Resident Proficiency Research Articles

What do internal medicine residents know about rheumatology? A needs assessment for curriculum design.

We sought to determine if analyzing internal medicine (IM) resident performance on the in-training exam (ITE) might reveal curricular needs in rheumatology education beyond those intuitive to learners and educators from their perceptions and experience. We analyzed ITE scores of post-graduate year (PGY) 2 IM residents at our institution from 2010 to 2017. We sorted rheumatology-related educational objectives on the ITEs into 10 disease categories and calculated average scores. We then surveyed our IM residents' self-reported confidence and rheumatology educators' perceptions of IM resident proficiency in the 10 categories on a 10-point Likert scale. Finally, we tallied diagnoses in each category encountered by IM residents in rheumatology clinic. Pearson's correlation coefficients were calculated for the relationship between these data. The ITEs exposed 402 residents to 63 rheumatology-related educational objectives in the 10 categories; 24 objectives were categorized as "other." Survey respondents included 38 residents and 22 educators. There was no correlation between ITE scores in the 10 categories and resident confidence (r = - 0.226, p = 0.530), educator perception (r = - 0.274, p = 0.445), or diagnoses encountered (r = - 0.310, p = 0.383). There was a strong positive correlation between resident confidence and educator perception (r = 0.934, p < 0.001). ITE performance was low in crystalline arthritis and osteoarthritis despite high resident confidence, educator perception, and number of diagnoses seen. Our analysis of IM resident ITE performance identified curricular gaps not apparent in surveys of learner and educator perceptions or an assessment of learner experience. Key Points • In this study, we demonstrate how a systematic analysis of internal medicine resident performance on the in-training exam can identify important curricular gaps in rheumatology education that are not apparent in assessments of learners and educator perceptions or learner experience in rheumatology clinic. • In-training exam performance was low in crystalline arthritis and osteoarthritis despite high resident confidence, educator perception of proficiency, and number of diagnoses seen in these categories. • When rheumatology curricula for internal medicine residents are developed solely on the basis of learner and educator perceptions, common disorders traditionally considered "easy" may be overlooked.

Establishing an Orthopedic Program–Specific, Comprehensive Competency–Based Education Program

BackgroundCompetency-based education (CBE) seeks to determine resident proficiency in the knowledge, skills, and behaviors required for independent patient care. Multiple assessment instruments evaluate technical skills or direct patient care in the clinic setting, but there are few reports incorporating both within an orthopedic specialty rotation. This study reports a residency program's comprehensive CBE initiative using formative assessments in the clinic and operating room during a sports medicine rotation. Materials and methodsThe sports medicine rotation used validated formative assessments to evaluate resident performance during clinic encounters and program-defined surgical entrustable professional activities (EPAs). Junior resident (postgraduate year [PGY] 1-2) EPAs included basic knee/shoulder arthroscopic procedures. Senior resident (PYG 5) EPAs comprised anterior cruciate ligament reconstruction, biceps tenodesis, shoulder stabilization, and rotator cuff repair. Assessment scores were compared between individuals and PGY groups. ResultsSixty-six clinical skills (CS) and 106 surgical skills assessments were conducted for 22 residents in one academic year. Surgical skills assessments demonstrated significant differences between each PGY group (P < 0.01). All PGY2 and PGY5 residents achieved independence on the evaluated EPAs. PGY5s earned higher scores in CS assessments than the other classes (P < 0.01). PGY2 residents scored higher than PGY1s in 7 of 9 CS domains. CS independence was achieved by 21 of 22 residents by the end of the rotation. ConclusionsThe CBE program effectively quantified expected differences in resident performance by PGY for clinic and surgical assessments on a sports medicine rotation. Assessments built an environment where feedback was more structured and standardized, creating a culture to improve resident education.

Pediatric Airway Assessment Tool (PAAT): A Rating Tool to Assess Resident Proficiency in Simulated Pediatric Airway Skills Performance.

IntroductionThe Accreditation Council for Graduate Medical Education has identified the need for assessment of core skills for pediatric and emergency medicine residents, which includes pediatric airway management. Although there are standard courses for pediatric airway management, there is no validated tool to assess basic and advanced pediatric airway skills performance. Our objective was to develop a simulation-based tool for the formative assessment of resident pediatric airway skills performance that was concise, yet comprehensive, and to evaluate the evidence supporting the argument for the tool's validity.MethodsWe developed a pediatric airway assessment tool (PAAT) to assess six major domains of pediatric airway skills performance: basic airway maneuvers, airway adjuncts, bag-valve mask ventilation, advanced airway equipment preparation, direct laryngoscopy, and video laryngoscopy. This tool consisted of a 72-item pediatric airway skills assessment checklist to be used in simulation. We enrolled 12 subjects at four different training levels to participate. Assessment scores were rated by two independent expert raters.ResultsThe interrater agreement was high, ranging from 0.92 (adult bagging rate) to 1 (basic airway maneuvers). There was a significant trend of increasing scores with increased training level.DiscussionThe PAAT demonstrated excellent interrater reliability and provided evidence of the construct's validity. Although further validation of this assessment tool is needed, these results suggest that the PAAT may eventually be useful for assessment of resident proficiency in pediatric airway skills performance.

The effect of simulation training on resident proficiency in thoracolumbar pedicle screw placement using computer-assisted navigation.

Residency work-hour restrictions necessitate efficient, reproducible training. Simulation training for spinal instrumentation placement shows significant benefit to learners' subjective and objective proficiency. Cadaveric laboratories are most effective but have high cost and low availability. The authors' goal was to create a low-cost, efficient, reproducible spinal instrumentation placement simulation curriculum for neurosurgery and orthopedic surgery residents using synthetic models and 3D computer-assisted navigation, assessing subjective and objective proficiency with placement of thoracolumbar pedicle screws. Fifteen neurosurgery and orthopedic surgery residents participated in a standardized curriculum with lecture followed by two separate sessions of thoracolumbar pedicle screw placement in a synthetic spine model utilizing 3D computer-assisted navigation. Data were collected on premodule experience, time and accuracy of screw placement, and both subjective and objective ratings of proficiency. Fifteen of 15 residents demonstrated improvement in subjective (Physician Performance Diagnostic Inventory Scale [PPDIS]) and 14 in objective (Objective Structured Assessment of Technical Skills [OSATS]) measures of proficiency in navigated screw placement with utilization of this curriculum (p < 0.001 for both), regardless of the number of cases of previous experience using thoracolumbar spinal instrumentation. Fourteen of 15 residents demonstrated decreased time per screw placement from session 1 to session 2 (p = 0.006). There was no significant difference in pedicle screw accuracy between session 1 and session 2. A standardized curriculum using synthetic simulation training for navigated thoracolumbar pedicle screw placement results in significantly improved resident subjective and objective proficiency. Development of a nationwide competency curriculum using simulation training for spinal instrumentation placement should be considered for safe, efficient resident training.

Accuracy and usefulness in assessing proficiency of the observational clinical human reliability assessment checklist of the open inguinal hernia repair procedure: A cross-sectional study.

The Observational Clinical Human Reliability Assessment (OCHRA) can be used to score errors during surgical procedures. To construct an OCHRA-checklist, steps, substeps, and hazards of a surgical procedure need to be defined. A step-by-step framework was developed to segment surgical procedures into steps, substeps, and hazards. The first aim of this study was to investigate if the step-by-step framework could be used to construct an accurate Lichtenstein open inguinal hernia repair (LOIHR) stepwise description. The second aim was to investigate if the OCHRA-checklist based on this stepwise description was accurate and useful for surgical training and assessment. Ten expert surgeons rated statements regarding the accuracy of the LOIHR stepwise description, the accuracy, and the usefulness of the LOIHR OCHRA-checklist (eight, seven, and six statements, respectively) using a 5-point Likert scale. One-sample Wilcoxon signed-rank test was used to compare the outcomes to the neutral value of 3. The accuracy of the stepwise description and the accuracy and usefulness of the OCHRA-checklist were rated statistically significantly higher than the neutral value of 3 (median 4.75 [5.00-4.00] with p=.009, median 5.00 [5.00-4.00] with p=.012, median 4.00 [5.00-4.00] with p=.047, respectively). The experts rated the OCHRA-checklist to be useful for the training (5.00 [5.00-4.00], p=.009), and assessment (4.50 [5.00-4.00], p=.010) of surgical residents. This preliminary study showed that the stepwise LOIHR description constructed using the step-by-step framework was found to be accurate. The LOIHR OCHRA-checklist developed using the stepwise description was also accurate, and particularly useful for the training and assessment of proficiency of surgical residents.

51. INCREASING PEDIATRIC RESIDENT LOGGING OF PROCEDURES THROUGH DEVELOPMENT OF A MOBILE APP

Background Learning to perform common medical procedures is one of many elements of Pediatric residency training. In our program, we have observed great proficiency of residents’ procedural skills, but an unfortunate deficiency in completion of procedural logs. Incomplete procedure logs make it difficult to ensure each resident is receiving adequate procedural skills training and to certify competency to future employers. At our institution, the biggest barrier to timely completion of procedure logs was a cumbersome, tedious, and time-consuming logging system (New Innovations). Using QI methodology and technology, we aimed to improve the procedure logging process. Aim Statement To increase the number of procedures logged per resident, from 14 per year to 20 per year (1.66 per month), by March 31, 2020. Interventions We used the model for improvement to perform multiple PDSA cycles to create a simpler, quicker, and more efficient process for logging procedures. After analyzing failures in our legacy process, we tested multiple commercially available apps and web-based platforms as potential replacements. Based on our learning, we opted to design and create our own “NYU Peds App”. The app was iteratively tested using small groups of Pediatric residents, allowing us to modify the design and maximize efficiency, prior to implementation across the full program. Following the launch of the app, the program created a new policy, specifying the number of procedures to be completed each year. Results Since its launch, 1192 procedures have been logged using the NYU Peds App. The number of procedures logged per resident per month has increased from 0.9 to 3.2 (see Figure 1). Further, we have improved resident satisfaction. On an anonymous survey, the percent of residents who strongly agree that the logging system is easy to use significantly increased from 3% (New Innovations) to 82% (NYU Peds App). Conclusions and Next Steps We were able to successfully increase the number of procedures logged by our residents. The main driver of the improvement was implementation of a mobile app that is easy, fast, and usable at the time of care.

Improving point-of-care ultrasound proficiency of primary care residents through a formal, faculty-led training course

Improving point-of-care ultrasound proficiency of primary care residents through a formal, faculty-led training course

Effect of Prior Formal Education on Successful Thoracic Epidural Placement By Anesthesia Residents

Catheter placement for thoracic epidural analgesia (TEA) is technically challenging; however, methods for teaching this technique to anesthesia residents have not been well-studied. The present study aimed to determine optimal teaching methods for proficient TEA catheter placement by comparing video-based formal resident education with traditional bedside training by attending physicians. Prospective, randomized study. Large academic hospital, single institution. The study comprised 76 postgraduate year 3 and 4 anesthesiology residents (38 intervention, 38 control). Formal education included an instructional video on proper TEA technique. Measures of proficiency in TEA catheter placement included the time needed to complete the procedure successfully and the success of placement as indicated by patient confirmation. Residents who received formal video instruction had similar success in catheter placement and similar procedure times compared with the traditionally trained residents. The overall success rate was 99.2%, with faculty intervention required in only 17% of cases. More experienced residents (ie, having placed more epidural catheters) were faster at TEA catheter placement. Formal video education for TEA catheter placement provided no additional improvement of resident proficiency compared with traditional training at a high-volume academic center. The success rate was very high in this group of residents; however, experiences at other institutions may vary. Future studies are needed to determine optimum teaching strategies for TEA.

An Empirical Study on the Relationship between Language Proficiency and Economic Income of Chinese and Vietnamese Border Residents: A Case Study of Dongxing City, Guangxi Province

Based on the full sample survey of border residents in Dongxing City, Guangxi, this paper uses language economics theory and data analysis methods to analyze the relationship between language proficiency and income of border residents in Dongxing City, Guangxi. The conclusions of the study include: multilingual ability can enhance residents' self-employment ability, obtain more employment opportunities and stable income sources, and have a positive correlation with their annual income. Putonghua popularization is an effective measure to promote poverty alleviation in border areas; Government departments should optimize and improve local industrial policies and promote the promotion and protection of traditional cultures of ethnic minorities while giving full play to the positive economic and social benefits of Putonghua popularization and cultivating new economic drivers.

Objective measure of learning curves for trainees in cardiac surgery via cumulative sum failure analysis.

Objective measures of cardiac surgery trainee progress are limited despite a push for competency-based assessments. We hypothesized that the cumulative sum failure technique could provide a risk-adjusted, quantitative measure of resident learning curves and competence. Records of all coronary artery bypass grafting and valve operations performed by cardiac-track residents from 2007 to 2017 at a single institution were stratified by operative resident. Multivariable regression evaluated the association among resident, case number, and postoperative outcomes. To evaluate performance over time, risk-adjusted cumulative sum failure analysis was performed, taking into account institutional expected values and comparing residents with study-defined "early alert" and "concern" boundaries. A total of 3937 Society of Thoracic Surgeons Predicted Risk of Mortality cases were evaluated from 19 residents. Observed-to-expected ratios for mortality and combined morbidity-mortality were 0.66 and 0.72, respectively, and each individual resident exhibited better than predicted outcomes (all observed:expected ratios <1). When evaluating cumulative sum failure learning curves, residents exhibited an initial slight increase in complications, followed by improvement and better than expected performance. The "early alert" boundary was crossed by 36.8% of residents at any point in training, with 94.7% of residents under this boundary at the end of training. The higher "concern" boundary was crossed by 2 residents (10.5%), although all residents ended their training below this boundary. Outcomes for trainee-performed cardiac surgery procedures were excellent, with no association between individual trainees and adverse events. Cumulative sum failure analysis based on postoperative outcomes is a potential tool for objective evaluation of resident proficiency.

A survey of anesthesia residents′ proficiency in epidural puncture and training needs in China

Objective To investigate the anesthesia residents′ proficiency in the epidural puncture and training needs using questionnaire survey in China. Methods A questionnaire designed by ourselves was sent to anesthesia residents via the WeChat platform within 1 month.The data were recorded by the system automatically. Results A total of 795 anesthesia residents involved in the investigation, and the number of valid questionnaires was 753 (94.7%). There were 233 (30.9%) junior residents (0-2 yr of training), 279 (37.1%) semi-senior residents (3-5 yr of training), and 241 (32.0%) senior residents (>5 yr of training). Compared with junior group, the difficulty score for epidural puncture was significantly decreased, and the confidence scores for performing normal middle lumbar, difficult lumbar, lateral lumbar and thoracic epidural puncture were increased in semi-senior and senior groups (P<0.05). Compared with semi-senior group, the difficulty score for epidural puncture was significantly decreased, and the confidence scores for performing normal middle lumbar, difficult lumbar, lateral lumbar and thoracic epidural puncture were increased in senior group (P<0.05). The self-evaluated difficulty of epidural puncture was lower as the number of prior epidural cases was more (r=-0.719, P<0.01). There were 46.6% of the residents who had received simulation-based training before performing epidural puncture on the patient, among which most residents considered the simulation-based training is effective in helping to familiarize with procedure (77.2%), familiarize with anatomy (70.4%), simulate the texture of different layers (47.9%), and enhance success rate of epidural puncture (56.7%). There were 75.0% residents who considered visualization technology is helpful in enhancing the success rate and confidence of epidural puncture. Conclusion Currently, the proficiency of junior anesthesia residents in epidural puncture needs to be strengthened.The simulation-based training has not been widely applied in the epidural training, while residents think high of simulation-based training and are looking forward to visualization technique training. Key words: Questionaires; Epidural puncture; Simulation-based training

Does orthopaedic resident efficiency improve with respect to decreased fluoroscopic times in tibial intramedullary nailing? A measure of an ACGME milestone

Background: Intramedullary nailing of tibial fractures is a surgical milestone from the Accreditation Council for Graduate Medical Education (ACGME). Our purpose was to evaluate if fluoroscopic time decreased with increasing resident experience and could be used as a measure of this milestone. Methods: Current Procedural Terminology (CPT) codes were used to identify patients who underwent intramedullary nailing of tibial shaft fractures under the direction of fellowship-trained trauma attending staff. The data collected included patient demographics, fracture classification, fluoroscopic imaging total time, and the post-graduate years (PGY) of orthopaedic residency of the operating resident. Exclusions of patients included concomitant fluoroscopic procedures, inadequate records, or surgeries involving primary assisting residents with less than PGY-2 experience. We compared overall groups between half years and looked at individual resident years for each of the continuous variables. Results: When residents were grouped as senior (PGY-4 and PGY-5) or junior (PGY-2 and PGY-3), seniors used significantly less fluoroscopy than juniors (207.39 sec vs. 258.30 sec, P=0.018). In the first half of the academic year, PGY-2 residents completed tibial nailing slowest in terms of fluoroscopic usage (P=0.003). PGY-4 residents completed tibial nailing faster in terms of fluoroscopic usage than other years (P=0.031). In the second half of the academic year, PGY-5 residents used significantly less fluoroscopy than PGY-2 residents (P=0.035). Conclusions: As the ACGME currently has no measurement for resident progress and efficiency regarding tibial shaft intramedullary nailing, our data indicate that fluoroscopic measurements may be useful in assessing resident proficiency.

Cognitive load theory as a framework for simulation-based, ultrasound-guided internal jugular catheterization training: Once is not enough.

The main objective of this study was to use the principles of cognitive load theory to design a curriculum that incorporates a progressive part practice approach to teaching ultrasound-guided (USG) internal jugular catheterization (IJC) to novices. A secondary objective was to compare the technical proficiency of residents trained using this curriculum with the technical proficiency of residents trained with the current local standard of a single simulation session. The experimental group included 16 residents who attended three 2-hour sessions of progressive part practice in a simulation lab. The control group included 46 residents who attended the current local standard of a single 2-hour simulation session just prior to their intensive care unit rotation. Technical proficiency was assessed using hand motion analysis and time to procedure completion. After three sessions, median scores for right hand motion (RHM) (34.5; [27.0-49.0]), left hand motion (LHM) (35.5; [20.0-45.0]), and total time (TT) (117.0 s; [82.7-140.0]) in the experimental group were significantly better than the control group (p<0.001). Results for eight experimental group residents who were assessed for retention at a later date revealed median scores for RHM (45.0; [32.0-58.0]), LHM (33.5; [20.0-63.0]), and TT (150.0 s; [103.0-399.6]), which were significantly better than those of the control group (p=0.01, p<0.01, and p=0.02, respectively). These results support multiple sessions of progressive part practice in a simulation lab as an effective competency-based approach to teaching USG IJC in preparation for the clinical setting.

Creation and Validation of Tool to Assess Resident Competence in Neonatal Resuscitation

BackgroundThe American Board of Pediatrics requires that pediatricians be able to initiate stabilization of a newborn. After residency, 45% of general pediatricians routinely attend deliveries. However, there is no standard approach or tool to measure resident proficiency in newborn resuscitation across training programs. In a national survey, we found a large variability in faculty assessment of the amount of supervision trainees need for various resuscitation scenarios. Objective documentation of trainee performance would permit competency-based decisions on the level of supervision required and facilitate feedback on trainee performance. MethodsA simplified tool was created following the Neonatal Resuscitation Program (NRP) algorithm, with emphasis on communication, leadership, knowledge of equipment, and initial stabilization. To achieve content validity, the tool was evaluated by the NRP steering committee. To assess internal structure of the tool, we filmed 10 simulated resuscitation scenarios, 9 of which contained errors. Experienced resuscitation team members used the tool to assess performance of the team leader in the videos. To evaluate the response process, the tool was used to assess experienced resuscitators in real time at academic and non-academic sites. ResultsThe NRP steering committee approved the tool, providing evidence of content validity. Performance of the team leader in the simulated videos was assessed by 16 evaluators using the tool. There was an intraclass coefficient of 0.86, showing excellent agreement. There was no statistical difference in scores between 102 resuscitations led by experienced resuscitators at academic and nonacademic hospitals (P = .98), which demonstrates generalizability. ConclusionsThe tool we have developed to assess performance in initiating newborn resuscitation shows evidence of construct validity based on assessment of content and internal structure (interobserver agreement, response processes, and generalizability).

Resident simulation training improves operative time of the retropubic midurethral sling procedure for stress incontinence.

Our aim was to assess whether immediate preoperative resident simulation training decreases operative time and improves resident proficiency when performing a retropubic midurethral sling (MUS) procedure. This prospective cohort study took place over 8months at the Icahn School of Medicine, New York, USA. During the first 4months, all retropubic MUS procedures were performed by residents who underwent immediate preoperative simulation training. The cases completed during the following 4months were performed by residents who had not received preoperative simulation training. During the 8-month period, residents completed self-assessment questionnaires upon completion of the surgery and attendings evaluated the residents using the Objective Structured Assessment of Technical Skills (OSATS) global rating scale. Operative time between the two periods were compared using two-sample Student's t test. Comparative analysis between groups was performed based on the OSATS scores using the Wilcoxon rank-sum nonparametric test. There were 22 cases in the simulation group (SG) and 20 in the no simulation group (NSG). SG mean operative time was 12.6min and NSG mean operative time was 14.6min (p = 0.12). The SG mean OSATS score was 30.4 versus NSG of 27.8 (p < 0.001). This study demonstrates that preoperative simulation significantly improves operative performance of the retropubic MUS procedure among residents and also improves their confidence in the operating room. There was a decrease in mean operative time of 2min in the SG, but the difference was not statistically significant. This data is consistent in demonstrating improved surgical performance and resident confidence with simulation training.

102 - An Initiative to Increase Pediatric Resident Laceration Repair Procedure Logs

Background: The Accreditation Council for Graduate Medical Education (ACGME) governs accredited residency programs for compliance with pediatric resident proficiency in several procedures. Our institution utilizes Suture Technicians; therefore, residents may graduate without performing a sufficient number of required laceration repairs to reach proficiency.

What factors influence attending surgeon decisions about resident autonomy in the operating room?

Educating residents in the operating room requires balancing patient safety, operating room efficiency demands, and resident learning needs. This study explores 4 factors that influence the amount of autonomy supervising surgeons afford to residents. We evaluated 7,297 operations performed by 487 general surgery residents and evaluated by 424 supervising surgeons from 14 training programs. The primary outcome measure was supervising surgeon autonomy granted to the resident during the operative procedure. Predictor variables included resident performance on that case, supervising surgeon history with granting autonomy, resident training level, and case difficulty. Resident performance was the strongest predictor of autonomy granted. Typical autonomy by supervising surgeon was the second most important predictor. Each additional factor led to a smaller but still significant improvement in ability to predict the supervising surgeon's autonomy decision. The 4 factors together accounted for 54% of decision variance (r=0.74). Residents' operative performance in each case was the strongest predictor of how much autonomy was allowed in that case. Typical autonomy granted by the supervising surgeon, the second most important predictor, is unrelated to resident proficiency and warrants efforts to ensure that residents perform each procedure with many different supervisors.

Significance of Objective Structured Clinical Examinations to Plastic Surgery Residency Training.

Objective structured clinical examinations (OSCEs) have proven to be a powerful tool. They possess more than a 30-year track record in assessing the competency of medical students, residents, and fellows. Objective structured clinical examinations have been used successfully in a variety of medical specialties, including surgery. They have recently found their way into the subspecialty of plastic surgery. This article uses a systematic review of the available literature on OSCEs and their recent use in plastic surgery. It incorporates survey results assessing program directors' views on the use of OSCEs. Approximately 40% of programs surveyed use OSCEs to assess the Accreditation Council for Graduate Medical Education core competencies. We found that 40% use OSCEs to evaluate specific plastic surgery milestones. Objective structured clinical examinations are usually performed annually. They cost anywhere between $100 and more than $1000 per resident. Four milestones giving residents the most difficulties on OSCEs were congenital anomalies, noncancer breast surgery, breast reconstruction, and practice-based learning and improvement. It was determined that challenges with milestones were due to lack of adequate general knowledge and surgical ward patient care, as well as deficits in professionalism and system-based problems. Programs were able to remediate weakness found by OSCEs using a variety of methods. Objective structured clinical examinations offer a unique tool to objectively assess the proficiency of residents in key areas of the Accreditation Council for Graduate Medical Education core competencies. In addition, they can be used to assess the specific milestones that plastic surgery residents must meet. This allows programs to identify and improve identified areas of weakness.

Personal Digital Assistant-Based Self-Work Sampling Study of Pediatric Interns Quantifies Workday and Educational Value

ObjectiveOptimizing clinical proficiency and education of residents has become more important with restricted residency duty hours. Our objective was to investigate how interns spend their time on inpatient rotations and the perceived educational value of workday activities. MethodsWe performed a descriptive self-work sampling study using a personal digital assistant (PDA) to randomly query interns on inpatient rotations in real time regarding their activity and the perceived educational value of that activity on a 4-point Likert scale. ResultsA total of 31 interns participated on 88 workdays over a 5-month period, generating 2082 samples from which the average workday was modeled. Time spent using the electronic health record (EHR) accounted for 33% of intern time, communicating with the health care team 23%, educational activities 17%, and time with patients and families 12%. Time with patients and families was perceived to be the most educational part of clinical service. Time spent using the EHR was perceived as the least educational. Interns perceived clinical service as excellent or good 37% of the time, while planned educational activities were perceived as excellent or good 81% of the time. ConclusionsInterns spend the majority of their time using the EHR and communicating with the health care team. Interns perceive time spent in planned educational activities has more educational value than time spent in clinical service. The distribution of daily activities is discordant with the perceived educational value of those activities.

Expert consensus of general surgery residents’ proficiency with common endocrine operations

Proficiency with common endocrine operations is expected of graduating, general surgery residents. However, no expert consensus guidelines exist about these expectations. Members of the American Association of Endocrine Surgeons were surveyed about their opinions on resident proficiency with common endocrine operations. Overall response rate was 38%. A total of 92% of the respondents operate with residents. On average, they believed that the steps of a total thyroidectomy for benign disease and a well-localized parathyroidectomy could be performed by a postgraduate year 4 surgery resident. Specific steps that they thought might require more training included decisions to divide the strap muscles or leaving a drain. Approximately 66% of respondents thought that a postgraduate year 5 surgery resident could independently perform a total thyroidectomy for benign disease, but only 45% felt similarly for malignant thyroid disease; 79% thought that a postgraduate year 5 surgery resident could independently perform a parathyroidectomy. Respondents' years of experience correlated with their opinions about resident autonomy for total thyroidectomy (benign r=0.38, P<.001; malignant r=0.29, P=.001) but not parathyroidectomy. On multivariate analysis, sex and years of experience of the respondents were independently associated with opinions on autonomy but only for total thyroidectomy for benign disease (P=.001). Annual endocrine volume of the respondents did not correlate with beliefs in autonomy. There was general agreement among responding members of the AAES about resident proficiency and autonomy with common endocrine operations. As postgraduate year 5 residents may not be proficient in advanced endocrine operations, opportunities exist to improve training prior to the transition to independent practice for graduates that anticipate performing endocrine operations routinely.