Postgraduate Year Research Articles

81 A Snapshot of Entrustability of Acute Care Procedural Skills in Paediatrics Residents

Abstract Background General paediatricians are expected to be competent in the resuscitation of children and important to this competency is the ability to perform certain acute care procedural skills. Paediatric residents are expected to be competent in these procedural skills by the end of their training as specified by the Royal College (RCPSC). However, the extent to which residents are actually competent is not fully assessed or understood. There are currently no evidence-supported guidelines suggesting the best path toward procedural skills competency for residents, and they are less likely to receive formal training and or supervision for completing procedural skills than their nursing counterparts. They also report feeling inadequately prepared. To address this gap, the Paediatrics program at McMaster University aimed to conduct a longitudinal cross-sectional study examining the competency of their trainees in specific acute care procedures. Objectives The purpose of this first study was to present a cross-sectional observation of the entrustability of paediatric residents in 6 procedural skills. Design/Methods The procedures were bag-valve mask (BVM) ventilation, intubation, intraosseous (IO) line insertion, chest tube insertion, and cardiopulmonary resuscitation (CPR), and defibrillation, which are all requirements of the RCPSC. Paediatric residents attended an “Acute Care Procedure Day” where they performed each procedure with direct observation and feedback. Entrustable professional activity (EPA) scores (from 1 to 5) were recorded for each attempt. Prior, a 1-hour interactive lecture was given that included procedural information and a video demonstration of each procedure. Residents received a copy of the milestones per EPA. Demographic information, self-perceived comfort, and EPA data were collected. Descriptive statistics and Pearson correlation for PGY level versus EPA scores were performed. Results Of the 36 residents who participated, 24(67%) were in postgraduate year (PGY) 1-2, and 12 PGY 3-4(33%). Reported levels of past experience were lowest for placement of chest tubes (n=3, 8.3%), followed by IOs (n=19, 52.8%). During the sessions, residents showed the highest levels of initial entrustment with IO placement (EPA 4-5 in 28/33), BVM skills (EPA 4-5 in 27/33), and CPR (EPA 4-5 in 16/25), and lowest for chest tube placement (EPA 4-5 in 0/35), defibrillation (EPA 4-5 in 5/31 residents) and intubation (EPA 4-5 in 17/31). Despite this, self-reported overall confidence after training for these procedures was moderate to high. There was strong correlation between PGY level and EPA score for intubation, and no correlation for the other procedures. Conclusion Our findings show that entrustability of certain acute care skills is not being obtained (i.e., defibrillation, chest tube placement), and that there were large discrepancies between entrustment scores and perceived comfort among the PGY levels. Further research is needed to characterize the learning curves for these skills, and their relative importance in paediatrics training.

Intersectional Disparities in Emergency Medicine Residents’ Performance Assessments by Race, Ethnicity, and Sex

Previous studies have demonstrated sex-specific disparities in performance assessments among emergency medicine (EM) residents. However, less work has focused on intersectional disparities by ethnoracial identity and sex in resident performance assessments. To estimate intersectional sex-specific ethnoracial disparities in standardized EM resident assessments. This retrospective cohort study used data from the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education Milestones (Milestones) assessments to evaluate ratings for EM residents at 128 EM training programs in the US. Statistical analyses were conducted in June 2020 to January 2023. Training and assessment environments in EM residency programs across comparison groups defined by ethnoracial identity (Asian, White, or groups underrepresented in medicine [URM], ie, African American/Black, American Indian/Alaska Native, Hispanic/Latine, and Native Hawaiian/Other Pacific Islander) and sex (female/male). Mean Milestone scores (scale, 0-9) across 6 core competency domains: interpersonal and communications skills, medical knowledge, patient care, practice-based learning and improvement, professionalism, and system-based practice. Overall assessment scores were calculated as the mean of the 6 competency scores. The study sample comprised 128 ACGME-accredited programs and 16 634 assessments for 2708 EM residents of which 1913 (70.6%) were in 3-year and 795 (29.4%) in 4-year programs. Most of the residents were White (n = 2012; 74.3%), followed by Asian (n = 477; 17.6%), Hispanic or Latine (n = 213; 7.9%), African American or Black (n = 160; 5.9%), American Indian or Alaska Native (n = 24; 0.9%), and Native Hawaiian or Other Pacific Islander (n = 4; 0.1%). Approximately 14.3% (n = 386) and 34.6% (n = 936) were of URM groups and female, respectively. Compared with White male residents, URM female residents in 3-year programs were rated increasingly lower in the medical knowledge (URM female score, -0.47; 95% CI, -0.77 to -0.17), patient care (-0.18; 95% CI, -0.35 to -0.01), and practice-based learning and improvement (-0.37; 95% CI, -0.65 to -0.09) domains by postgraduate year 3 year-end assessment; URM female residents in 4-year programs were also rated lower in all 6 competencies over the assessment period. This retrospective cohort study found that URM female residents were consistently rated lower than White male residents on Milestone assessments, findings that may reflect intersectional discrimination in physician competency evaluation. Eliminating sex-specific ethnoracial disparities in resident assessments may contribute to equitable health care by removing barriers to retention and promotion of underrepresented and minoritized trainees and facilitating diversity and representation among the emergency physician workforce.

Longitudinal Integrated Ambulatory, Didactic, and Evidenced-Based Medicine Curriculum in Internal Medicine.

The Accreditation Council for Graduate Medical Education (ACGME) endorses evolving scholarly education regarding evidence-based medicine (EBM) and its clinical application in Internal Medicine (IM). The IM residents at Navy Medical Readiness and Training Center San Diego (NMRTC-SD) communicated the need for both increased ambulatory didactic sessions as well as a formal EBM curriculum. Prior to the academic year of 2021-2022, no formal ambulatory or EBM curriculum existed. In July 2021, an integrated EBM-ambulatory curriculum was implemented. A pre-curriculum needs assessment was performed and thereafter an eight-session integrated ambulatory-EBM curriculum was implemented in the 2021-2022 academic year. Faculty members facilitated small group discussions focused on a particular didactic topic and EBM principle and integrated the learning of both into one session. After each session, residents completed a feedback form. At the end of the year, a post-curriculum needs assessment was collected. Thirty-four residents of all post-graduate years (PGY) levels participated from July 2021 to June 2022. Primary outcomes were satisfaction with the didactic portion of the curriculum, perception of receipt of adequate training in EBM principles, and perception of level of competency in practicing EBM principles. Overall, participants reported a substantial increase in satisfaction with didactic teaching and a large increase in the perceived competency in practicing EBM principles. This integrated didactic-EBM curriculum represents an effective method of incorporating didactic topics in IM with the teaching and application of EBM principles, which improved resident satisfaction with the curricula and self-perception of competency in critically appraising medical literature.

The Evolving Role of Postgraduate Year 7 in Neurological Surgery Residency.

In 2013, all neurosurgery programs were mandated to adopt a 7-year structure. We sought to characterize how programs use the seventh year of training (postgraduate year 7 [PGY7]). We surveyed all accredited neurosurgery programs in the United States regarding the PGY7 residents' primary role and the availability of enfolded fellowships. We compiled responses from different individuals in each program: chair, program director, program coordinator, and current chiefs. Of 120 accredited neurological surgery residency programs within the United States, 91 (76%) submitted responses. At these programs, the primary roles of the PGY7 were chief of service (COS, 71%), enfolded fellowships (EFF, 18%), transition to practice (10%), and elective time (1%). Most residencies have been 7-year programs for >10 years (52, 57%). Sixty-seven programs stated that they offer some form of EFF (73.6%). The most common EFFs were endovascular (57, 62.6%), spine (49, 53.9%), critical care (41, 45.1%), and functional (37, 40.7%). These were also the most common specialties listed as Committee on Advanced Subspecialty Training accredited by survey respondents. Spine and endovascular EFFs were most likely to be restricted to PGY7 (24.2% and 23.1%, respectively), followed by neuro-oncology (12, 13.2%). The most common EFFs reported as Committee on Advanced Subspecialty Training accredited but not restricted to PGY7 were endovascular (24, 26.4%) and critical care (23, 25.3%). Most accredited neurological surgery training programs use the COS as the primary PGY7 role. Programs younger in their PGY7 structure seem to maintain the traditional COS role. Those more established seem to be experimenting with various roles the PGY7 year can fill, including enfolded fellowships and transition-to-practice years, predominantly. Most programs offer some form of enfolded fellowship. This serves as a basis for characterization of how neurological surgery training may develop in years to come.

Gender Bias and Ophthalmology Accreditation Council for Graduate Medical Education Milestones Evaluations

Women remain underrepresented in ophthalmology and gender-based disparities exist in salary, grant receipt, publication rates, and surgical volume throughout training and in practice. Although studies in emergency medicine and general surgery showed mixed findings regarding gender differences in Accreditation Council for Graduate Medical Education (ACGME) Milestones ratings, limited data exist examining such differences within ophthalmology. To examine gender differences in ophthalmology ACGME Milestones. This was a retrospective cross-sectional study of postgraduate year 4 (PGY-4) residents from 120 ophthalmology programs graduating in 2019. PGY-4 midyear and year-end medical knowledge (MK) and patient care (PC) ratings and Written Qualifying Examination (WQE) scaled scores for residents graduating in 2019 were included. Differential prediction techniques using Generalized Estimating Equations models were performed to identify differences by gender. Of 452 residents (median [IQR] age, 30.0 [29.0-32.0] years), 275 (61%) identified as men and 177 (39%) as women. There were no differences in PC domain average between women and men for both midyear (-0.07; 95% CI, -0.11 to 0; P =.06) and year-end (-0.04; 95% CI, -0.07 to 0.03; P =.51) assessment periods. For the MK domain average in the midyear assessment period, women (mean [SD], 3.76 [0.50]) were rated lower than men (mean [SD], 3.88 [0.47]; P = .006) with a difference in mean of -0.12 (95% CI, -0.18 to -0.03). For the year-end assessment, however, the average MK ratings were not different for women (mean [SD], 4.10 [0.47]) compared with men (mean [SD], 4.18 [0.47]; P = .20) with a difference in mean of -0.08 (95% CI, -0.13 to 0.03). Results suggest that ACGME ophthalmology Milestones in 2 general competencies did not demonstrate major gender bias on a national level at the time of graduation. There were, however, differences in MK ratings at the midyear mark, and as low ratings on evaluations and examinations may adversely affect career opportunities for trainees, it is important to continue further work examining other competencies or performance measures for potential biases.

Gender and Inconsistent Evaluations: A Mixed-methods Analysis of Feedback for Emergency Medicine Residents.

Objectives: Prior research has demonstrated that men and women emergency medicine (EM) residents receive similar numerical evaluations at the beginning of residency, but that women receive significantly lower scores than men in their final year. To better understand the emergence of this gender gap in evaluations we examined discrepancies between numerical scores and the sentiment of attached textual comments. Methods: This multicenter, longitudinal, retrospective cohort study took place at four geographically diverse academic EM training programs across the United States from July 1, 2013-July 1, 2015 using a real-time, mobile-based, direct-observation evaluation tool. We used complementary quantitative and qualitative methods to analyze 11,845 combined numerical and textual evaluations made by 151 attending physicians (94 men and 57 women) during real-time, direct observations of 202 residents (135 men and 67 women). Results: Numerical scores were more strongly positively correlated with positive sentiment of the textual comment for men (r = 0.38, P < 0.001) compared to women (r = -0.26, P < 0.04); more strongly negatively correlated with mixed (r = -0.39, P < 0.001) and negative (r = -0.46, P < 0.001) sentiment for men compared to women (r = -0.13, P < 0.28) for mixed sentiment (r = -0.22, P < 0.08) for negative; and women were around 11% more likely to receive positive comments alongside lower scores, and negative or mixed comments alongside higher scores. Additionally, on average, men received slightly more positive comments in postgraduate year (PGY)-3 than in PGY-1 and fewer mixed and negative comments, while women received fewer positive and negative comments in PGY-3 than PGY-1 and almost the same number of mixed comments. Conclusion: Women EM residents received more inconsistent evaluations than men EM residents at two levels: 1)inconsistency between numerical scores and sentiment of textual comments; and 2)inconsistency in the expected career trajectory of improvement over time. These findings reveal gender inequality in how attendings evaluate residents and suggest that attendings should be trained to provide all residents with feedback that is clear, consistent, and helpful, regardless of resident gender.

Scaffolding the Transition to Residency: A Qualitative Study of Coach and Resident Perspectives.

This study explores coaching during transition from medical school to residency through the perspectives of residents and faculty coaches participating in a coaching program from residency match through the first year of residency. From January to September 2020, 15 faculty coaches in internal medicine, obstetrics and gynecology, emergency medicine, orthopedics, and pathology participated in a synchronous, in-person coaching training course. All 94 postgraduate year 1 residents in these 5 training programs participated. Between November 2021 and March 2022, focus groups were held with interns from all residency programs participating in the program. Interviews were conducted with faculty coaches in February 2022. Faculty and residents discussed their experiences with and perceptions of coaching. De-identified transcripts were coded, and researchers organized these codes into broader categories, generated cross-cutting themes from the concepts described in both cohorts, and proposed a model for the potential of coaching to support the transition to residency. Descriptive themes were constructed and analytic themes developed by identifying concepts that crossed the data sets. Seven focus groups were held with 39 residents (42%). Residents discussed the goals of a coaching program, coach attributes, program factors, resident attributes, and the role of the coach. Coaches focused on productivity of coaching, coaching skills and approach, professional development, and scaffolding the coaching experience. Three analytic themes were created: (1) coaching as creating an explicit curriculum for growth through the transition to residency, (2) factors contributing to successful coaching, and (3) ways in which these factors confront graduate medical education norms. Learner and faculty perspectives on coaching through the transition to residency reveal the potential for coaching to make an explicit and modifiable curriculum for professional growth and development. Creating structures for coaching in graduate medical education may allow for individualized professional development, improved mindset, self-awareness, and self-directed learning.

Career Outcomes of Nondesignated Preliminary Surgery Residents: A Systematic Review and Meta-Analysis

Nondesignated preliminary surgery (NDPS) residency offers postgraduate medical education with no guarantee of a subsequent categorical position. Some literature exists detailing the career outcomes of these residents, but these results are complicated by the limited scale of these studies. The purpose of this systematic review and meta-analysis is to summarize the career outcomes of these residents from the existing literature. The PubMed, Scopus, Cochrane, CINAHL, and PsycINFO databases were queried from inception for studies reporting the career outcomes of NDPS residents. Data were collected and extracted by 2 independent reviewers in accordance with PRISMA guidelines. The primary outcome of this study is the proportion of NDPS residents obtaining a categorical general surgery position. Secondary outcomes include the percentages of residents obtaining surgical subspecialty positions, obtaining nonsurgical specialty positions, and leaving graduate medical education. Overall, 13 studies reporting NDPS residents (n = 2606) were identified. The overall pooled estimate for obtaining a categorical general surgery position after NDPS residency was 37.1% (95% CI, 31.3%-43.2%), with significant heterogeneity (I2 = 81.8%; p < 0.001). Residents in the second postgraduate year were significantly more likely than those in the first year to obtain a general surgery position (50.6% vs 29.0%, respectively; p < 0.001). Residents subsequently training in a surgical subspecialty (13.3%) largely entered orthopedics (3.6%), urology (2.1%), and obstetrics and gynecology (1.6%). For residents entering nonsurgical training (32.1%), a majority entered anesthesiology (11.7%), internal medicine (3.8%), and radiology (3.8%). Although NDPS residents have heterogenous career outcomes, they largely obtain categorical positions in general surgery and surgical subspecialties.

Team-based preceptor model: The foundation of a longitudinal residency learning experience focused on education.

A structured pharmacy grand rounds (PGR) learning experience that incorporates all aspects of the Accreditation Council for Pharmacy Education (ACPE) continuing pharmacy education (CPE) development process for postgraduate year 1 and 2 pharmacy residents is described. Pharmacy residents at The University of Texas MD Anderson Cancer Center participate in a structured PGR learning experience as part of the residency completion requirements. Residents are involved in all aspects of educational activity development, including (1) conducting a needs assessment; (2) developing learning objectives; (3) implementing learning assessment methodologies; (4) constructing assessment questions; and (5) applying ACPE standards in the development of CPE activities. A team-based preceptor model focused on the unique attributes of the learning experience, comprising subject matter experts in content and educational best practices, is utilized to support the resident, provide feedback, conduct an evaluation, and ensure a successful experience. Key factors for success include resident instruction related to educational best practices, resources to exemplify the CPE development process, preceptor coaching, and guided self-reflection to identify areas of strength and improvement as an educator. A structured PGR learning experience that incorporates all aspects of the ACPE CPE development process enables pharmacy residents to understand and apply best practices for educational activity development. Utilizing a team of subject matter experts in educational best practices in collaboration with content experts allows for shared preceptor responsibilities and a successful experience for the resident.

Financial Literacy Among Medical Trainees and Faculty: A Pilot Study.

Medical education systems are trained to produce efficient, thorough clinicians. These programs provide limited training on personal finances. The current socioeconomic climate for medical trainees includes increasing education debt and stagnating reimbursement. We conducted a survey-based cross-sectional pilot study at an academic institution targeted at residents, fellows, and attendings of all medical specialties. Our aim was to understand baseline levels of financial literacy at different training and career stages, which can inform targeted interventions to improve this crucial aspect of physician well-being. Asurvey was devised with the assistance of a certified financial planner. This survey was distributed at an academic institution targeting residents, fellows, and attendings. The survey was anonymous, and no identifying data were collected.Two reminders were sent to subjects to complete the survey. A total of 50 physicians completed the survey in 2021.There were eight responses from interns, 14 responses from residents (post-graduate year 2 or later), 14 responses from fellows, and nine responses from attendings. The majority of our respondents reported not having any particular financial education, and over 70% of respondents reported that their graduate education had not provided them with the tools needed for personal financial success. Financial education and financial literacy are important topics that need to be further incorporated into the medical education pathway.Physicians are not well equipped in this realm, and further training is necessary.This study provides pilot data that highlightimportant aspects of physician knowledge and practices in regard to finances.

"It's What We Can Do Right Now": Professional Identity Formation Among Internal Medicine Residents During the COVID-19 Pandemic.

The COVID-19 pandemic represents a consequential moment of disruption for medical training that has far-reaching implications for professional identity formation (PIF). To date, this has not been studied. As medical education grapples with a postpandemic era, it is essential to gain insight into how the pandemic has influenced PIF to better support its positive influences and mitigate its more detrimental effects. This study examined how PIF occurred during the COVID-19 pandemic to better adapt future medical training. Constructivist grounded theory guided the iterative data collection and analyses. The authors conducted semistructured group interviews with 24 Ontario internal medicine residents in postgraduate years (PGYs) 1 to 3 between November 2020 and July 2021. Participants were asked to reflect on their day-to-day clinical and learning experiences during the pandemic. Twenty-four internal medicine residents were interviewed (12 PGY-1 [50.0%], 9 PGY-2 [37.5%], and 3 PGY-3 [12.5%]). Participants described how navigating patient care and residency training through the pandemic consistently drew their attention to various system problems. How participants responded to these problems was shaped by an interplay among their personal values, their level of personal wellness or burnout, self-efficacy, institutional values, and the values of their supervisors and work community. As they were influenced by these factors, some were led toward acting on the problem(s) they identified, whereas others had a sense of resignation and deferred action. These interactions were evident in participants' experiences with communication, advocacy, and learning. Residents' professional identities are continuously shaped by how they perceive, reconcile, and address various challenges. As residents navigate tensions between personally held values and apparent system values, individuals in supervisory positions should be mindful of their influence as role models who empower values and practices that are recognized by participants to be important aspects of physician identity.

Determinants of Attitude Toward End-of-Life Care Among Junior Physicians: Findings from a Nationwide Survey in Japan.

Physicians' attitudes can be critical in quality end-of-life care. However, the determinants of the attitudes and whether the attitudes can be modified remain unclear. To investigate factors correlated with physicians' positive attitudes toward end-of-life care and whether these attitudes are modifiable through acquired factors (e.g., education or mentorship). A nationwide survey was conducted in 300 institutions and selected randomly from 1037 clinical training hospitals in Japan. From each selected institution, two resident physicians of postgraduate year (PGY) 1 or 2 and two clinical fellows from PGY 3-5 were requested to answer the survey. The primary outcome was the Frommelt Attitudes Toward the Care of the Dying (FATCOD) scale score. Factors (e.g., the respondents' age, sex, number of years of clinical experience, training environment, religion, and beliefs around death) were examined for correlation with FATCOD score. In all, 198 physicians and 134 clinical fellows responded to the survey (response rate: 33.0% and 22.3%, respectively). Factors with the strongest correlation with FATCOD scores were mostly unmodifiable factors (e.g., being female and one's beliefs around death). Modifiable factors were also identified-number of patient deaths experienced, level of interest in palliative care, availability of support from senior mentors, and frequency of consultation with nonphysician medical staff. Physicians' attitudes toward end-of-life care correlate more strongly with nonmodifiable factors, but attitudes can be meaningfully improved via mentoring by senior physicians. Future studies are warranted to determine the effective interventions to foster positive attitudes among physicians involved in end-of-life care.

Neurosurgery Resident Attrition Rates Defy Trends and Decrease During COVID-19 Pandemic

We sought to determine the effects of the coronavirus disease 2019 (COVID-19) pandemic on U.S. neurosurgery resident attrition. We report the changes in resident attrition due to transfers, withdrawal, or dismissal from program training during the COVID-19 pandemic. Neurosurgery resident attrition data reported by the American Council of Graduate Medical Education for the academic year starting in July 2007 to the academic year ending in June 2022 were collected, and the rate of attrition was calculated. Individual postgraduate year program transfer rates were also calculated for the previous 7 consecutive academic years. The attrition rates for the academic years before the pandemic were compared with those during the pandemic. A total of 465 residents did not graduate from neurosurgical training during the past 15 academic years, of which 3 years were at least partially during the COVID-19 pandemic, resulting in a mean attrition rate of 2.5%. The attrition rates during the pandemic were lower than those before the pandemic (1.7% vs. 2.7%; P < 0.001), driven largely by a nearly twofold decrease in the withdrawal rate (0.67% vs. 1.2%; P= 0.003). Bivariate regression between the withdrawal and attrition rates showed a statistically significant correlation (r = 0.809; P < 0.001; r2 = 0.654). The first full year of the COVID-19 pandemic saw the most dramatic changes, with a z score for attrition of-1.9. Linear regression of the effect of training during the COVID-19 pandemic on attrition revealed a statistically significant difference (r = 0.563; P = 0.029; r2 = 0.317). The rate of withdrawal was most affected by training during the pandemic (r = 0.594; P = 0.010; r2 = 0.353). A statistically significant decline occurred in the rate of neurosurgery resident attrition during the COVID-19 pandemic that was most notable during the first full academic year (2020-2021). These findings were largely driven by a decrease in residents withdrawing from training programs. This contrasts with the overall trend toward resignation among healthcare workers during the pandemic. It is unclear what enduring ramifications this will have on neurosurgery residencies moving forward and whether we will see higher attrition rates as we transition toward a new normal. Future studies should examine trends in the attrition rates after the COVID-19 pandemic and determine the long-term effects of decreased attrition rates of residents during the pandemic.

Operative dictations in surgical trainees: an underutilized educational resource?

Accurate operative notes are imperative to patient care and are used for communication, billing, quality assurance, and medical-legal conflicts. However, operative note quality often varies and many lack critical details. Unfortunately, no standardized training exists in operative dictations for surgical trainees. This pilot study sought to determine resident ability to dictate a comprehensive operative note and to determine a need for a formal operative dictation curriculum. Thirty-eight surgical residents between post-graduate years (PGY) one to four participated in a ventral hernia repair simulation. One senior (PGY3/4) resident coached two junior residents (PGY1/2). Residents completed an informal needs assessment regarding operative dictations. Post-simulation, residents completed an operative dictation. Notes were graded using a modified validated rubric. Thirty-five residents completed the needs assessment, and 38 residents submitted an operative note. Eighty-two percent of this group have completed ≤ 25 operative dictations in training and 77% have received minimal feedback on operative dictations. Out of 33 total points, mean overall score was 18.9 ± 5.4 (Junior resident: 17.9 ± 5.4; Senior resident: 20.9 ± 4.8) Total mean scores did not significantly differ between junior and senior residents (p = 0.10). Senior and junior residents scored similarly on the procedural details component (p = 0.29). Senior residents scored higher on relevant patient history and operative note headers (p = 0.04). Standard surgical training may not provide enough teaching and feedback to residents on operative note dictations. A formal residency training curriculum may bolster trainee ability to learn the components of an effective operative note.

Variability in Opioid Prescribing Among Plastic Surgery Residents After Bilateral Breast Reduction.

Prescription opioid misuse in the United States accounts for significant avoidable morbidity and mortality. Over one third of all prescriptions written by surgeons are for opioids. Although opioids continue to provide needed analgesia for surgical patients, there are few guidelines in the plastic surgery literature for their safe and appropriate use after surgery. The consequence is wide variability and excessive opioid prescriptions. Understanding patterns of prescribing among plastic surgery residents is a crucial step toward developing safer practice models for managing postoperative pain. The authors performed a retrospective analysis of discharge opioid prescriptions after bilateral breast reduction at a single academic medical center from 2018 to 2021. Single factor 1-way analysis of variance was used to evaluate prescribing patterns by resident, postgraduate year, attending of record, and patient characteristics for 126 patients. A multivariate analysis was performed to determine the degree to which these factors predicted opioid prescriptions. This analysis revealed significant variability among residents prescribing opioids after bilateral breast reductions (P < 0.001) irrespective of patient comorbidities and demographics. Residents were found to be the main predictor of opioid prescriptions after surgery (P < 0.001) with a greater number of morphine milligram equivalents prescribed by the more junior residents (P < 0.001). Excessive and variable opioid prescriptions among plastic surgery residents highlight the need for opioid prescribing education early in surgical training and improved oversight and communication with attending surgeons. Furthermore, implementation of evidence-based opioid-conscious analgesic protocols after common surgical procedures may improve patient safety by standardizing postoperative analgesic prescriptions.

Neuropsychological Differences Between Surgery Interns and Age-Matched Adults

The purpose of this study was to assess how neuropsychological factors differ between general surgery interns and normative data from age-matched adults in the general population. Participants completed a comprehensive neuropsychological assessment battery. Neuropsychological factors assessed included: executive function (Behavioral Rating Inventory of Executive Function, BRIEF), working memory (Wechsler Adult Intelligence Scale, or WAIS, digit span), psychomotor speed (WAIS coding, Trails A and B), selective attention (D2 Test of Attention), and problem solving (Tower of London, TOL). Data for all measures was compared to previously published normative data for age-matched, healthy adults in the general population using one-sample t-tests. This study was completed at Indiana University School of Medicine in Indianapolis, IN, which is a large academic healthcare training institution. Postgraduate year 1 general surgery residents (PGY1s) voluntarily participated in this study. Twenty-six general surgery PGY1s completed all measures. We found that PGY1s had significantly better behavioral inhibition, working memory, selective attention, problem solving, and psychomotor speed than their counterparts in the general population (Table 1). Conversely, we found that PGY1s had significantly lower cognitive flexibility (p = 0.02) and ability to monitor task progress (p = 0.006) than the general population. The results from this study indicate that there are several neuropsychological factors that may help explain the high achievement of general surgery PGY1s. Assessment of these factors could aid general surgery programs in the selection and training of high-caliber residents. However, there are indicators that PGY1s struggle from cognitive inflexibility and task monitoring compared to the general population. These skills are needed to manage the complex and dynamic nature of surgical performance, so educators should consider methods to enhance junior residents' development of these characteristics.

I Read, Therefore I Am: Examining Nonmedical Reading and Its Relationship to Empathy in Anesthesia Training.

High levels of empathy among resident physicians are associated with improved patient outcomes. Empathy may be learned and practiced when reading nonmedical writing through narrative transportation, a process by which readers identify with characters and become emotionally involved in the plot. We hypothesized that residents and fellows who reported more nonmedical reading would have higher empathy levels and that empathy would decrease during training. An emailed survey was sent to program directors of Accreditation Council on Graduate Medical Education-accredited anesthesiology residency and fellowship programs, with a request to distribute the survey to trainees. The Toronto Empathy Questionnaire, reading volume, and demographics were included in the survey. Response data were analyzed using a multiple variable regression model. Of 136 responses, 119 were included for data analysis. Seventeen partially completed surveys were excluded. Higher empathy scores were reported among women (P < .0001) and residents who worked 60 to 80 hours per week (P = .039). Age, postgraduate year of training, relationship status, time spent with family, and avid reading were not significantly associated with increased empathy. In this study, we examined whether nonmedical fiction reading would increase empathy in medical trainees. Our study was not able to find any significant association with time spent reading and increased empathy; however, we found that trainees who worked more hours, specifically 60 to 80 hours, had higher empathy scores. Limitations for this study included a smaller sample size. Further research should be done in this field to determine if there are other intangible factors that affect empathy in trainees.

Resident Engagement With a Web- and App-based Journal Club Curriculum Utilizing Email and Text Notifications.

High learner engagement is important for the success of asynchronous and online learning for graduate medical education. Medical trainees have recently reported using medical mobile apps. App-based interactions may provide more participation than email-based interactions. We sought to investigate (1) if there were higher levels of engagement with an online curriculum using notifications sent via email as compared with via text, and (2) if there were higher levels of engagement with the mobile app or website format. We implemented an online Journal Club curriculum with weekly topics for anesthesiology residents (postgraduate years 2-4) from July 2020 to June 2021. Weekly notifications were sent to residents via email for weeks 1-10, text for weeks 11-20, then email for weeks 21-49. Based on activity logs, we compared (1) the weekly numbers of interactions when email notifications were sent with the weekly numbers of interactions when text notifications were sent, and (2) the weekly numbers of interactions via the app with the weekly numbers of interactions via the website. Thirty-eight of the 54 anesthesiology residents in our department at the time of the study (70.4%) interacted with the online Journal Club at least once throughout the study. The weekly numbers of interactions with email notifications (median [interquartile range (IQR)]: 13 [7-28]) were significantly higher than with text notifications (median [IQR]: 6 [4-8]) (P = .023). The weekly numbers of interactions via the website (median [IQR]: 9 [4-24]) were significantly higher than via the app (median [IQR]: 0 [0-1]) (P < .001). Although mobile technology may increase engagement and participation for some educational resources, learners may prefer accessing others through more conventional methods.

Ankle fracture internal fixation performed by cadaveric simulation-trained versus standard-trained orthopaedic trainees: a preliminary, multicentre randomized controlled trial.

Ankle fracture fixation is commonly performed by junior trainees. Simulation training using cadavers may shorten the learning curve and result in a technically superior surgical performance. We undertook a preliminary, pragmatic, single-blinded, multicentre, randomized controlled trial of cadaveric simulation versus standard training. Primary outcome was fracture reduction on postoperative radiographs. Overall, 139 ankle fractures were fixed by 28 postgraduate year three to five trainee surgeons (mean age 29.4 years; 71% males) during ten months' follow-up. Under the intention-to-treat principle, a technically superior fixation was performed by the cadaveric-trained group compared to the standard-trained group, as measured on the first postoperative radiograph against predefined acceptability thresholds. The cadaveric-trained group used a lower intraoperative dose of radiation than the standard-trained group (mean difference 0.011 Gym2, 95% confidence interval 0.003 to 0.019; p = 0.009). There was no difference in procedure time. Trainees randomized to cadaveric training performed better ankle fracture fixations and irradiated patients less during surgery compared to standard-trained trainees. This effect, which was previously unknown, is likely to be a consequence of the intervention. Further study is required.

Implementing and evaluating a diversity, equity, and inclusion resident recruitment strategy.

A recruitment strategy was designed to increase the racial diversity of applicants to the postgraduate year 1 pharmacy program at University of Michigan Health, Michigan Medicine (MM). This article describes MM's diversity, equity, and inclusion (DEI) residency recruitment approach, from conceptualization through implementation, and includes an evaluation of its effectiveness. The report of the American Society of Health-System Pharmacists (ASHP) Task Force on Racial Diversity, Equity, and Inclusion, published in January 2021, provided a foundation for our recruitment approach. The approach consisted of establishing a residency DEI subcommittee, conducting outreach to under-represented students, and reducing bias in the process by amending the application screening rubric. The combination of these efforts resulted in a 5% increase in applicants from pharmacy schools with a high proportion of under-represented minority students. A diverse residency program benefits patients, trainees, and the larger healthcare organization. In addition, incorporating DEI into resident recruitment is required by the new ASHP Accreditation Standard for postgraduate pharmacy residency programs effective July 1, 2023. Evaluation of our recruitment efforts demonstrated targeted recruitment as an effective strategy to increase the diversity of a residency program's applicants. There may be additional barriers not addressed by our interventions to be further explored.