training, received a one-hour teaching and mannequin session prior to performing the procedures. Forty patients, mean age 65 (standard deviation, 16) yr were randomized to VL (n = 20) or DL (n = 20). Sixty percent of the patients received endotracheal intubation for respiratory failure, and all patients received a neuromuscular blocker. Multiple attempts were required in 25/40 (63%) patients, and this did not differ with technique (P = 1.0) Video-laryngoscopy resulted in improved glottic visualization with 85% of patients having a Cormack-Lehane grade 1 view compared with 30% of patients in the DL group (P < 0.001). Total time-to-intubation for VL was 221 sec (interquartile range [IQR 103-291]) vs 156 sec [IQR 67-220] for DL (P = 0.15). Video-laryngoscopy resulted in a lower median SaO(2) (86%) during endotracheal intubation [IQR 75-93] compared with a median SaO(2) of 95% in the DL group [IQR 85-99] (P = 0.04). Video-laryngoscopy resulted in improved glottic visualization compared with DL; however, this did not translate into improved clinical outcomes. The trial was registered on ClinicalTrials.gov number, NCT00911755.

Does residents' involvement in mastectomy cases increase operative cost? If so, who should bear the cost?

IntroductionIt is a widely held belief that surgical residents' involvement in operative cases increases operative time and costs. However, there is little published data regarding the veracity of this belief, and there is poor documentation of the actual costs associated with involving surgical residents in operative cases. This report represents a retrospective analysis of the additional cost associated with involving surgical residents of all training years in mastectomy cases over a 6-y period. MethodsA total of 1063 mastectomy cases (with and without reconstruction) were performed over a 6-y period (2004–2010) at the Saint Barnabas Medical Center, Livingston, NJ. Data relating to the type of mastectomy performed, operative times, training level of residents involved, and the surgical attendings' case volume were collected. Two major groups (attendings-only and attendings with residents) and 19 mastectomy subcategories were formed. Differences in operating room (OR) times between the attendings-only and attendings with residents groups were multiplied by the hospital OR charges per minute of time ($15/min after the initial 30min) to determine the additional operative costs associated with residents' involvement. The impact of postgraduate training year and the attendings' case volume on operative time was analyzed separately. Statistical analysis was conducted using IBM SPSS 18.0.1 Windows version (PASW Statistics for Windows, SPSS Inc, Chicago). ResultsTwenty-six surgeons and 97 residents were involved in 1063 mastectomy cases. Eight hundred ninety-five cases involved residents, of which 405 cases had reconstruction and 490 cases did not. Among 168 cases involving residents, 107 cases had reconstruction and 61 cases did not. The mean OR time was increased in nearly all cases involving surgical residents but statistically significant in only nine of the 19 mastectomy subcategories. Postgraduate year (PGY) 1 or PGY2 residents increased OR time for unilateral mastectomy, whereas the involvement of PGY1 through PGY3 residents increased OR time for bilateral mastectomy+reconstruction (P<0.05). No significant difference was observed when PGY4 and PGY5 were involved in mastectomy cases. The additional calculated time required to perform mastectomies involving surgical residents was 41,366min, which corresponded to an increase in OR costs of $620,340 over 6y. ConclusionThe involvement of surgical residents in mastectomy cases significantly increases operative times and cost. This difference is most apparent when junior-level residents are involved and disappears by the PGY4–PGY5. Increased operative costs and the lost opportunity costs for surgical attendings are significant issues associated with residency education. Center for Medicare and Medicaid Services and Accreditation Council on Graduate Medical Education should consider such data when establishing appropriate reimbursements for graduate training programs.

The Relationship Between Response Time and Diagnostic Accuracy

Psychologists theorize that cognitive reasoning involves two distinct processes: System 1, which is rapid, unconscious, and contextual, and System 2, which is slow, logical, and rational. According to the literature, diagnostic errors arise primarily from System 1 reasoning, and therefore they are associated with rapid diagnosis. This study tested whether accuracy is associated with shorter or longer times to diagnosis. Immediately after the 2010 administration of the Medical Council of Canada Qualifying Examination (MCCQE) Part II at three test centers, the authors recruited participants, who read and diagnosed a series of 25 written cases of varying difficulty. The authors computed accuracy and response time (RT) for each case. Seventy-five Canadian medical graduates (of 95 potential participants) participated. The overall correlation between RT and accuracy was -0.54; accuracy, then, was strongly associated with more rapid RT. This negative relationship with RT held for 23 of 25 cases individually and overall when the authors controlled for participants' knowledge, as judged by their MCCQE Part I and II scores. For 19 of 25 cases, accuracy on each case was positively related to experience with that specific diagnosis. A participant's performance on the test overall was significantly correlated with his or her performance on both the MCCQE Part I and II. These results are inconsistent with clinical reasoning models that presume that System 1 reasoning is necessarily more error prone than System 2. These results suggest instead that rapid diagnosis is accurate and relates to other measures of competence.

Use of an Integrated, Anatomic-Based, Orthopaedic Resident Education Curriculum: A 5-Year Retrospective Review of Its Impact on Orthopaedic In-Training Examination Scores

Experts have called for a comprehensive didactic curriculum in orthopaedic residency training. This study examined the effects of an anatomic-based, integrated conference program on annual Orthopaedic In-Training Examination (OITE) scores at a single orthopaedic residency program. We implemented a new, integrated, anatomic-based curriculum in January 2005. Differences between scores were analyzed by postgraduate year (PGY) of training. OITE scores (percentile ranking and raw scores) of year 1 (PGY-2) through year 4 (PGY-5) residents exposed to the curriculum (2005-2009) were compared to prior PGY-2 through PGY-5 residents (2000-2004) who had experienced the previous unstructured curriculum. To evaluate for cohort effects, United States Medical Licensing Examination (USMLE) Step I scores for these 2 groups were also compared. Eight residents were exposed to the new conference program and 8 to the prior conference program. All residents' percentile rankings improved after exposure to the curriculum, although improvement was not statistically significant for all participants. The most dramatic improvements in OITE scores were seen for PGY-4 and PGY-5 residents, which improved from 65th to 91st percentile (P = .03) and from 66th to 91st percentile (P = .06), respectively. There were no differences between the cohorts in USMLE Step I scores. Initiation of an integrated, anatomic-based, resident conference program had a positive impact on resident performance on the OITE.

3. California Pediatric Residents' Knowledge, Practices and Comfort Using Expedited Partner Therapy for Sexually Transmitted Infections

Expedited partner therapy (EPT) is as effective as other methods of partner treatment for sexually transmitted infections (STIs). However, EPT utilization by providers is poor and varies depending on state laws. There are limited data describing provider practices and comfort with EPT for adolescents. We examined the knowledge, practices, and comfort of EPT among California pediatric residents, by post-graduate year (PGY) of training and presence of an Adolescent Medicine fellowship program.

The world of trauma working together

The world of trauma working together

As Accessible as a Book on a Library Shelf: The Imperative of Routine Simulation in Modern Health Care

As Accessible as a Book on a Library Shelf: The Imperative of Routine Simulation in Modern Health Care

Use of Structured Portfolio in Surgical Training of Postgraduate Medical Education

Background: Reflection on the process of learning is an essential ingredient in transforming novice into expert learners. Learning to compile portfolio encourages reflective skills, which help students to work systemically in translating metacognition into self-regulatory control in order to adjust their action and monitor their learning objectives. Introducing to compile portfolio in the early years of postgraduate training is an effective tool to stimulate students’ reflective abilities. Reflective learners are better motivated than the conventional learners to take the responsibilities as researcher in future. Reflective skills achieve both learning in right direction and learning for whole life. However, use of formal methods of reflective portfolio to monitor the learning objectives is an uncommon practice in postgraduate training, primarily due to intensive time and labor required. Challenged with those constraints in Master’s of Surgery Program of Otolaryngology and Head-Neck Surgery in School of Medical Sciences at Universiti Sains Malaysia, a structured self-reflective portfolio was introduced to determine its feasibility and acceptance among supervisors and trainees. Portfolio was practiced as one of the tool for formative and for making recommendations to certify independent thyroid surgery allowed to practice in future. Methodology: A self-reflective structured portfolio was introduced to monitor the learning objectives in trainees of 2007 cohort, using a model as mentor-system for authentic and structured learning with self-reflective assessment (MASSRA). Initially a semi-structured portfolio comprising of 12 items and guidelines to compile a portfolio was followed by a structured format in training of thyroid module in sub-specialty of Head and Neck Surgery. Mentoring was organized by putting one-mentor verses 9 students to provide general pastoral guidance to compile portfolio as two entries a year. Mentors held the counseling session with student twice a year after evaluating the portfolios to monitor their progress. Besides, candidates were also observed for their performance in thyroid surgery during a 4-years training program. Those identified with problems for their level of training were referred to Joint Committee for Surgical Training comprising of 3 supervisors from Head and Neck Surgery Sub-specialty and a chairman supposedly the head of the department. 7 randomly selected students were also interviewed for direct feedback to evaluate this model. Result: 28 trainees at different level of their training compiled a self-reflection structured portfolio minimum twice a year with instructional feedback from the mentor, which was used as a tract for their personal development plan (produced by each trainee) for training in thyroid surgery. Initial analysis of portfolio revealed interesting feedback from the trainees reflecting on their knowledge, surgical skills and attitude towards thyroid surgery seen in tables 2-4. Conclusion: Self-reflections about each structured items in portfolio-helped trainees to identify their problems, seek mentors guidance and work systemically to help adjust their actions by revising learning objectives. Though time and labor intensive, portfolio was rated as feasible and practical.

Musculoskeletal Oncology Training during Residency

To evaluate the efficacy of a musculoskeletal oncology training module during residency. 24 orthopaedic residents with differing years of experience were recruited. 12 of them received musculoskeletal oncology training for 6 months. The remaining 12 were controls who did not attend the training and had no clinical experience in a musculoskeletal oncology unit but had at least 3 years of postgraduate surgical training. Upon completion, residents in both groups were assessed by a knowledge test and then an objective structured clinical examination (OSCE). Residents who attended the training module had better mean knowledge test scores (48 vs 25 out of 58, p<0.0001) and OSCE scores (32 vs 22 out of 42, p<0.004), compared to those who did not attend. No residents who attended the training module marked an inappropriate biopsy site that would have compromised definitive surgery, compared to 5 (42%) of the untrained residents who marked an inappropriate biopsy site that may have resulted in an unnecessary amputation. All residents who attended the training module agreed that such a module should be included in the orthopaedic residency programme. Residents who attended the training module were more aware of the biopsy principles and risks. A training module for musculoskeletal oncology should be included in the orthopaedic residency programme.

Residents' awareness of racial and ethnic disparities in cardiovascular care.

To characterize attitudes of residents toward racial/ethnic disparities in health care and to explore the effect of a simple intervention to improve awareness of these disparities. The authors surveyed residents in internal and emergency medicine rotating through the Coronary Care Unit of a major teaching hospital about their attitudes toward disparities in cardiovascular care before and after an intervention that fostered discussion of evidence for the existence of disparities, possible causes of disparities, and clinically focused approaches to quality improvement tailored to the residents' practice environment. Before the intervention, 35% of residents agreed that racial/ethnic disparities might occur for patients within the US health care system in general, and only 7% agreed that patients they personally treated might experience racial/ethnic disparities in healthcare. These proportions increased significantly after the intervention: 85% agreement at level of US health care system and 32% at the level of individual practice (P < .001). Changes in awareness did not differ by sex, postgraduate year of training, race/ethnicity, reported prior diversity training, or plans to subspecialize. Awareness of racial/ethnic disparities in care among residents remains low, particularly at the level of individual practice, but is amenable to intervention.

Response to Drs Cappell and Daram

To the Editor: I would like to thank Drs Cappell (1) and Daram (2) for their thoughtful comments on my article on the future of Gastroenterology fellowship training (3). It appears that we all agree that 7 years of post-graduate training for Gastroenterology is too long. First, this length of training is probably not needed to produce well-trained clinicians; second, there is a financial disadvantage to the physician with lengthy training; and third, long training may discourage physicians from pursuing a subspecialty and/or an academic focus. Both Drs Cappell and Daram suggest shortening Internal Medicine (IM) residency or incorporating a “GI specialty focus” during the third year of IM residency. This is in contrast to the suggestion made by the Multi-Society Task Force on GI Training to move much of the subspecialty Gastroenterology (GI) training into the traditional 3-year fellowship (perhaps with the sole exception of interventional endoscopy).

The effect of seniority and education on departmental dictation utilization

BackgroundElectronic medical records (EMR) are considered the best solution to improved dissemination of health information for patients. The associated transcription caused a significant cost increase in an academic pediatric center. An educational campaign was implemented to achieve cost-effective transcriptions without compromising the number of EMR transcriptions.MethodsWe analyzed the effect of seniority on transcription times over a 4-month period. We also compared the dictation volume before and 4 months after educational interventions. This study was performed in a pediatric academic center with both inpatient and outpatient transcription utilization analyzed. All clinicians providing pediatric care and utilizing the hospital-based transcription over the study time period were analyzed. Interventions included targeted education about efficiencies in transcription, time-based dictation costs, avoidance of lengthy pauses and unnecessary detail, shortening of total transcriptions, superfluous phrases as well as structured templates. Level of training by postgraduate year of training and seniority within faculty were measured for impact on dictation time and effect of education to improve times.ResultsLearners in year one had an average dictation time of 7.5 ± 2.2 minutes, which decreased with seniority to an average of 4.1 ± 2.2 minutes for senior faculty (0.0007, ANOVA). After educational initiatives were implemented, there was progressive decline in dictation utilization. The total dictation time decreased from 8,750 minutes per month in August 2009 to 4,296 minutes in December of 2009 (p = 0.0045, unpaired t-test).ConclusionWe identified a substantial need for education in dictation utilization and demonstrated that relatively simple interventions can result in substantial costs savings.

Integrating pharmacology and clinical pharmacology

I here reaffirm some of the points that I made in the manifesto for UK clinical pharmacology [1], in response to letters from others. Much of what I wrote in the manifesto addresses points that correspondents have made, but as some of the important points may not have been clear on a first reading, I shall reiterate them and add clarifications. I am surprised that Professor Page [2] should think that I have taken no cognizance of the erosion of the discipline of pharmacology in recent years. Nothing that I said, wrote or did, while I was President-Elect and President of the British Pharmacological Society (BPS) during 2006 to 2009, should have given that impression. If he doubts this, and my commitment to the integration of all pharmacological science across the clinical and non-clinical spectra, he may want to reread some of my articles in the newsletter of the BPS, previously called pA2, now called Pharmacology Matters[3, 4], and indeed the manifesto itself, where I wrote that ‘the importance of integrating pharmacology and clinical pharmacology cannot be overestimated’. In relation to this, I strongly believe that the distinction that many make between basic and applied science is a false dichotomy. As I wrote in the manifesto, ‘functions in biology emerge … as a result of integration of different components of relevant systems at different levels.’ This is true of pharmacology and clinical pharmacology. Although it is sometimes useful to refer separately to basic and applied science, it is the crosstalk between them, at all levels and from one level to another, that is important. I have recently had the opportunity to make these views known more widely, in my opening plenary lecture at WorldPharma 2010, the 16th World Congress of the International Union of Basic and Clinical Pharmacology (IUPHAR). The contents of that lecture have been posted on the BPS's website [5].

An Acute Care Surgery Rotation Contributes Significant General Surgical Operative Volume to Residency Training Compared With Other Rotations

Surgical resident rotations on trauma services are criticized for little operative experience and heavy workloads. This has resulted in diminished interest in trauma surgery among surgical residents. Acute care surgery (ACS) combines trauma and emergency/elective general surgery, enhancing operative volume and balancing operative and nonoperative effort. We hypothesize that a mature ACS service provides significant operative experience. A retrospective review was performed of ACGME case logs of 14 graduates from a major, academic, Level I trauma center program during a 3-year period. Residency Review Committee index case volumes during the fourth and fifth years of postgraduate training (PGY-4 and PGY-5) ACS rotations were compared with other service rotations: in total and per resident week on service. Ten thousand six hundred fifty-four cases were analyzed for 14 graduates. Mean cases per resident was 432 ± 57 in PGY-4, 330 ± 40 in PGY-5, and 761 ± 67 for both years combined. Mean case volume on ACS for both years was 273 ± 44, which represented 35.8% (273 of 761) of the total experience and exceeded all other services. Residents averaged 8.9 cases per week on the ACS service, which exceeded all other services except private general surgery, gastrointestinal/minimally invasive surgery, and pediatric surgery rotations. Disproportionately more head/neck, small and large intestine, gastric, spleen, laparotomy, and hernia cases occurred on ACS than on other services. Residents gain a large operative experience on ACS. An ACS model is viable in training, provides valuable operative experience, and should not be considered a drain on resident effort. Valuable ACS rotation experiences as a resident may encourage graduates to pursue ACS as a career.

Fundamental Skills for Entering Neurosurgery Residents: Report of a Pacific Region “Boot Camp” Pilot Course, 2009

Incorporation of the first postgraduate year of training into neurological surgery residencies in 2009 posed new challenges to neurosurgical educators. A "boot camp" course was held in August 2009 to introduce first year neurosurgical trainees to various fundamental cognitive and practical skills. The effectiveness of this course was evaluated by electronic survey of all trainees and faculty members. Eighteen trainees entering 5 western neurosurgical residencies (in either the first or second postgraduate year) participated in a course taught by 10 faculty members at a single host institution (Oregon Health & Science University) for 2 days. All trainees completed an online survey evaluating the relevance and quality of each didactic and hands-on course component and answered additional questions about the goals and design of the course. Faculty members were also surveyed. All trainees thought the course met its goals, provided relevant and useful information and experience, and was likely to improve patient care. In particular, hands-on procedural and operative course components were highly valued. A fundamental skills boot camp course for first year neurosurgical trainees seems valuable.

Encouraging a new kind of leadership

There is increasing evidence that good management and leadership lead to better patient outcomes ( Mountford and Webb, 2009 ). In the UK there is an increasing demand that NHS leaders have a clinical background ( DoH, 2009a ), yet there is relatively little focus on leadership skills during clinical training. We describe here an innovative programme commissioned and designed to bridge that gap in the final year of postgraduate medical training. We explain the structure of the programme, and that the aim was, and still is, to use experiential and reflective learning to enable doctors on the cusp of becoming consultants to broaden their horizons and manage their circumstances (both personal and professional) more effectively. This means helping them to understand their own individual needs, strengths and development areas, and to grasp with greater insight the system in which they work. We found that a tailored, non-didactic leadership programme, coupled with leadership coaching, was critical to improving clarity of goals, self-management, self-perception, self-confidence, preparedness for leadership and NHS knowledge for Specialist Registrars, who have gone on to gain hospital posts.