Practice Residency Research Articles

Fire futures: design for community-led resilience

ABSTRACT The increasing threat of catastrophic wildfires (referred to as bushfires in Australia) highlights the need for both governments and communities to collectively develop strategies for resilience. The principle of shared responsibility suggests a way forward, however, in practice residents and agencies often have contrary understandings of what sharing means in practice and asymmetric distributions of power can curtail community initiatives. Meanwhile, a focus on life and property does not account for broader issues of environmental health. This article details research that aimed to design media to support community-led fire management among two communities north-west of Brisbane, Australia. Findings from in-depth interviews and a codesign workshop reveal a need for more effective communication with residents, greater transparency from agencies, and a desire to better understand the role of fire in the local environment. We present design concepts targeted to foster engagement and action towards a fire-resilient future. The project reveals opportunities to conceive shared responsibility as a process of negotiating action between communities, agencies, and government and to extend the principle beyond people to the environment. We see the landscape as a dynamic actor in the process of sharing responsibility. Key policy highlights The concept of shared responsibility can be understood as a process of negotiating action between communities, agencies and the natural environment. In the context of wildfire resilience, the natural environment is a dynamic participant in the process of sharing responsibility. Participatory processes of community engagement could support the renegotiation of responsibilities that are jointly owned between citizens and government. A changed narrative about shared responsibility for the natural environment by agencies and communities could realign priorities and help establish alternative practices.

The impact of knowledge management on the quality of services in nursing homes.

Current management strategies in nursing homes (NH) aim to ensure effective knowledge management (KM) in order to provide both best possible services to residents, and care for staff in NH. Teamwork in NH is essential for effective delivery of the highest quality of services. As a result, NH are increasingly adopting KM activities to enable knowledge creation, storage, transfer, and implementation in an environment facing many challenges such as lack of staff, increasing demands, and expectations of residents. In our quantitative study, we examined how two Slovenian state NH that adopted the E-Qalin quality management model (European quality-improving learning model) adapted their KM, and what impact their quality management system and KM activities actually have on the quality of services. Furthermore, we examined how two Slovenian private NH that have not adopted a certified quality management program (like ISO or E-Qalin) tackle the issue of quality of services from the KM perspective. The sample consisted of 80 nursing professionals. In every NH that is part of this study, teamwork is essential and every individual that was involved in our survey is part of a team. In our study, we analyzed relationships between individual variables using linear regression. We found a significant and positive relationship between knowledge creation, transfer, and implementation in NH with and without the E-Qalin certificate. We found a significant and positive relationship between knowledge storage and the quality of services only in NH without a E-Qualin certificate. It seems that when connecting multidisciplinary fields such as NH and KM, there is still a lack of awareness and knowledge on the topic of KM, which might be one of the reasons for some bias in the answers provided by respondents. We also found different teamwork approaches in NH with and without a E-Qalin certificate. Our research results therefore emphasize the need to gain additional insight into quality management and KM in the environment of NH. Teamwork based on knowledge storage, transfer, the implementation of existing knowledge, and creation of new knowledge are essential for well-trained professionals and, as a result, contribute to continuous improvement in service quality. Implementation of KM is well received by NH, and enables them to better meet the needs and expectations of residents. More importantly, nursing staff also share and pass on tacit knowledge through teamwork. Finally, all of the NH in our study that implemented quality and KM activities noted an improvement in the quality of services that are offered to residents in practice. Our results indicate that the topic of KM in NH is interesting, and it has a positive impact on the quality of services in practice. However, the problem of awareness and knowledge on the topic of KM in the environment of NH still exists, highlighting the need for further research, additional insight, and dissemination of knowledge to every interested stakeholder functioning in the field of NH. The results of the study make an important contribution to the research of KM in NH, focusing on the transfer of tacit knowledge.

COVID-19 and Dermatologist: A Scenario from Nepal

Corona virus disease-2019 (COVID-19) had impacted the healthcare sector severely. The impact of pandemic had a foothold even on dermatology practice and dermatology residency teaching programs. Patients with dermatological diseases, few diseases arising due to COVID-19 and patients with immunosuppressive for chronic dermatological conditions were affected. In the midst of this pandemic, all dermatologist should learn and contribute to the mankind with precaution at all level either in healthcare or society.
 

Does burnout affect clinical reasoning? An observational study among residents in general practice

BackgroundBurnout results from excessive demands at work. Caregivers suffering from burnout show a state of emotional exhaustion, leading them to distance themselves from their patients and to become less efficient in their work. While some studies have shown a negative impact of burnout on physicians’ clinical reasoning, others have failed to demonstrate any such impacts. To better understand the link between clinical reasoning and burnout, we carried out a study looking for an association between burnout and clinical reasoning in a population of general practice residents.MethodsWe conducted a cross-sectional observational study among residents in general practice in 2017 and 2019. Clinical reasoning performance was assessed using a script concordance test (SCT). The Maslach Burnout Inventory for Human Services Survey (MBI-HSS) was used to determine burnout status in both original standards of Maslach’s burnout inventory manual (conventional approach) and when individuals reported high emotional exhaustion in combination with high depersonalization or low personal accomplishment compared to a norm group (“emotional exhaustion +1” approach).ResultsOne hundred ninety-nine residents were included. The participants’ mean SCT score was 76.44% (95% CI: 75.77–77.10). In the conventional approach, 126 residents (63.31%) had no burnout, 37 (18.59%) had mild burnout, 23 (11.56%) had moderate burnout, and 13 (6.53%) had severe burnout. In the “exhaustion + 1“ approach, 38 residents had a burnout status (19.10%). We found no significant correlation between burnout status and SCT scores either for conventional or “exhaustion + 1“ approaches.ConclusionsOur data seem to indicate that burnout status has no significant impact on clinical reasoning. However, one speculation is that SCT mostly examines the clinical reasoning process’s analytical dimension, whereas emotions are conventionally associated with the intuitive dimension. We think future research might aim to explore the impact of burnout on intuitive clinical reasoning processes.

Impact of ISBAR Communication Training on Interpersonal Communication and Teamwork of Residents in General Practice Standardized Training

Interpersonal communication and teamwork is one of the training objectives of standardized training for residents. The ISBAR (Identify, Situation, Background, Assessment, Request) communication training model can effectively improve physicians’ clinical communication skills and teamwork ability. Our research aims to explore the impact of the ISBAR communication training on the interpersonal communication and teamwork of residents in general practice standardized training. A total of 92 general practitioners (GP) who participated in the Standardized Residency Training in the First Affiliated Hospital of Xi’an Jiaotong University in September 2018 were randomly recruited and divided into observation group（n=46） and control group（n=46） using simple random grouping method. GP in the observation group was trained by the ISBAR communication training model, whereas GP in the control group was trained by the traditional clinical education model. Six different scales were used to assess the interpersonal communication ability and teamwork ability of the two groups at different time points. After two weeks of training，the scores of interpersonal communication ability and teamwork ability in the observation group were higher than those in the control group（P<0.05）. ISBAR communication training model may significantly improve the interpersonal communication skills and teamwork ability of residents in general practice standardized training.

Implementation of TeamSTEPPS concept at an academic primary care clinic

Abstract Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) is an evidence-based team building curriculum developed by the Department of Defense and the Agency for Healthcare Research and Quality (AHRQ). We utilized the TeamSTEPPS Primary Care curriculum to teach teamwork skills to all members of our primary care team, including frontline clerks, nursing staff, advanced practice providers, residents and faculty. All team members learned the same specific skills in leadership, communication, situation monitoring and mutual support which are essential for effective clinic team functioning. Additionally, team members from each of the different disciplines were given leadership roles. Since the implementation in 2013, we observed increases in staff job satisfaction, Press Ganey patient satisfaction scores, patient safety, resident perceptions of teamwork and teamwork culture.

Abstract NS6: Neuroscience Healthcare professionals want Training for End of Life Management in Catastrophic Stroke Patients

Background: There is a paucity of literature on EOL management in patients with catastrophic stroke (CS). CS is unique due to the acuity of the injury and the unresponsive state of the patient. In CS, the families are the decision makers and it is imperative to have the communication skills necessary to begin a difficult conversation with families regarding prognosis and treatment planning. We performed a needs assessment to determine how our Neuroscience staff viewed our current EOL management process and areas for potential improvement. Methods: A multidisciplinary team created a survey with 3 main categories: Process of EOL management, Comfort Level with EOL communication, and roles and responsibility for EOL treatment and decision making. We administered the survey to neuroscience faculty, fellows and advance practice providers (APP), residents, nurses, case managers and social workers. Qualtrics Program pooled the responses of the EOL questionnaire for counts and proportions. Results: The survey was distributed to 419 people with 102 respondents (39.6% MDs, 52.5% RNs, 8.0% others). We found that only 48% of our employees felt comfortable beginning a conversation regarding EOL topics; 67% do not feel trained to address EOL topics and the overwhelming majority felt EOL communication should be part of educational training (Figure). Conclusion: We found that our Neuroscience staff does not have formal training in EOL communication, does not feel comfortable initiating EOL conversations and desires more training in EOL management. Future work should prioritize a patient/family centered approach to EOL care and training for healthcare professions so we are better prepared to handle the needs of our families and patients with CS.

Development and pilot testing of a tool to assess evidence-based practice skills among French general practitioners

BackgroundThere is currently an absence of valid and relevant instruments to evaluate how Evidence-based Practice (EBP) training improves, beyond knowledge, physicians’ skills. Our aim was to develop and test a tool to assess physicians’ EBP skills.MethodsThe tool we developed includes four parts to assess the necessary skills for applying EBP steps: clinical question formulation; literature search; critical appraisal of literature; synthesis and decision making. We evaluated content and face validity, then tested applicability of the tool and whether external observers could reliably use it to assess acquired skills. We estimated Kappa coefficients to measure concordance between raters.ResultsTwelve general practice (GP) residents and eleven GP teachers from the University of Bordeaux, France, were asked to: formulate four clinical questions (diagnostic, prognosis, treatment, and aetiology) from a proposed clinical vignette, find articles or guidelines to answer four relevant provided questions, analyse an original article answering one of these questions, synthesize knowledge from provided synopses, and decide about the four clinical questions. Concordance between two external raters was excellent for their assessment of participants’ appraisal of the significance of article results (K = 0.83), and good for assessment of the formulation of a diagnostic question (K = 0.76), PubMed/Medline (K = 0.71) or guideline (K = 0.67) search, and of appraisal of methodological validity of articles (K = 0.68).ConclusionsOur tool allows an in-depth analysis of EBP skills, thus could supplement existing instruments focused on knowledge or specific EBP step. The actual usefulness of such tools to improve care and population health remains to be evaluated.

Emergency Medicine Education and Research in Nepal: Challenges and Opportunities

Emergency medicine (EM) is a young but prestigious medical discipline worldwide.1 However, in Nepal, it is in preliminary phase.2 EM is not only restricted to urban emergency departments but also a multifaceted discipline.3 Several EM training modules are currently practiced fragmented with different curriculum and duration.4,5 Pre-hospital emergency medical services (EMS), hospitals, trauma centres, and public health are working in silos and most of them devoid of proper emergency facility.2 This brought us to the realization of an urgent need of bringing all the stakeholders together in a symposium like this.
 The symposium was arranged into four different sessions as listed below:
 
 To familiarize with the history and current state of EM from Global Emergency Medicine perspective.
 To highlight the different clinical experiences and advancements in EM in Nepal.
 To emphasize the importance and possibilities in EM education and research in Nepal.
 To discuss the roadmap to develop and establish EM as a recognized medical speciality in Nepal.
 
 The overall objectives of the symposium were to discuss the challenges faced by current Emergency Medicine providers and identify the opportunities for the future development and recognition in Nepal.
 The most important current task for Nepal’s emergency physicians of advocating for policies, programs, and funding to support further development of the specialty was realized. Rural and urban emergency service providers from academic and non-academic institutions, governmental/non-governmental organizations and international medical institutions attended the symposium. General Practice (GP) residents, medical officers, medical students, interns and paramedics were among active participants.

Perception versus reality: elucidating motivation and expectations of current fellowship council minimally invasive surgery fellows.

The aim of our study is to determine minimally invasive trainee motivation and expectations for their respective fellowship. Minimally Invasive Surgery (MIS) is one of the largest non-ACGME post-residency training pathways though little is known concerning the process of residents choosing MIS as a fellowship focus. As general surgery evolves, it is important to understand resident motivation in order to better prepare them for a surgical career. A survey invitation was sent to current trainees in the Minimally Invasive and related pathways through the Fellowship Council. The participants were asked to complete a web-based questionnaire detailing demographics, experiences preparing for fellowship, motivation in choosing an MIS fellowship, and expectations for surgical practice after fellowship. Sixty-seven MIS trainees responded to the survey out of 151 invitations (44%). The Fellowship Council website, mentors, and other fellows were cited as the most helpful source of information when applying for fellowship. Trainees were active in surgical societies as residents, with 78% having membership in the ACS and 60% in SAGES. When deciding to pursue MIS as a fellowship, the desire to increase laparoscopic training was the most important factor. The least important reasons cited were lack of laparoendoscopic training in residency and desire to learn robotic surgery. The majority of trainees believed their laparoscopic skill set was above that of their residency cohort (81%). The most desired post-fellowship employment model is hospital employee (46%) followed by private practice (27%). Most fellows plan on marketing themselves as MIS surgeons (90%) or General Surgeons (78%) when in practice. Residents who choose MIS as a fellowship have a strong exposure to laparoscopy and want to become specialists in their field. Mentors and surgical societies including ACS and SAGES play a vital role in preparing residents for fellowship and practice.

Abstract WP401: What Goes Around Comes Around: The Impact of Adding the Stroke Coordinator to Daily Rounds

Background: Multidisciplinary rounds have classically consisted of the attending, advanced practice providers, residents and fellows. For most large comprehensive stroke centers (CSC), the stroke coordinator role is not intimately engaged in these teaching rounds thus disconnected from the team during focused discussions on care management. In order to advance the quality and comprehensiveness of patient care the stroke coordinator was added to clinical rounds. Purpose: We propose allocating dedicated time to the stroke coordinator role for daily morning rounds with the stroke neurologist and team to increase compliance with quality care measures. Method: Following the core and care team measures required for certification of a comprehensive Stroke Center, the stroke program manager selected three targets for improvement from the provider team and collected retrospective and prospective data for comparison once implementing the role change. Baseline patient data (collected the year prior to initiation of the stroke coordinator at rounds, was compared to patient safety and quality variables after initiation of rounds. Results: The action of provider intervention triggered by scoring threshold in depression screening improved a yearly mean of 52% to 82%. The documentation of rTPA compliance went from a mean of 0% to 94%, The timely documentation of NIHSS as a severity score in acute ischemic stroke rose from a mean of 90% to 93% Conclusions: Each of the metrics reflect Improvement over time. During rounds the coordinator would actively discuss gaps in care including documentation of eligibility for TPA, team action on patients with high scores on depression screening and timely documentation of NIHSS. In addition, the stroke coordinator reflected feeling more like a team member and not an "outsider looking in". It can further be hypothesized that the team remained very receptive to suggestions in the care of stroke patients, as the stroke coordinator was well known to them and available for questions and discussion each day. The closer role of stroke coordinator is still ongoing due to its success.

Improving the image of psychiatry and psychiatrists: Results of a French national survey

BackgroundA decline of recruitment into psychiatry has been observed in low and high income countries. It has been suggested that the negative image of psychiatrists may play a role in this issue. Thus, one mission of the AFFEP (French National Association of Psychiatric Trainees) is to improve the image of psychiatry and to fight the related stigma.ObjectiveThis study aimed to highlight prejudices about psychiatric trainees.MethodsThis study is a descriptive cross-sectional survey conducted toward French residents specialized in psychiatry, anaesthesia, neurology, paediatrics, orthopaedic surgery or general medicine, between June and July 2013. An invitation email and an anonymous web-based auto-questionnaire were sent to the residents through their national associations mailing-lists. AFFEP local representatives also disseminated the survey to psychiatric trainees. The survey, hosted by the MODALISA software was made of four sections:– sociodemographic data;– school records;– prejudices from the other specialities towards psychiatric trainees;– professional identity.A statistical analysis was performed using MODALISA in order to describe and compare the data.ResultsOne thousand two hundred and ninty-six trainees participated in the study, including 760 psychiatrists, 253 residents in general practice, 123 anaesthetists, 60 neurologists, 57 paediatrics and 43 orthopaedics. 56% of the participants think that psychiatrists are odd trainees with previous history of mental health, 42% consider they are not doctors, and 37% describe them as lazy persons. Comparisons of personal history cases did not show any significant difference between psychiatric trainees and non-psychiatric trainees (12.6% vs. 9,3%, P = 0.074). Besides, the results show that almost all psychiatric trainees (95%) are happy becoming a psychiatrist.ConclusionsThese results suggest that prejudices about psychiatric trainees exist and are wrong. They will allow to work on the image of psychiatry and psychiatrists, to communicate about the great satisfaction of the psychiatric trainees and to break down old “cliché”.

Pediatric news.

Pediatric news.

Partnering With Residents for Evidence-Based Practice

Medical residents are a distinct group of health sciences library users that need detailed instruction in literature searching. Core residency competencies from the Accreditation Council for Graduate Medical Education require that all residents be competent in finding, critically appraising, and incorporating the latest clinical evidence into their daily practice with patients. With the collaboration of the library and a clinical department of pediatrics, a program was developed that teaches residents the basic elements of EBM searching and then reinforces this learning over the course of three years.

Residents provide feedback to their clinical teachers: Reflection through dialogue

Background: Physicians play a crucial role in teaching residents in clinical practice. Feedback on their teaching performance to support this role needs to be provided in a carefully designed and constructive way.Aims: We investigated an evaluation system for evaluating supervisors and providing formative feedback.Method: In a design based research approach, the ‘Evaluation and Feedback For Effective Clinical Teaching System’ (EFFECT-S) was examined by conducting semi-structured interviews with residents and supervisors of five departments in five different hospitals about feedback conditions, acceptance and its effects. Interviews were analysed by three researchers, using qualitative research software (ATLAS-Ti).Results: Principles and characteristics of the design are supported by evaluating EFFECT-S. All steps of EFFECT-S appear necessary. A new step, team evaluation, was added. Supervisors perceived the feedback as instructive; residents felt capable of providing feedback. Creating safety and honesty require different actions for residents and supervisors. Outcomes include awareness of clinical teaching, residents learning feedback skills, reduced hierarchy and an improved learning climate.Conclusions: EFFECT-S appeared useful for evaluating supervisors. Key mechanism was creating a safe environment for residents to provide honest and constructive feedback. Residents learned providing feedback, being part of the CanMEDS and ACGME competencies of medical education programmes.

Integrating Systems-Based Practice, Community Psychiatry, and Recovery Into Residency Training

Behavioral health services involving multiple systems of care are increasingly being provided in community as well as hospital settings. Residents therefore should be familiar with multiple systems and the role of the psychiatrist in these systems. The authors describe a curriculum incorporating principles of systems-based practice (SBP), community psychiatry, and recovery. This curriculum was designed to include lectures, clinical rotations, specialized written/oral presentations, and supervision focused on SBP and recovery principles. Residents also participate in home and site visits for further immersion into the multiple systems that their patients have to navigate. The essential elements of this curriculum are the 1) consistent review and emphasis on the four researched-based SBP roles of the psychiatrist; 2) recovery principles of person-centered care and shared decision-making; 3) requirement that residents interact with patients in community and home settings; 4) integration of didactic courses and clinical rotations; and 5) focus on the supervisor/supervisee relationship.

Clinical decision-making by the emergency department resident physicians for critically ill patients

The application of main methodologies for clinical decision-making by residents in emergency medical practice was assessed, and issues in this area were investigated. The treatments provided to 2 611 critical patients by the Emergency Department of Peking Union Medical College Hospital were analyzed by independent investigators who evaluated the main clinical decision-making processes applied by the hospital residents. The application of decision-making strategies by PG1 and PG3 groups, which means the residents in first year and the third year, were compared. The patients were treated according to pattern recognition (43.0%), hypothetico-deductive reasoning (23.4%), event-driven models (19.3%), and rule-using algorithms (5.9%). A significant difference was found between PG1 and PG3 groups (χ(2)= 498.01, P < 0.001). Pattern recognition and hypothetic-deductive methods were the most common techniques applied by emergency physicians in evaluating critically ill patients. The decision-making processes applied by junior and senior residents were significantly different, although neither group adequately applied rule-using algorithms. Inclusion of clinical decision-making in medical curricula is needed to improve decision-making in critical care.

A Consensus Curriculum for Laboratory Management Training for Pathology Residents

Through the combined efforts of the American Pathology Foundation (APF), the American Society for Clinical Pathology (ASCP), and the Program Directors Section (PRODS) of the Association of Pathology Chairs (APC), a needs assessment was performed via a survey on the PRODS listserv, workshops at the APC/PRODS annual meetings in 2009 and 2010, and a Work Group of representatives of APF, ASCP, and PRODS. Residency program needs and resource constraints common to training pathology residents in practice and laboratory management were identified. In addition, a consensus curriculum for management training was created to serve as a resource for residency training program directors and others. The curriculum was converted into a "wiki" design tool for use by program directors, residents, and faculty.

Resident Participation in Housing Regeneration in France

The involvement of local residents in housing regeneration policy and practice has become a ‘new orthodoxy’ across Western Europe. This paper considers the experience of France, a country noted for its history of ‘third sector’ activism and innovative practice in, for example, neighbourhood management. It is argued here that—notwithstanding three decades of central government rhetoric and exhortation—there remain few examples of genuine involvement of residents in formal regeneration decision-making processes at a local level in France (especially in respect of strategic issues). There exists a ‘participation deficit’. This paper explores this phenomenon empirically through case studies of housing regeneration in Lyon, Marseille and Mantes la Jolie. It also seeks to explain the ‘participation deficit’, drawing a distinction between those factors that are pan-European and those that are particularly French, not least the apparent resilience of representative democracy.

Systematic Review: Association of Shift Length, Protected Sleep Time, and Night Float With Patient Care, Residents' Health, and Education

The Accreditation Council for Graduate Medical Education's new duty-hour standards limit interns' shifts to 16 hours and night float to 6 consecutive nights. Protected sleep time (that is, "nap") is strongly encouraged. As duty-hour reforms are implemented, examination of the quality and outcomes of the relevant literature is important. To systematically review the literature examining shift length, protected sleep time, and night float. MEDLINE, PREMEDLINE, and EMBASE from January 1989 through May 2010. Studies examined the associations of shift length, protected sleep time, or night float with patient care, resident health, and education outcomes among residents in practice settings. Study quality was measured by using the validated Medical Education Research Study Quality Instrument and the U.S. Preventive Services Task Force criteria. Two investigators independently rated study quality, and interrater agreement was calculated. Sixty-four studies met inclusion criteria. Most studies used single-group cross-sectional (19 studies [29.7%]) or pre-post (41 studies [64.1%]) designs, and 4 (6.3%) were randomized, controlled trials. Five studies (7.8%) were multi-institutional. Twenty-four of 33 (72.7%) studies examining shift length reported that shorter shifts were associated with decreased medical errors, motor vehicle crashes, and percutaneous injuries. Only 2 studies assessed protected sleep time and reported that residents' adherence to naps was poor. Night floats described in 33 studies involved 5 to 7 consecutive nights. Most studies used single-institution, observational designs. Publication bias is likely but difficult to assess in this methodologically weak and heterogeneous body of evidence. For the limited outcomes measured, most studies supported reducing shift length but did not adequately address the optimal shift duration. Studies had numerous methodological limitations and unclear generalizability for most outcomes. Specific recommendations about shift length, protected sleep time, and night float should acknowledge the limitations of this evidence. Accreditation Council for Graduate Medical Education.