Resident Proficiency Research Articles

Intraoperative resident education for robotic laparoscopic gastric banding surgery

Introduction The incorporation of robotic surgery into resident education poses questions regarding the impact on intra-operative teaching and patient care. The aim of this study was to evaluate the impact of gradually increasing resident console responsibility in the presence of an expert proctor and bedside surgeon for robotic adjustable gastric banding (R-LAGB) on resident proficiency and patient safety compared to the classical training mode (CTM) of residents as first assistant. Methods After successful completion of a six-skill inanimate robotic simulation program, eight PGY-4 residents completed 60 R-LAGB using a one-to-one proctored setting (PTM). R-LAGB was distilled into 7 key steps: GE-junction dissection, gastrohepatic ligament dissection, retrogastric space creation, band placement, band closure, gastrogastric suturing, and port placement. Residents performed more complex steps after each case to gain competence in all aspects of the operation. Patient demographics, operative complications, operating times, and clinical outcomes were examined and compared to a control group of 287 R-LAGB completed using the CTM. Unpaired t-test were used for analysis (P=0.05). Results While residents using the proctored training mode (PTM) were able to successfully complete a R-LAGB as primary surgeon after a median of 8 operations (range: 4-11), none of the residents in the CTM completed a R-LAGB as primary surgeon. Mean operative time, patient demographics, intraoperative complications were similar between groups (Table).DemographicProctored training mode (n=60)Classical training mode (n=287)p ValueProcedure length (min, mean ± SD)99.3±22.191.5±21.1NSIntra-operative Complications, n (%)0(0%)0(0%)NSLength of stay (days, mean ± SD)1.3±0.71.3±0.6NSBMI (mean ± SD)42.4±4.445.4±5.5NSPatient age (mean ± SD)46.3±1145±11NS Conclusions Using a PTM for R-LAGB, residents reach competence after a median of 8 cases. All residents in the proctored setting claimed competence and have persistent console experience without significantly increasing procedure length or complications.

Impact of Fatigue on Neurophysiologic Measures of Surgical Residents

To gain additional insight into the impact of fatigue on surgery resident proficiency, we set out to quantify its impact on behavioral and neurophysiologic measures. Simulations were first created using a visio-haptic joystick attached to a surgical instrument (tool) that allows realistic interactions. Before baseline (pre-call) and after call, 7 PGY1 surgery residents performed simulation tasks that required varying levels of psychomotor and cognitive skill. Residents completed 3 sessions per week for 4 weeks. Surgical proficiency was established using 5 metrics: hand movement smoothness; instrument movement smoothness; time to task completion; gesture level proficiency and cognitive errors. Data (percent change from baseline, pre-call) were analyzed using repeated measures ANOVA. While performing these tasks, the residents also wore an EEG cap (B-Alert; Advanced Brain Monitoring), the data from which provided second to second insight into the effects of workload, distraction, and attention on task performance. Mean (±SD) pre-call and post-call values for each were analyzed using repeated measures ANOVA. Residents experienced significant (p < 0.014) post-call erosions in surgical proficiency, punctuated by dramatic increases in cognitive errors. EEG-based attention scores showed a significant (p < 0.014) concomitant decrement of 40%; distraction/drowsiness scores increased by 91%; and workload score increased by 51%. Fatigue adversely affects PGY1 resident surgical proficiency and neurophysiologic performance.

Surgical Simulators and Hip Fractures: A Role in Residency Training?

Orthopedic surgery residency training requires intellectual and motor skill development. In this study, we utilized a computer-based haptic simulator to examine a potential model for evaluation of resident proficiency and efficiency in the placement of a center guide wire during fixation of an intertrochanteric proximal femur fracture. We hypothesize the junior residents will utilize more fluoroscopy and require more time to complete the task. Postgraduate year (PGY) 1-5 residents completed the same task of placing a single central guide pin into a femoral head for a dynamic hip screw construct utilizing a haptic surgical simulator. Residents were divided into 2 groups (PGY 1-2 and PGY 3-5) and then evaluated based on final tip-apex distance (TAD), fluoroscopy time, time to complete the task, total number of distinct attempts at pin placement for each femur construct, as well as final 3-dimensional location of the pin from the isometric center of the femoral head. No statistically significant differences were noted between the 2 groups in total time or for tip-apex distance, anterior/posterior medial/lateral position, anterior/posterior superior/inferior, and lateral x-ray medial/lateral positioning measurements. Significant differences between Groups I and II were observed in anterior/posterior final position on the lateral view (p = 0.01), unique attempts (0.77 and 1.5, p = 0.03), and total fluoroscopic time (18.4 seconds and 12.9 seconds, p = 0.05). In this study, we displayed that based on our simulator model there was no statistical difference between Group I and II in time to completion, final placement on anterior/posterior (A/P) view, and tip-apex distance. There was a statistically significant difference in the anterior/posterior placement of the wire in lateral view between the 2 groups, fluoroscopy time, and number of attempts per trial. Our findings suggest a computer-based surgical simulator can identify measurable differences in surgical proficiency between junior and senior orthopedic surgery residents and may play an expanding role in resident education.

Effects of duty hours and time of day on surgery resident proficiency

Background Night floats have evolved in the era of limited resident work hours. This study was designed to define the effect of restricted nighttime duty hours on the psychomotor and cognitive skills of surgery residents. Methods To quantify the effect of fatigue on the skills of residents on day-shift and night-float rotations, residents were asked to complete visuohaptic simulations before and after 12-hour duty periods and to rate their fatigue level with questionnaires. Results Both groups showed significant decrements in proficiency measures after their shifts compared with baseline. The night-float group showed more significant declines ( P < .05) in all areas assessed than the day-shift group. The night-float group was significantly less proficient in cognitive tasks after their shifts compared with the day-shift group. Conclusions The deterioration of surgical proficiency is to a degree dependent on the time of day during which call occurs, not solely on the length of call.

Delivering the News With Compassion: The GRIEV_ING Death Notification Protocol

OPEN ACCESSAugust 3, 2010Delivering the News With Compassion: The GRIEV_ING Death Notification Protocol Cherri Hobgood, MD, Joey Woodyard, Susan Sawning, Katherine Savage Cherri Hobgood, MD University of North Carolina at Chapel Hill School of Medicine Google Scholar More articles by this author , Joey Woodyard UNC School of Medicine Google Scholar More articles by this author , Susan Sawning UNC School of Medicine Google Scholar More articles by this author , Katherine Savage UNC School of Medicine Google Scholar More articles by this author https://doi.org/10.15766/mep_2374-8265.8210 SectionsAbout ToolsDownload Citations ShareFacebookTwitterEmail Abstract Introduction: Nearly 2.4 million deaths occur annually, over a million of which take place in hospitals. As a result, death notification remains a daunting and emotionally challenging task that physicians encounter throughout their careers. However, in one study, fewer than half of all physicians reported receiving death notification education in medical school or residency, while in another, 94% reported that such education is needed. Nevertheless, no validated educational interventions exist that are specifically designed to teach medical students, residents, and fellows effective skills in death notification that can be implemented in a practical time frame and allow easy integration into busy schedules. To address this need, a 2-hour-long educational intervention based on the GRIEV_ING Death Notification Protocol was developed and validated. The intervention provides a complete teaching and learning module composed of small-group, role-play, and didactic experiences to train residents and medical students in effective death notification skills. Methods: This resource is a comprehensive teaching and learning module designed to provide educators with practical, proven teaching and assessment tools to help residents and medical students develop confidence and competence in death notification. The resource includes a PowerPoint presentation that provides training on the GRIEV_ING mnemonic, as well as documents that detail small-group activities in the form of structured discussions and role-plays to facilitate interactive learning. The resource also includes a self-efficacy survey, detailed standardized survivor scenarios, and assessment tools such as a Relationship and Communication Instrument and the GRIEV_ING Competence Instrument to help gauge progress. Results: In one study, 20 residents significantly improved and retained their confidence and competence in death notification following exposure to this intervention. In another study, all 138 fourth-year medical students who were exposed to this intervention improved their overall competence and self-confidence in death notification. In addition, students who were exposed to a simulated survivor and provided feedback on their performance, in addition to being taught the GRIEV_ING protocol, improved their competence and confidence significantly. Discussion: The significance of this resource is that it addresses an important educational need by providing practical, proven, and effective teaching and assessment tools to help students learn effective death notification skills. Educational Objectives Use of this module will: Provide educators practical, proven teaching and assessment tools for death notification.Develop proficiency of residents, medical students, and fellows in effective death notification skills.Measure and improve confidence and competence in death notification through participation in an interactive teaching and learning module based on the GRIEV_ING mnemonic. ReferencesHobgood C., Harward D., Newton K., & Davis W. (2005). The educational intervention “GRIEV_ING” improves the death notification skills of residents. Academic Emergency Medicine, 12(4), 296–301. http://dx.doi.org/10.1111/j.1553-2712.2005.tb01943.xMedline, Google ScholarHobgood C. D., Tamayo-Sarver J. H., Hollar D. W., & Sawning S. (2009). GRIEV_ING: Death notification skills and applications for fourth-year medical students. Teaching and Learning in Medicine, 21(3), 207–219. http://dx.doi.org/10.1080/10401330903018450Medline, Google Scholar Sign up for the latest publications from MedEdPORTAL Add your email below FILES INCLUDEDReferencesRelatedDetails FILES INCLUDED Included in this publication: Trainer's Manual Cover.doc Table of Contents.doc Rationale.doc Schedule.doc How To Use These Materials.doc Appendix A and C PowerPoint.ppt Appendix B Facilitator's Discussion Guide.doc Appendix D Role Plays Instructions Scenarios.doc Appendix E Guidelines Training Standardized Patients.doc Appendix F Self-Efficacy Survey.doc Appendix G GRIEVING Competence Instrument.doc Appendix H Relationship Communication Instrument.doc To view all publication components, extract (i.e., unzip) them from the downloaded .zip file. Download editor’s noteThis publication may contain technology or a display format that is no longer in use. CitationHobgood C, Woodyard J, Sawning S, Savage K. Delivering the News With Compassion: The GRIEV_ING Death Notification Protocol. MedEdPORTAL. 2010;6:8210. https://doi.org/10.15766/mep_2374-8265.8210 Copyright & Permissions© 2010 Hobgood et al. This is an open-access publication distributed under the terms of the Creative Commons Attribution-NonCommercial-Share Alike license.KeywordsGRIEV_INGDeath NotificationTruth Disclosure Disclosures None to report. Funding/Support None to report. Loading ...

A study of resident proficiency with thyroid surgery: Creation of a thyroid-specific tool

Objective Creation and testing of a tool, Hemithyroidectomy-Specific Scale (HSS), to evaluate performance of a hemithyroidectomy. Study Design Prospective, multi-center study of our HSS tool versus a Global Scale (GS). Setting Two tertiary care academic medical centers. Subjects and Methods Sixteen unique residents (postgraduate years [PGY] 2-5) evaluated a total of 97 times with a performance tool by a single endocrine surgeon evaluator (B.C.S.). Results Overall, the reliability of both evaluation instruments was good. Cronbach's alpha was 0.972 for the GS and 0.959 for the HSS. This indicates high internal consistency of each instrument. In general, the scores increased with increasing PGY level, indicating reasonable construct validity. Conclusion This study describes a new HSS checklist type of evaluation instrument for hemithyroidectomy and compares it to a validated GS. HSS offers advantages to GS. Most residents reached competence in hemithyroidectomy by the PGY4 level. A large, multi-institutional study would be required for adequate evaluation of our tool prior to its routine use in resident evaluations.

The Use of a Simulation Center to Improve Resident Proficiency in Performing Ultrasound-Guided Procedures

With advancements in technology and push for health care reform and reduced costs, minimally invasive procedures, such as those that are ultrasound-guided, have become an essential part of radiology, and are used in many divisions of radiology. By incorporating standardized training methodologies in a risk free environment through utilization of a simulation center with phantom training, we hope to improve proficiency and confidence in procedural performance. Twenty-nine radiology residents from four levels of training were enrolled in this prospective study. The residents were given written, video, and live interactive training on the basics of ultrasound-guided procedures in our simulation center on a phantom mannequin. All of the teaching materials were created by residents and staff radiologists at the institution. Residents demonstrated statistically significant improvement (P < .05) between their pre- and posttest scores on both the written and practical examinations. They also showed a trend toward improved dexterity in the technical aspects of ultrasound-guided procedures (P = .07) after training. On the survey questionnaire, residents confirm improved knowledge level, technical ability, and confidence levels pertaining to ultrasound-guided procedures. The use of controlled simulation based training can be an invaluable tool to improve the knowledge level, dexterity, and confidence of residents performing ultrasound-guided procedures. Additionally, a simulation model allows standardization of education.

Establishment of resident laparoscopic virtual reality skills proficiency

Establishment of resident laparoscopic virtual reality skills proficiency

Electrodiagnostic Medicine Skills Competency in Physical Medicine and Rehabilitation Residents

This project sought to create an educational module including evaluation methodology to instruct physical medicine and rehabilitation (PM&R) residents in electrodiagnostic evaluation of patients with neuromuscular problems, and to verify acquired competencies in those electrodiagnostic skills through objective evaluation methodology. Sixteen residents were trained by board-certified neuromuscular and electrodiagnostic medicine physicians through technical training, lectures, and review of self-assessment examination (SAE) concepts from the American Academy of Physical Medicine & Rehabilitation syllabus provided in the Archives of Physical Medicine and Rehabilitation. After delivery of the educational module, knowledge acquisition and skill attainment were measured in (1) clinical skill in diagnostic procedures via a procedure checklist, (2) diagnosis and ability to design a patient-care management plan via chart simulated recall (CSR) exams, (3) physician/patient interaction via patient surveys, (4) physician/staff interaction via 360-degree global ratings, and (5) ability to write a comprehensive patient-care report and to document a patient-care management plan in accordance with Medicare guidelines via written patient reports. Assessment tools developed for this program address the basic competencies outlined by the Accreditation Council for Graduate Medical Education (ACGME). To test the success of the standardized educational module, data were collected on an ongoing basis. Objective measures compared resident SAE scores in electrodiagnostics (EDX) before and after institution of the comprehensive EDX competency module in a PM&R residency program. Fifteen of 16 residents (94%) successfully demonstrated proficiency in every segment of the evaluation element of the educational module by the end of their PGY-4 electrodiagnostic rotation. The resident who did not initially pass underwent remedial coursework and passed on the second attempt. Furthermore, the residents' proficiency as demonstrated by the evaluation after implementation of the standardized educational module positively correlated to an increase in resident SAE scores in EDX compared with resident scores before implementation of the educational module. Resident proficiency in EDX medicine skills and knowledge was objectively verified after completion of the standardized educational module. Validation of the assessment tools is evidenced by collected data correlating with significantly improved SAE scores and American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM) exam scores, as outlined in the result section. In addition, the clinical development tool (procedure checklist) was validated by residents being individually observed performing skills and deemed competent by an AANEM-certified physician. The standardized educational module and evaluation methodology provide a potential framework for the definition of baseline competency in the clinical skill area of EDX.

Effectiveness of an Educational Intervention in Oral Health for Pediatric Residents

To evaluate the effectiveness of an oral health educational intervention designed to increase proficiency of pediatric residents in oral health. Pediatric residents at the University of North Carolina at Chapel Hill (UNC) participated in oral health education that included didactic sessions, hands-on instruction by pediatric dentists and residents, preventive dentistry prompts, and change strategies to introduce oral health into practice. Pediatric residents at East Carolina University (ECU), who had a short practicum in oral health, and Wake Forest University (WFU), who had no specific oral health instruction, served as comparison groups. All residents completed questionnaires before and 12 months after instruction began at UNC. Effects were tested for each school separately by repeated-measure analysis of variance. The mean percentage of UNC residents who answered 18 knowledge questions correctly and reported frequently performing 10 preventive dental practices increased by 17.7% and 65.1%, respectively, from baseline levels. Residents' confidence in performing 10 counseling and oral health screening activities improved by 17.9%. Opinions about including oral health in their clinical care improved only slightly. Changes at ECU and WFU were small, but low response rates in those schools preclude substantive conclusions from between schools comparisons. Multifaceted instruction in oral health was effective in improving pediatric residents' knowledge about oral health, their confidence in providing oral health services, and the delivery of these services in their ambulatory care practices. Residents also adopted the use of fluoride varnish, an innovation in pediatrics. More studies are needed to define the most efficient and effective residency-based instruction.

The development and evaluation of a clinical test of surgical resident proficiency.

The two purposes of this study were to develop a clinical test of surgical resident proficiency and to compare this clinical test with currently applied methods of resident evaluation. Appendicitis is a common surgical disease, and its accurate diagnosis depends largely on clinical acumen. Ten third-year surgical residents prospectively evaluated 107 patients admitted because of suspected appendicitis. After taking a history, performing a physical examination, and reviewing laboratory data, these residents were asked to state, as a percentage, the likelihood that each patient had appendicitis. Sixty-three patients had appendicitis documented by pathologic inspection after appendectomy. Forty-four patients did not have appendicitis, as was determined by operation (17) or by in-house observation and resolution of abdominal pain (27). These outcomes were used to calculate a diagnostic ability score (DAS) for each resident. Residents were evaluated by standard methods including in-service examinations and monthly evaluations by the attending staff. Residents were also evaluated by nonstandard, but potentially useful, neuropsychologic and psychologic tests, including the trail making test, the Ravens progressive matrices test, the paced auditory serial addition test (PASAT), the grooved pegboard test of manual dexterity, and the profile of mood states (POMS) psychologic questionnaire. Cumulative scores were calculated and compared by multiple regression with coefficient variance analysis. The correlation (R2) of DAS with standard evaluation techniques was as follows: In-service (0.055), faculty (0.508), trails (-0.293), Ravens (0.028), PASAT (0.251), dexterity (0.432), POMS (0.381). We found that (1) the DAS is a discriminating clinical test; (2) the DAS correlates with subjective faculty evaluation; and (3) the DAS does not correlate with in-service examination scores. We conclude that faculty evaluation remains the best currently applied test of surgical resident clinical proficiency as measured by the DAS.

Placement of a Word catheter: A resident training model

The present study developed and evaluated a practical teaching model and training protocol for Word catheter placement in the treatment of a Bartholin gland cyst. Residents were asked to treat a model of the female perineum, fashioned from harvested porcine tissue, with a simulated Bartholin cyst via Word catheter placement and drainage. Each resident was evaluated for procedural competence. They were retested after the viewing of a continuous 59-second video demonstrating catheter placement. The model's resemblance to female genitalia was confirmed by 68% of residents. Correct diagnosis and treatment of a Bartholin gland cyst was made by 61%. The mean pretraining score was 5.5 +/- 1.46, while the post-training average was 8.2 +/- 1.20, indicating an approximate 58% increase in resident proficiency (P < .05). A model of the female perineum fashioned from harvested porcine tissue is a suitable instructional aid in the recognition and treatment of a Bartholin cyst. Proficiency in Word catheter placement is improved through the use of the model and instructional video.

Proficiency of pediatric residents in performing neonatal endotracheal intubation.

Current guidelines of the Accreditation Council for Graduate Medical Education have restricted the amount of intensive care experience obtained during pediatric residency. The impact on performing procedures has not been evaluated. To determine the current level of competency in 1 common procedure, we investigated the proficiency of pediatric residents in performing neonatal endotracheal intubation during the academic years 1998-1999 and 2000-2001. Indication for intubation, number of attempts, and achievement of success were recorded by the respiratory therapist present for the procedure. Each intubation was scored according to the attempt on which intubation was successful. Indications for intubation were categorized as respiratory failure, delivery room resuscitation, and meconium-stained amniotic fluid. Competency was defined as a successful intubation occurring on the first or second attempt >or=80% of the time. Intubation scores were compared between residents at various stages of training and analyzed by multivariate logistic regression analysis for significance. Comparisons were then performed to determine percentage success with confidence intervals. We also surveyed previous graduates of the training program not included in the observations for this study and asked them to indicate how frequently they perform intubation in current practice and to assess their own competence in the procedure. A total of 449 resident procedures were observed during the study periods: 192 by postgraduate year 1 (PGY-1) residents, 126 by PGY-2 residents, and 131 by PGY-3 residents. A total of 35% (160 of 449) of intubation procedures were never successful by pediatric house officers. Intubation was successful on the first or second attempt for 50% of PGY-1 residents (95% confidence interval [CI]: 42.6-56.8), 55% of PGY-2 residents (95% CI: 46-63.5), and 62% of PGY-3 residents (95% CI: 53.9-70.7). The third-year residents exhibited a significantly higher likelihood of performing a successful intubation compared with first-year residents. The first-year residents in 1998-1999 showed no improvement by their third year in 2000-2001. Surveys were sent to 56 graduates of our residency program (1998-2000). Completed surveys were received from 31 (66%) of 47. A total of 71% of the respondents are practicing general pediatrics, and 36% attend deliveries or perform intubations. A total of 87% reported that their level of confidence with endotracheal intubation was good or excellent after completion of residency training. We provide objective and subjective data concerning the proficiency of pediatric residents in performing neonatal endotracheal intubation. None of our resident groups met the specified definition of technical competence, although there was improvement with advancing training level in bivariate analyses. However, graduates of our training program felt confident with their intubation skills in contrast to our objective findings. As exposure to these important skills becomes limited, methods to ensure attainment of technical competency during training may need to be redefined.

Transnasal jet ventilation is a useful adjunct to teach fibreoptic intubation: a preliminary report.

Fibreoptic intubation (FOI) has become an essential technique in the anesthetic management of patients with difficult airways. Unfortunately, residents may graduate from anesthesiology training programs with insufficient skills in FOI. To enhance resident proficiency at FOI without compromising patient comfort or safety, the technique of transnasal jet ventilation-assisted FOI was developed. This report describes our initial experience with this technique. Sixty-four patients scheduled for oromaxillofacial surgery under nasal endotracheal anesthesia were recruited. Twenty-eight residents at all levels of training performed FOI through the patient's right nostril after the induction of general anesthesia and neuromuscular blockade. Oxygenation and ventilation were maintained by a faculty anesthesiologist using a Sanders device to deliver a jet of oxygen through a nasal trumpet placed in the patient's left nostril. The time from induction until completion of the FOI was recorded. Residents were subsequently queried about the educational benefit of the technique using a standardized questionnaire. All residents were able to successfully intubate all patients in this study. Thirteen residents successfully performed intubations on three or more occasions with 70% performing the technique faster on the third trial than on the first. No evidence of hypoxemia, gastric distension, pneumothorax, hemodynamic instability or recall was observed. All respondents to the questionnaire reported that the technique was useful as an educational tool and recommended its use with other residents. Transnasal jet ventilation-assisted FOI is a useful method to train residents in FOI while maximizing patient comfort and safety.

A comprehensive pelvic dissection course improves obstetrics and gynecology resident proficiency in surgical anatomy

Objective This study was undertaken to evaluate the impact of a pelvic dissection course on resident proficiency in surgical anatomy. Study design Over a 1-year period, residents attended a course consisting of pretesting and posttesting, lectures, and pelvic dissection. Tests results were analyzed using paired Student t test, analysis of variance, and Kruskal-Wallis statistics. Results Of 42 residents, 24 completed all testing (study cohort). On written and practical examinations, resident scores improved a median of 42% and 29% (both P<.0001). Postgraduate year (PGY) 2 demonstrated the greatest improvement on the practical and PGY-3s demonstrated the greatest improvement on the written. Baseline written and practical results discriminated PGY level (construct validity): PGY-2 = PGY-3<PGY-4 on written pretest, PGY-2<PGY-3 = PGY-4 on practical pretest. No difference between resident cohorts was seen in either posttest. Conclusion Resident surgical anatomy proficiency is measurably improved by a comprehensive course.

Cusum analysis is a useful tool to assess resident proficiency at insertion of labour epidurals.

Cumulative sum (cusum) analysis is a statistical and graphical tool that examines trends for sequential events over time. It has been used to determine proficiency in technical procedures. We used cusum to determine the number of labour epidural attempts necessary for proficiency in our training program. Residents unfamiliar with epidural anesthesia kept a log of their labour epidural successes and failures during a six-month hospital rotation. Failure was defined as a dural puncture or relinquishing the procedure to staff. Cusum analysis was performed using an acceptable failure rate of 10%. Residents were deemed competent when their graph remained below the calculated cusum boundary. Eleven anesthesia residents were recruited. The number of epidural attempts over six months ranged from 75 to 128. Ten residents attained competency by cusum between one and 85 attempts. One resident failed to achieve competency by cusum after 75 attempts. After a period of training, residents are expected to perform the skill of labour epidural insertion independently. This study illustrates that some residents may need as many as 75 attempts to ensure proficiency. Training programs could use cusum to track the progress of their residents' technical skills in order to guarantee an adequate experience.

Teaching of pulmonary auscultation in pediatrics: a nationwide survey of all U.S. accredited residencies.

Structured teaching of pulmonary auscultation is greatly underrepresented during internal medicine (IM) or family practice (FP) training. It is not known, however, whether this underrepresentation applies to the other major field of primary care, pediatrics. To answer this question, we surveyed all accredited U.S. residencies in pediatrics by mailing a 1-page questionnaire to 174 pediatrics program directors, and by comparing results to those previously gathered from internal medicine and family practice residencies. Pediatrics directors' response rate was 62%. More pediatrics than family practice residencies offered structured teaching of pulmonary auscultation (21.5% vs. 9.7%, P < 0.004). When compared to internal medicine programs, this difference showed a trend toward significance (21.5% for pediatrics and 14.1%, for internal medicine, P = 0.08). Teaching modalities included: lectures (91.2%); audiotapes (13%); seminars (8.3%); and miscellaneous (21.7%). University-affiliated residencies taught auscultation significantly more frequently than nonuniversity-affiliated programs (25.4% vs.10.5%, P = 0.07). Pediatrics directors gave great importance to pulmonary auscultation, and wished for more time devoted to its teaching (5.52 +/- 0.84 and 5.01 +/- 1.07, respectively, on a 1-6 scale, with 6 indicating the highest value). They also attributed great clinical importance to 13 commonly encountered pulmonary auscultatory events (all rated, on average, between 4-5.8 on a 1-6 scale, with 6 indicating highest importance). In summary, training programs in pediatrics offered significantly more structured teaching of pulmonary auscultation than IM or FP residencies. Whether this difference in teaching may have a beneficial impact on the auscultatory proficiency of pediatric residents, as compared to internal medicine and family practice trainees, needs to be determined.

Structured assessment of minor surgical skills (SAMSS) for family medicine residents.

To develop a valid and reliable examination to assess the technical proficiency of family medicine residents' performance of minor surgical office procedures. A multi-station OSCE-style examination using bench-model simulations of minor surgical procedures was developed. Participants were a randomly selected group of 33 family medicine residents (PGY-1 = 16, PGY-2 = 17) and 14 senior surgical residents who functioned as a validation group. Examiners were qualified surgeons and family physicians who used both checklists and global rating scales to score the participants' performances. When family medicine residents were evaluated by family physicians, interstation reliabilities were .29 for checklists and .42 for global ratings. When family medicine residents were evaluated by surgeons, the reliabilities were .53 for checklists and .75 for global ratings. Interrater reliability, measured as a correlation for total examination scores, was .97. Mean scores on the examination were 60%, 64%, and 87% for PGY-1 family medicine, PGY-2 family medicine, and surgery residents, respectively. The difference in scores between family medicine and surgery residents was significant (p < .001), providing evidence of construct validity. A new examination developed for assessing family medicine residents' skills with minor surgical office procedures is reliable and has evidence for construct validity. The examination has low reliability when family physicians serve as examiners, but moderate reliability when surgeons are the evaluators.

Proficiency of PG-1 internal medicine residents in performing the pelvic examination.

Proficiency of PG-1 internal medicine residents in performing the pelvic examination.

Quality in HIV/AIDS Care Specialty-Related or Experience-Related?

In this issue, Markson et al. describe the characteristics of New York state clinics caring for Medicaid- enrolled outpatients with a new AIDS diagnosis between 1987–92.1 Their work is interesting because these descriptions can be used to measure the process of care provided by various types of clinics. Results suggest that HIV/AIDS-dedicated and infectious disease clinics provide better care than community-based primary care clinics, which in turn provide better care than hospital-based general medicine clinics. While they did not measure clinical outcomes or the costs of care, Markson and colleagues do reference a literature that supports the connection between improved outcomes and the process of care, including for example, access to care and the availability of comprehensive services. Given these results, one might reasonably reconsider the proposition that HIV/AIDS care is best provided by generalists.2