Resident Members Research Articles

Should All Duty Hours Be the Same? Results of a National Survey of Surgical Trainees

Although duty hours regulations (DHR) were introduced as a measure to improve patient safety and graduate medical education, new evidence suggests that the opposite might be happening. This study was designed to assess surgery resident perceptions of the impact that DHR have had on their education, the number of hours they believed would be ideal for their training, and to evaluate the effect of seniority on these opinions. An Internet-based survey was electronically distributed to all Resident and Associate members of the American College of Surgeons. Of 599 respondents, 247 (41%) believed that DHR were an important barrier to their education, and 266 (44%) believed that the ideal work week should have 80 to 100 hours. These two opinions were highly correlated, and were increasingly voiced with increased resident experience. Senior residents were more likely to view DHR as an important barrier to their education whether or not they were general surgery residents or were trained in small, medium, or large programs. A large subset of surgery residents, particularly senior residents, considered DHR an important barrier to their education and expressed a desire to work longer hours than restrictions allow. These findings suggest that strict and uniform DHR do not allow for optimal training of residents at different levels who have disparate educational goals and needs. Introducing some flexibility into senior residents' limitations should be considered.

Programs Help Residents Cope With Patient's Suicide

Programs Help Residents Cope With Patient's Suicide

P02-249 Publishing as resident education: The ASCP model psychopharmacology curriculum

The ACGME has defined six core competencies for residents, including medical knowledge, practice-based learning and improvement, professionalism, and interpersonal and communication skills. While clinical learning and experience contribute to improving interpersonal skills, professionalism, and general medical knowledge, residents and training programs struggle with educational models that help address more rigorous education in evidence-based medicine and scholarly projects. In this regard, we developed a collaborative academic project for a resident and faculty member that exemplifies these ACGME requirements in a practical and purposeful manner. This project was aimed to enhance the resident's psychopharmacology knowledge, learn evidence based child psychiatry, and develop writing and editing skills; a means to improve clinical as well as academic abilities.One senior faculty member and one child psychiatry resident were invited to become section editors for the child and adolescent section of the American Society of Clinical Psychopharmacology Model Psychopharmacology Curriculum for psychiatry residents. Authors from various university programs nationally, prepared or revised lectures based on their expertise and areas of interest. The authors were provided with as much support and assistance as they desired from the section editors. The resident author/editor met in person with the faculty to plan the project and routinely throughout the process, with frequent e-mail communication throughout the writing and editorial work. After submission of lectures, the section was reviewed and revised by the resident and faculty editors, and submitted for publication. This mentorship experience with psychopharmacology curriculum is an exciting tool that will continue through biennial revisions.

Results of a National Survey of Surgical Resident Interest in International Experience, Electives, and Volunteerism

Data are emerging about the essential nature of sustainable global surgical care and interest among North American surgeons. Currently, there is no formal mechanism for US surgical residents to participate in international training opportunities. A small, single-institution survey found that general surgery residents at New York University are highly motivated to pursue international training. But little research has addressed the attitudes of North American residents about international training. The goal of this study was to acquire a broader understanding of surgical resident interest in international training. A structured questionnaire was administered anonymously and voluntarily to all American College of Surgeons resident members. Seven hundred twenty-four residents completed surveys. Ninety-four percent of respondents planned careers in general surgery. Ninety-two percent of respondents were interested in an international elective, and 82% would prioritize the experience over all or some other electives. Fifty-four percent and 73% of respondents would be willing to use vacation and participate even if cases were not counted for graduation requirements, respectively. Educational indebtedness was high among respondents (50% of respondents carried >or=$100,000 debt). Despite debt, 85% of respondents plan to volunteer while in practice. The most frequent barriers identified by respondents were financial (61%) and logistic (66%). American College of Surgeons resident members are highly motivated to acquire international training experience, with many planning to volunteer in the future. A consensus among stakeholders in North American surgical education is needed to further explore international training within surgical residency.

Critical issues in vascular surgery: Education in Brazil

Vascular surgery practice and education vary widely across the globe. In Brazil, the largest and most populated country of South America, vascular surgery is an independent specialty, with >3000 practicing specialists. Vascular surgery education in Brazil consists of 6 years of medical school, followed by a 4-year residency in vascular surgery. Endovascular surgery training is provided by part-time mini-fellowships after a residency program has been completed. The author of this report, who represents the Sociedade Brasileira de Angiologia e de Cirurgia Vascular (SBACV) or Brazilian Society of Angiology and Vascular Surgery, presents the critical issues in vascular surgery education in Brazil. An informal survey was conducted among residency program directors and members of the SBACV National Board to identify the critical issues in vascular surgical education in Brazil. The 25 responders pointed to two issues as the most critical. The first is funding for vascular surgical education. Currently, 73 vascular residency programs are accredited, with 142 first-year positions and 288 residents in training. Vascular surgery residents are paid a meager stipend, but instructors receive no pay. Endovascular fellows have to pay for their training. This has led to endovascular training being financed by the industry, despite the potential conflicts of interest created by this situation. The second critical issue is endovascular surgery training. The vascular surgical community in Brazil faces the huge task of how to offer training in endovascular techniques to the 140 or so young vascular surgeons coming out of residency programs every year, as well as how to teach endovascular techniques to several hundred certified vascular surgeons already in practice. Funding vascular surgery educational programs and training surgeons in the new endovascular techniques are the critical issues faced by vascular surgical educators in Brazil.

Assessment of Genetic Divergence between Lacustrine and Riverine Smallmouth Bass in Lake Erie and Four Tributaries

Diverse freshwater lacustrine fishes enter tributaries to spawn, but resident riverine members may also occupy these same tributaries. While mark-recapture and biotelemetry studies suggest reproductive isolation between such populations, the assertion has rarely been tested genetically. To address this question, Micropterus dolomieu (Smallmouth Bass) from the southern shoreline of Lake Erie were compared genetically to bass in adjacent tributaries. Results from mitochondrial DNA sequences support the hypothesis that lacustrine and riverine populations segregate. Furthermore, divergences among tributary populations were often as large as those divergences between lacustrine and riverine bass, suggesting that each river population may become genetically distinct.

The relationship between members' perceptions of their neighborhood organization and their involvement and perceived benefits from participation

AbstractA major resource of small voluntary neighborhood organizations is their members, who give their time and energy to the organization to improve their community. In recent years, there has been a revitalization of strategies that focus on engaging residents to volunteer for neighborhood‐based organizations. The current study was guided by organizational empowerment theory and explored the relationship between resident members' perceptions of their neighborhood organization and their level of involvement and perceived personal and collective benefits from participation. The results demonstrated that members' perceptions of their neighborhood organizations' characteristics and effectiveness were more related to their perceived benefits from involvement than their level of participation. Members' perceptions of their neighborhood organizations' effectiveness, particularly the ability to make tangible community improvements, were the most related to their perceived benefits, including their ability to influence government policies, knowledge and skills in neighborhood and community development, and sense of community. Implications for research and practice are also discussed. © 2008 Wiley Periodicals, Inc.

Accreditation Council for Graduate Medical Education Initiatives Improve the Education of Cardiology Fellows

Training cardiovascular specialists in the present era is highly complex. The list of topics and procedures continues to grow; the required knowledge base for providing cutting-edge clinical care and passing examinations is increasing; and technologies and research are advancing rapidly. Cardiology fellows face a changing template of demands from training programs, governing bodies, professional societies, and potential employers. At the completion of the cardiovascular fellowship training process, it is imperative that graduates are highly capable and complete physicians. Certainly, strict accreditation and adjudication of the fellowship training process are necessary to ensure the highest-quality training of cardiologists and other healthcare providers. Response by Bashore and Wang p 531 Established in 1981, the Accreditation Council for Graduate Medical Education (ACGME) is a private, not-for-profit organization that evaluates, accredits, and oversees >100 000 postgraduate medical trainees in nearly 8400 training programs representing 126 specialties and subspecialties in the United States. Cardiovascular fellowship programs represent a large portion of these trainees. There are presently 177 general cardiology fellowship programs with 2362 filled positions. In addition, there are 95 electrophysiology and 130 interventional subspecialty cardiology fellowship programs with 173 and 290 filled spots, respectively. The member organizations of ACGME include the American Board of Medical Specialties, American Hospital Association, American Medical Association, Association of American Medical Colleges, and the Council of Medical Specialty Societies. Each member organization appoints 4 members to the Board of Directors, which also includes 2 resident members, 3 public directors, the chair of the Council of Review Committee Chairs, and a federal representative. The ACGME has 28 review committees: 1 committee for each of the 26 specialties, 1 for the 1-year transitional-year program, and 1 for institutional review. Before the ACGME, postgraduate medical training was managed by the Liaison Committee for Graduate Medical Education, which was established in 1972. The …

Gravidez na adolescência e uso freqüente de álcool e drogas no contexto familiar

To assess individual and family factors associated to teenage pregnancy, including frequent use of alcohol and illicit drugs by family members. Case-control study conducted with a sample of 408 sexually active female adolescents (aged 13-17 years) in school from the city of Marília (Southeastern Brazil) in 2003-2004. Cases consisted of 100 primigravid teenagers assisted in prenatal care programs in health units. Controls were 308 nulligravid students from state public schools. Standardized instruments identified demographic and educational factors, contraceptive behavior, mental health problems, and family characteristics. Statistical analysis included chi-square tests and logistic regression models. Low paternal education (p=0.01), lack of information on sexuality and fertilization (p=0.001) and the use of illicit drugs by a resident family member (p=0.006) were independent risk factors. Family income per capita and asking the partner to use a condom were confounders. The frequent use of illicit drugs by a resident family member is a factor strongly associated to teenage pregnancy, regardless of other risk factors. The expectation of going to college constitutes a protective factor, mainly in the presence of low maternal education.

Discussing preferences for cardiopulmonary resuscitation: What do resident physicians and their hospitalized patients think was decided?

Objective To explore the ways in which seriously ill hospitalized patients, their family members and physicians interpret the discussion of the patient's preferences for cardiopulmonary resuscitation (CPR). Methods Resident physicians, their patients, and family members were interviewed following a discussion regarding preferences for CPR. We sought the participants’ perceptions of the resulting decision, examined how often these interpretations differed, and explored the communicative factors underlying discrepancies when they occurred. Results Fifty-six interviews with 28 matched dyads were completed. In six dyads (21%), the participants reported differing results of the discussion. Two patients had orders to limit their care based on the physician's interpretation of their discussion. Another two patients who did not want resuscitation lacked a DNR order. Two patients did not recall having the conversation. These discrepancies could be attributed to the physician misconstruing the patient's wishes, interference of a family member, and fluctuating preferences. Conclusions Discrepant interpretations of a DNR discussion occur with a concerning frequency between resident physicians and their hospitalized patients. Practice implications Educational efforts should focus on training physicians to clarify the language used in these discussions, remain vigilant about discerning the patient's preferences, and be aware that these preferences may be contextually fluid.

Practice-based research network as a research training model for community/ambulatory pharmacy residents

Objective: To describe our experience with a practice-based research training network (PBRTN) in a 1-year residency program.Setting: Ohio State University in Columbus from 1997 to 2007.Practice description: The program includes two accredited postgraduate year 1 residencies and one postgraduate year 2 residency. Seven residents, 11 preceptors, and three faculty members participated during the time frame discussed in this article. Practice settings included three community sites and three ambulatory sites.Practice innovation: The PBRTN includes a residency director, a research director, preceptor and resident members, and research faculty. The group works collaboratively to meet training goals. The PBRTN maintains a project timeline, foundational training, and structured research development, implementation, and presentation phases. Each resident submits five required research products: abstract, grant, poster, podium presentation, and research manuscript.Main outcome measures: Quantitative measures included the number of abstracts, grants, and peer-reviewed publications over two time periods, one before and one after a deliberate attempt to increase the research focus of the residencies. The ratio of research products to number of residents was used as a measure of productivity. Postresidency career choice and postresidency publications are reported.Results: Over a decade, the program has produced 37 graduates, 50 abstracts, 15 grants, and 12 peer-reviewed publications. The publication-to-resident ratio increased from 0.25 in the pre-emphasis period of 1997–2001 to 0.56 in 2002–2007, after the research focus was intensified. Of graduates, 38% are in faculty positions, with 48 postresidency publications.Conclusion: Use of a PBRTN has successfully provided research training and improved research outcomes for the program. This model could be implemented in other residencies.

Failure to Communicate Complicates Aftermath of Patient Assaults

Failure to Communicate Complicates Aftermath of Patient Assaults

Receptor Activator of Nuclear Factor-κB Ligand-Induced Nuclear Factor of Activated T Cells (C1) Autoregulates Its Own Expression in Osteoclasts and Mediates the Up-Regulation of Tartrate-Resistant Acid Phosphatase

Osteoclasts are large multinucleated, bone-resorbing cells derived from hematopoietic precursors in response to receptor activator of nuclear factor-kappaB ligand (RANKL). RANKL activates a number of signal transduction pathways, which stimulate, in turn, a series of specific transcription factors that initiate the process of osteoclastogenesis. Perhaps the most important of these is nuclear factor of activated T cells cytoplasmic 1 (NFATc1), a DNA-binding protein that upon activation translocates to the nucleus where it stimulates transcription. The objective of this study was to explore the process whereby RANKL induces NFATc1 and to assess the role of this factor in the activation of an additional key osteoclast target gene. We found that whereas several NFAT members are expressed in RAW264.7 cells, soluble RANKL-induced up-regulation is limited to NFATc1 through a mechanism that is largely autoregulatory. Thus, although we observed the presence of resident NFAT members at the inducible Nfatc1 P1 promoter at very early times after RANKL treatment, a selective and time-dependent increase in the binding of up-regulated NFATc1 to Nfatc1 was observed beginning at 12 h. Several additional factors that are activated by soluble RANKL and also participate in NFATc1 up-regulation include c-Fos and RNA polymerase II. Chromatin immunoprecipitation analysis also revealed a similar, time-dependent accumulation of NFATc1 at multiple sites on the Acp5 promoter, thereby highlighting a central contributing role for NFATc1 in the activation of this gene as well. Our studies provide additional molecular detail regarding the mechanisms through which RANKL induces NFATc1 in osteoclast precursors and into mechanisms by which NFATc1 induces the expression of at least one gene responsible for the osteoclast phenotype.

Survey of Implant Training in Oral and Maxillofacial Surgery Residency Programs in the United States

The status of implant training in US oral and maxillofacial surgery programs has been reported previously based on data gathered from residency program directors. Since the time of those earlier surveys, however, many new technological and surgical developments have occurred in implant therapy. The purpose of this study was to evaluate the current status of implant training in oral and maxillofacial surgery residency programs in the United States. E-mail invitations were sent to 559 resident members of the American Association of Oral and Maxillofacial Surgeons asking them to participate in an online survey between January 23 and February 6, 2006. Each survey invitation was assigned a unique URL so that each resident could respond only once to the survey during the specified interval. The survey contained 17 questions assessing various aspects of training in implant placement. A total of 201 completed surveys were received by the specified deadline. The participation rate was roughly similar in residents of 4-year certificate programs and those of 6-year MD combined programs (56% vs 44%). In total, 48% of residents reported receiving less than 20 hours of didactic training in implantology per year, and 57% reported using 2 or fewer implant systems. Some 57% estimated that they would place fewer than 20 implants in the coming year, whereas 52% reported that they would place more than 50 implants during their residency. Interestingly, 98% of the residents reported that implant dentistry would be an important part of their practice, but 28% felt inadequately prepared by residency training. There is a broad range of experience in implant training in US oral and maxillofacial surgery residency programs. Almost all oral and maxillofacial surgery residents feel that implant dentistry will be an important part of their practice; however, many residents feel that their training during residency has not adequately prepared them for implant surgery. Our findings identify a potential need for additional training in implant surgery during oral and maxillofacial surgery residency.

Seasonal timing of the Royal College examination in general paediatrics: A survey of residents' preferences

Currently, the general paediatrics examination administered by the Royal College of Physicians and Surgeons of Canada is offered annually in the spring. Controversy exists regarding its seasonal timing. Assessing the views of residents anticipating the examination is relevant to examination administrators. To determine paediatric residents' opinions regarding the timing of the general paediatrics examination. A survey was electronically distributed to all resident members of the Canadian Paediatric Society with an e-mail reminder after one week. Responses were collected independently, forwarded to the authors and summarized using descriptive statistics. Multinomial regression identified predictors of examination preference and estimated prediction value. One hundred sixty-four of 585 surveys (28%) were returned. Common preferences included 'spring of 4th year' (42%) and 'fall of 4th year' (22%). Respondents intending four years of general paediatrics demonstrated a 55% preference for 'spring of 4th year' and 11% for 'fall of 4th year', compared with preferences of 29% and 34%, respectively, for respondents intending three years of general paediatrics followed by subspecialty training (P<0.001). This was confirmed by multinomial regression (OR 2.49; P<0.0001). Increasing training year was associated with increasing support for examination in the fall relative to the spring of 4th year (OR 1.37; P=0.019). Residents' preferences for the timing of the examination are varied, with 'spring of 4th year' being most preferred. Residents demonstrated stronger support for 'fall of 4th year' with increasing years of training, and if planning to pursue subspecialty training after three years of general paediatrics.

THE ROLE OF THE JOURNAL CLUB IN NEUROSURGICAL TRAINING

The journal club (JC) plays a traditional role in resident education. However, little has been written on its current role in neurosurgical training programs. Our goal was to determine resident perception of JCs, factors that make JCs successful, and identifying variables for improving JCs. We electronically surveyed all resident members of the Congress of Neurological Surgeons to determine the format, prevalence, content, and efficacy of neurosurgical JCs. Eighty-five percent of the respondents stated that their residency programs have a JC. The perceived primary goal of JCs is for keeping current with the literature and the dissemination of information. Most JCs meet for 1 hour during the week on a monthly basis and review one to three articles. Residents generally present the articles, which are typically original research articles selected by either the faculty or the residents. Most residents consider JCs of good educational value with positive effects on reading habits. Resident and faculty attendance are important variables to a successful JC. Although the majority of residents have minimal background training in epidemiology, biostatistics, or research, fewer than one-third of the training programs provide any type of supplemental sessions or handouts regarding such methods. JCs have a high perceived value by neurosurgical residents and should be maintained at all neurosurgical residency training programs. Key factors to a successful JC include faculty and resident attendance. Additional studies are needed to assess optimal JC formats and the possible utilization of supplemental educational tools.

RESIDENT AND HONORED GUEST LUNCHEON Complimentary to CNS Resident Members!

RESIDENT AND HONORED GUEST LUNCHEON Complimentary to CNS Resident Members!

Students unite to create State of the Planet course

SIR — Ours is a world in crisis. We are despoiling our habitat, outstripping our resources and failing to provide an acceptable living standard for much of the world’s population. Although academic institutions are equipped to help remedy these problems by informing the leaders of tomorrow, they often fail to do so. Increasing pressure for specialization has led universities to trade breadth for depth in curricula, thereby depriving students of an understanding of complex, interconnected global issues. For example, solutions to our energy crisis span economics, engineering and politics, yet the typical student is exposed to only a portion of this spectrum. Here, we propose a first step in addressing such shortcomings. We, the undersigned graduate students, have created a campuswide ‘State of the Planet’ course at Cornell University under the mentorship of faculty members Tom Eisner and Mary Lou Zeeman (see www.nbb.cornell.edu/ neurobio/BioNB321). Our goal is threefold: to improve understanding of complex issues; to add global context to disciplinary education; and to motivate action and involvement. To this end, we recruited experts, mostly resident faculty members and community leaders, to address the challenges we agreed were paramount. Administrative support was quick to materialize, as was a pool of enthusiastic participants. We launched the course in January 2007, after campus-wide publicity highlighting its multidisciplinary nature. Our 250 current students come from 45 different majors ranging broadly across the humanities and basic and applied sciences. In lectures, experts familiar with our most pressing global problems emphasize how solutions span disciplines. Students participate in discussion groups led by graduate assistants, where they not only build on ideas presented in lectures, but also set up projects aimed at solving problems. Mid-semester student evaluations have been overwhelmingly positive, with 93% saying that the course has changed their views on education, career plans and lifestyle, and 95% believing that their peers should also take this course. Comments include: “This course has influenced my perspectives on almost everything, from the food I eat to how long I leave my computer on” and “The course demonstrates how many different skills and backgrounds can help shape policy that is instrumental for the planet.” We are continuing to expand our course in the hope that it will become a campus-wide requirement. Our vision is that other universities will adopt similar courses as a curriculum component for all students. We extend an open invitation to like-minded people at other institutions to join us, and others launching parallel efforts, in what we believe will be a modest but fundamental change to university education. We maintain the optimistic belief that, given the right information, people will change their habits and their world. But the burden is on us, as educators, to motivate this change. Krystal L. Rypien, Jill Anderson, Jason Andras, Rulon W. Clark, Gretchen A. Gerrish, James T. Mandel, Marie L. Nydam, Daniel K. Riskin Department of Ecology and Evolutionary Biology, Cornell University, Ithaca, New York 14853, USA

Height and Shape of the Skull Base as Risk Factors for Skull Base Penetration during Endoscopic Sinus Surgery

Computed tomography (CT) and magnetic resonance imaging have identified several risk factors for life-threatening complications of skull base penetration during endoscopic sinus surgery (ESS). We compared these risk factors between groups of patients with and without penetration. We performed a retrospective review of direct coronal paranasal sinus CT scans. Using preoperative CT scans of 100 patients without and 7 patients with penetration, we classified height into 4 groups and contour into 2 groups. The frequencies of shape and height differences of the right and left halves of the skull base were calculated in each group. In 6 of the 7 patients who had skull base penetration, ESS was performed by a resident or junior staff member who had less than 3 years of experience with this technique. Shape asymmetry was seen in 4 of the 7 patients (57%) with penetration, which was a significantly higher rate than in patients without penetration (18 of 100; p = .032). The frequencies of a low skull base and a height difference were 15% and 28%, respectively. The most important risk factor for skull base penetration was the surgeon's inexperience. An asymmetry of shape of the right and left halves of the skull base was significantly related to inadvertent skull base penetration during ESS.

The Creation of God Loves a Grunt

INTRODUCTION I first met George L. Skypeck Jr (Sky) in the late seventies. His artwork and poetry was on exhibit as part of the “Forgotten Warrior Research Project” sponsored by the Disabled American Veterans (DAV) Center in Washington, DC. The project was created by Dr. John Wilson at Cleveland State University. I had met Dr. Wilson when I worked as a physician assistant (PA) in psychiatry at the University of Pittsburgh. He had invited me to attend a presentation of his research in traumatic stress and to see the art show that accompanied it. At the time, Sky was doing a number of DAV works and his poetry and art were used to illustrate Dr. Wilson’s study. This was the first Veterans Service Organization study focused on the post-traumatic stress aftermath of the Vietnam War. Sky and I soon became friends, and I often visited his studio located in a loft in the old Stars and Stripes building across the street from Union Station in Washington, DC. It was a great place to meet a number of the veterans who were just starting to become involved in Vietnam veteran issues. This group included Chuck Hagel, Ron Brock, Rusty Lindley, Jack Smith and others who were dedicated to helping veterans of the war in Vietnam. They would drop by the loft to chat about one of Sky’s new paintings. (Of course, we all gave Sky advice, which he mostly ignored but thanked us for anyway.) Sky is one of America’s most prominent military-historical commemorative artists. He is a combatwounded, disabled Vietnam veteran who rose from private to captain while serving two combat tours as a special warfare and senior intelligence advisor from 1967 until 1971. He is a decorated veteran, having won two Bronze Stars, the Purple Heart, three Air Medals, and numerous other awards. Sky has a special fondness for medics and created a piece of art titled “Nobody Forgets a Medic,” based on his being treated by an Army medic after being wounded the first of three times in Vietnam. Sky studied art at the Corcoran Museum in Washington and is a resident artist member of the famous Society of Illustrators of New York City. He has received numerous national and international art awards, including the prestigious Military Order of the Purple Heart’s George Washington Medallion of Merit. His last active duty assignment was to design and conduct John Wayne’s famous 1974 arrival into Feature Editor’s Note: