Resident Rotation Research Articles

The Rural Plastic Surgery Residency Rotation: Rising to Meet a National Crisis

The Rural Plastic Surgery Residency Rotation: Rising to Meet a National Crisis

How do clinical competency committees use different sources of data to assess residents’ performance on the internal medicine milestones?A mixed methods pilot study

Purpose: This study examines how Clinical Competency Committees (CCCs) synthesize assessment data to make judgments about residents’ clinical performances.Methods: Between 2014 and 2015, after four six-month reporting periods to the Accreditation Council for Graduate Medical Education (ACGME), 7 of 16 CCC faculty at Rush University Medical Center completed questionnaires focused on their perspectives about rating residents on their achievement of the milestones and participated in a focus group. Qualitative data were analyzed using grounded theory. Milestones ratings for two six-month ACGME reporting cycles (n = 100 categorical residents) were also analyzed.Results: CCC members weighted resident rotation ratings highest (weight = 37%), followed by faculty rotation comments (weight = 27%) and personal experience with residents (weight = 14%) for making judgments about learner’s milestone levels. Three assessment issues were identified from qualitative analyses: (1) “design issues” (e.g. problems with available data or lack thereof); (2) “synthesis issues” (e.g. factors influencing ratings and decision-making processes) and (3) “impact issues” (e.g. how CCC generated milestones ratings are used).Conclusions: Identifying factors that affect assessment at all stages of the CCC process can contribute to improving assessment systems, including support for faculty development for CCCs. Recognizing challenges in synthesizing first and second-hand assessment data is an important step in understanding the CCC decision-making process.

Development of a pharmacy resident rotation to expand decentralized clinical pharmacy services.

The development of a pharmacy resident rotation to expand decentralized clinical pharmacy services is described. In an effort to align with the initiatives proposed within the ASHP Practice Advancement Initiative, the department of pharmacy at Cleveland Clinic, a 1,400-bed academic, tertiary acute care medical center in Cleveland, Ohio, established a goal to provide decentralized clinical pharmacy services for 100% of patient care units within the hospital. Patient care units that previously had no decentralized pharmacy services were evaluated to identify opportunities for expansion. Metrics analyzed included number of medication orders verified per hour, number of pharmacy dosing consultations, and number of patient discharge counseling sessions. A pilot study was conducted to assess the feasibility of this service and potential resident learning opportunities. A learning experience description was drafted, and feedback was solicited regarding the development of educational components utilized throughout the rotation. Pharmacists who were providing services to similar patient populations were identified to serve as preceptors. Staff pharmacists were deployed to previously uncovered patient care units, with pharmacy residents providing decentralized services on previously covered areas. A rotating preceptor schedule was developed based on geographic proximity and clinical expertise. An initial postimplementation assessment of this resident-driven service revealed that pharmacy residents provided a comparable level of pharmacy services to that of staff pharmacists. Feedback collected from nurses, physicians, and pharmacy staff also supported residents' ability to operate sufficiently in this role to optimize patient care. A learning experience developed for pharmacy residents in a large medical center enabled the expansion of decentralized clinical services without requiring additional pharmacist full-time equivalents.

What Are the Factors Influencing Implementation of Advanced Access in Family Medicine Units? A Cross-Case Comparison of Four Early Adopters in Quebec.

Introduction Advanced access is an organizational model that has shown promise in improving timely access to primary care. In Quebec, it has recently been introduced in several family medicine units (FMUs) with a teaching mission. The objectives of this paper are to analyze the principles of advanced access implemented in FMUs and to identify which factors influenced their implementation. Methods A multiple case study of four purposefully selected FMUs was conducted. Data included document analysis and 40 semistructured interviews with health professionals and staff. Cross-case comparison and thematic analysis were performed. Results Three out of four FMUs implemented the key principles of advanced access at various levels. One scheduling pattern was observed: 90% of open appointment slots over three- to four-week periods and 10% of prebooked appointments. Structural and organizational factors facilitated the implementation: training of staff to support change, collective leadership, and openness to change. Conversely, family physicians practicing in multiple clinical settings, lack of team resources, turnover of clerical staff, rotation of medical residents, and management capacity were reported as major barriers to implementing the model. Conclusion Our results call for multilevel implementation strategies to improve the design of the advanced access model in academic teaching settings.

Pediatric heart disease simulation curriculum: Educating the pediatrician.

Training guidelines state that pediatricians should be able to diagnose, manage, and triage patients with heart disease. Acutely ill cardiac patients present infrequently and with high acuity, yet residents receive less exposure to acute cardiac conditions than previous generations. Trainees must learn to manage these situations despite this gap. Simulation has been used successfully to train learners to provide acute care. We hypothesized that a simulation-based cardiac curriculum would improve residents' ability to manage cardiac patients. Pediatric residents completed 4 simulation cases followed by debriefing and a computer presentation reviewing the learning objectives. Subjects returned at 1 month for postintervention cases and again at 4-6 months to measure knowledge retention. Cases were scored by 2 raters using a dichotomous checklist. We used repeated measure ANOVA and effect size to compare groups and intra-class correlation (ICC) to assess inter-rater reliability. Twenty-five participants were enrolled. Scores were low on pretesting but showed significant improvement (P < .05) in all 4 cases. No decay was noted on late testing. Pre-post effect sizes ranged from 1.1 to 2.1, demonstrating meaningful improvement. Inter-rater reliability (ICC) ranged from 0.61 to 0.93 across cases. This novel simulation-based curriculum targets a gap in pediatric training and offers an effective way to train pediatricians. We plan to expand this curriculum to new populations of participants and have integrated it into our resident cardiology rotation.

Scheduling internal medicine resident rotations to ensure fairness and facilitate continuity of care.

Completing a residency program is a requirement for medical students before they can practice medicine independently. Residency programs in internal medicine must undergo a series of supervised rotations in elective, inpatient, and ambulatory units. Typically, a team of chief residents is charged to develop a yearly rotational schedule. This process is complex, as it needs to consider academic, managerial, regulatory, and legal restrictions while also facilitating the provision of patient care, ensuring a diverse educational experience, balancing the workload, and improving resident satisfaction. This study proposes (1) a multi-stage multi-objective optimization approach for generating yearlong weekly resident rotation schedules and (2) the use of Analytical Hierarchy Process (AHP) to compare schedules across multiple criteria to select those that are more equitable and hence to facilitate their adoption and implementation. Furthermore, the proposed approach allows the scheduling of periodic clinic rotation schemes that are commonly used to facilitate continuity of care, such as "4+1" or the "8+2" policies. In the "4+1" policy residents rotate for four consecutive weeks in different units prior to return for a week to a predetermined clinical post. Similarly, in the "8+2" policy, residents rotate eight weeks across multiple units before doing a two week rotation at a predetermined clinic.

A Self-Study Curriculum in Electromyography and Nerve Conduction Studies for Residents and Fellows.

To our knowledge, there are no freely available curricula for a focused resident or fellow rotation in electromyography and nerve conduction studies that address the Accreditation Council for Graduate Medical Education (ACGME) milestones for neurology, physical medicine and rehabilitation, clinical neurophysiology, or neuromuscular medicine. Thus, we created this curriculum to help trainees develop a basic understanding of clinical electrodiagnostic studies. The program objectives map to many of the relevant ACGME milestones, primarily those pertaining to medical knowledge, patient care, and practice-based learning and improvement. The curricular materials include an interactive, hyperlink-driven slide show with 19 educational modules, subdivided further into basic and advanced topics. We also created a 50-question multiple-choice test, paired each question with key concepts, and provided instructions on using the test results to develop a trainee-specific learning plan. Residents and fellows have been using this curriculum at the University of Michigan since 2007. The mean and median scores of 80 trainees who took the 50-item test between 2007 and 2016 were 80% and 82%, respectively, with a standard deviation of 10%. In annual surveys of neurology residents, this electromyography rotation has consistently had the highest mean approval rating of all clinical rotations in the training program. This curriculum is a complete, self-contained learning resource that may be used alone or to supplement a supervised apprenticeship for trainees who want to learn to perform electrodiagnostic studies independently. The content ensures that trainees demonstrate mastery of many of the ACGME milestones for their field.

Incorporation of lean methodology into pharmacy residency programs.

The implementation of lean methodology into pharmacy residency programs at a community teaching hospital is described. New Hanover Regional Medical Center, a community teaching hospital in southeastern North Carolina, fully adopted a lean culture in 2010. Given the success of lean strategies organizationally, this methodology was used to assist with the evaluation and development of its pharmacy residency programs in 2014. Lean tools and activities have also been incorporated into residency requirements and rotation learning activities. The majority of lean events correspond to the required competency areas evaluating leadership and management, teaching, and education. These events have included participation in and facilitation of various lean problem-solving and communication tools. The application of the 4 rules of lean has resulted in enhanced management of the programs and provides a set of tools by which continual quality improvement can be ensured. Regular communication and direct involvement of all invested parties have been critical in developing and sustaining new improvements. In addition to program enhancements, lean methodology offers novel methods by which residents may be incorporated into leadership activities. The incorporation of lean methodology into pharmacy residency programs has translated into a variety of realized and potential benefits for the programs, the preceptors and residents, and the health system. Specific areas of growth have included quality-improvement processes, the expansion of leadership opportunities for residents, and improved communication among program directors, preceptors, and residents.

Assessment of a Novel Point-of-Care Ultrasound Curriculum's Effect on Competency Measures in Family Medicine Graduate Medical Education.

Point-of-care ultrasound has been shown to decrease the use of expensive diagnostic studies and improve quality outcome measures. Currently, there is a large desire for training in family medicine residencies, but very few programs have established curricula. We sought to develop a family medicine residency curriculum and evaluate it with tools we developed. We wanted our curriculum to be easy to adopt by other residency programs, even if they did not have many well-trained ultrasound faculty. We developed a curriculum in the form of a 4-week rotation in a family medicine residency program. It consisted of self-study videos, hands-on training, and image review. We followed residents in postgraduate years 1 to 3 over a 12-month period. We developed tools, including a knowledge exam, to test image interpretation and clinical decision making, an observed structured clinical exam to assess scanning skills, and a survey to assess perceptions of point-of-care ultrasound in family medicine. The assessments were administered before and after each resident's rotation. Seventeen residents completed the rotation. The average knowledge test score improved significantly, from 62 to 84%. The average observed structured clinical exam scores also improved significantly, from 41 to 85%. The average perception survey scores improved slightly from 4.4 to 4.6. We developed a point-of-care ultrasound curriculum for family medicine residency programs that improves measures of resident attitude, skills, and knowledge. This curriculum can be adopted by residency programs with few faculty members who are experienced in ultrasound.

Comments on "Emergency Medicine Resident Rotations Abroad: Current Status and Next Steps".

Comments on "Emergency Medicine Resident Rotations Abroad: Current Status and Next Steps".

Evaluation of Appropriateness Admission and Hospital Stay at Educational Hospital.

Appropriate admissions and patients' length of stay are two of the most important indicators of efficient health care delivery in hospitals. Paying due attention to these indicators may lead to optimal use of hospital resources as well as provision of ambulatory services to a larger population of patients. The purpose of the current study is to quantify the rate of inappropriate hospital admissions and days of hospital stay to identify factors affecting them. Data were collected regarding admissions and length of stay of 1815 patients admitted to an educational hospital in Tehran, Iran, with a total 12,629 days of hospitalization using the Appropriateness Evaluation Protocol. A qualitative study was conducted using content analysis method by analyzing data from interviews with the hospital personnel about the factors affecting patients' length of stay. The results indicated that the average length of stay in medical and surgical wards was 9.4 to 6.3 days, and 8.5% of admissions and 3.4% of stays were inappropriate. The necessity to receive nursing care and/or to receive medical services and/or the patients' conditions accounted for 57.6% of total hospitalization days, followed by the need to receive nursing care alone (36.6%). Planning/Procedures/ Personnel factors were responsible for 77.3% of inappropriate stays. The qualitative study revealed that in addition to sound in house policy setting, abundance of suitable equipment and facilities at the hospital site had positively affected the appropriateness of hospital stay while incoordination of health care delivery groups, rotation of residents and other wards personnel and lack of a proper complementary patient follow-up system, had a negative impact on the same indicator. Inappropriate admissions and inappropriate stays are influenced by numerous factors, both inside and outside of the hospitals; the results of the current study indicate that structural factors such as techniques adopted in the studied hospital, contributed significantly to decreasing inappropriate stays. Improving and upgrading these techniques will make optimal use of hospital beds possible.

Surgical Pathology Resident Rotation Restructuring at a Tertiary Care Academic Center

Changes in the field of pathology and resident education necessitate ongoing evaluation of residency training. Evolutionary change is particularly important for surgical pathology rotations, which form the core of anatomic pathology training programs. In the past, we organized this rotation based on subjective insight. When faced with the recent need to restructure the rotation, we strove for a more evidence-based process. Our approach involved 2 primary sources of data. We quantified the number of cases and blocks submitted per case type to estimate workload and surveyed residents about the time required to gross specimens in all organ systems. A multidisciplinary committee including faculty, residents, and staff evaluated the results and used the data to model how various changes to the rotation would affect resident workload, turnaround time, and other variables. Finally, we identified rotation structures that equally distributed work and created a point-based system that capped grossing time for residents of different experience. Following implementation, we retrospectively compared turnaround time and duty hour violations before and after these changes and surveyed residents about their experiences with both systems. We evaluated the accuracy of the point-based system by examining grossing times and comparing them to the assigned point values. We found overall improvement in the rotation following the implementation. As there is essentially no literature on the subject of surgical pathology rotation organization, we hope that our experience will provide a road map to improve pathology resident education at other institutions.

Increasing the Value of VTE Prophylaxis in Patients Admitted to a Subspecialty Gastroenterology Inpatient Service

Introduction: Patients that are admitted to the inpatient subspecialty GI service who are eligible for venous thromboembolism (VTE) prophylaxis are routinely being managed with unfractionated heparin (UFH) instead of low-molecular weight heparin (LMWH), resulting in more costly care. LMWH has a lower tendency towards bleeding, is cheaper (per hospital day) and is dosed on a less frequent basis when compared to UFH. Methods: As part of continuous quality improvement (QI), we sought to increase the use of LMWH for VTE prophylaxis in this unique patient population to reduce the patient cost and increase the value of care. The Plan-Do-Study-Act (PDSA) model was used to allow for rapid idea development, intervention implementation, outcome measurement and turnaround if another intervention was to be tried. To measure the magnitude of the problem, admission data was reviewed for the length of one resident rotation cycle (5 weeks). Intervention(s) were devised after interviewing the residents at the end of their service period. Two interventions were devised: 1) Placing a reminder placard on the computer monitor bezel and 2) incorporate VTE prophylaxis education during the rotation orientation session. Data was again collected after the interventions over another 5 week resident cycle. Results: Before the intervention implementation, 97 patients were admitted to the resident service over a 5 week rotation period. Of these, 39 (40%) were eligible for VTE prophylaxis and 33 (85%) were managed with UFH compared to just 5 (13%) managed with LMWH. One patient refused VTE prophylaxis. After the combined intervention, 110 patients were admitted over the 5 week rotation period. Of these, 56 (51%) were eligible for VTE prophylaxis and 53 (95%) of them were managed with LMWH. This represented an increase of LMWH use by 7 times and reduced patient cost of VTE prophylaxis by 57% (2015 dollars) when compared to the previous rotation cycle. Reasons for prophylaxis ineligibility included active GI hemorrhage, already being on therapeutic anticoagulation, hospitalization of of < 24 hours and planned procedure within 24 hours. Conclusion: A simple, cost-effective, durable and brief intervention (using two QI strategies) can lead to a decrease in VTE prophylaxis cost and thus improvement in value.

Effect of a Global Surgery Resident Rotation on Physician Practices after Residency: The Mount Sinai Experience

Effect of a Global Surgery Resident Rotation on Physician Practices after Residency: The Mount Sinai Experience

Impact of Resident Rotations on Critically Ill Patient Outcomes: Results of a French Multicenter Observational Study.

PurposeThe impact of resident rotation on patient outcomes in the intensive care unit (ICU) has been poorly studied. The aim of this study was to address this question using a large ICU database.MethodsWe retrospectively analyzed the French CUB-REA database. French residents rotate every six months. Two periods were compared: the first (POST) and fifth (PRE) months of the rotation. The primary endpoint was ICU mortality. The secondary endpoints were the length of ICU stay (LOS), the number of organ supports, and the duration of mechanical ventilation (DMV). The impact of resident rotation was explored using multivariate regression, classification tree and random forest models.Results262,772 patients were included between 1996 and 2010 in the database. The patient characteristics were similar between the PRE (n = 44,431) and POST (n = 49,979) periods. Multivariate analysis did not reveal any impact of resident rotation on ICU mortality (OR = 1.01, 95% CI = 0.94; 1.07, p = 0.91). Based on the classification trees, the SAPS II and the number of organ failures were the strongest predictors of ICU mortality. In the less severe patients (SAPS II<24), the POST period was associated with increased mortality (OR = 1.65, 95%CI = 1.17–2.33, p = 0.004). After adjustment, no significant association was observed between the rotation period and the LOS, the number of organ supports, or the DMV.ConclusionResident rotation exerts no impact on overall ICU mortality at French teaching hospitals but might affect the prognosis of less severe ICU patients. Surveillance should be reinforced when treating those patients.

A Checklist Intervention to Assess Resident Diagnostic Knee and Shoulder Arthroscopic Efficiency

The purpose of this investigation was to apply an arthroscopic shoulder and knee checklist in the evaluation of orthopedic resident arthroscopic skill efficiency and to demonstrate the use of a surgical checklist for assessing resident surgical efficiency over the course of a surgical rotation. Orthopedic surgery residents rotating on the sports medicine service at our institution between 2011 and 2015 were enrolled in this study. Residents were administered a shoulder and knee arthroscopy assessment tool at the beginning and end of their 6-week rotation. The assessment tools consisted of checklist items for knee and shoulder arthroscopy skills. Residents were timed while performing these checklist tasks. The primary outcome measure was resident improvement as a function of time to completion for the checklist items, and the intervention was participation in a 6-week resident rotation with weekly arthroscopy didactics, cadaver simulator work, and operating room experience. A paired t test was used to compare means. Mean time to checklist completion during week 1 among study participants for the knee checklist was 787.4 seconds for the knee checklist and 484.4 seconds at the end of the rotation. Mean time to checklist completion during week 1 among study participants for the shoulder checklist was 1655.3 seconds and 832.7 seconds for the shoulder checklist at the end of the rotation. Mean improvement in time to completion was 303 seconds (p = 0.0006, SD = 209s) and 822.6 seconds (p = 0.00008, SD = 525.2s) for the arthroscopic knee and shoulder assessments, respectively. An arthroscopic checklist is 1 method to evaluate and assess resident efficiency and improvement during surgical training. Among residents participating in this study, we found statistically significant improvements in time for arthroscopic task completion. II.

General surgery resident rotations in surgical critical care, trauma, and burns: what is optimal for residency training?

BackgroundThere are no specific Accreditation Council for Graduate Medical Education General Surgery Residency Program Requirements for rotations in surgical critical care (SCC), trauma, and burn. We sought to determine the experience of general surgery residents in SCC, trauma, and burn rotations. MethodsData analysis of surgical rotations of American Board of Surgery general surgery resident applicants (n = 7,299) for the last 8 years (2006 to 2013, inclusive) was performed through electronic applications to the American Board of Surgery Qualifying Examination. Duration (months) spent in SCC, trauma, and burn rotations, and postgraduate year (PGY) level were examined. ResultsThe total months in SCC, trauma and burn rotations was mean 10.2 and median 10.0 (SD 3.9 months), representing approximately 16.7% (10 of 60 months) of a general surgery resident's training. However, there was great variability (range 0 to 29 months). SCC rotation duration was mean 3.1 and median 3.0 months (SD 2, min to max: 0 to 15), trauma rotation duration was mean 6.3 and median 6.0 months (SD 3.5, min to max: 0 to 24), and burn rotation duration was mean 0.8 and median 1.0 months (SD 1.0, min to max: 0 to 6). Of the total mean 10.2 months duration, the longest exposure was 2 months as PGY-1, 3.4 months as PGY-2, 1.9 months as PGY-3, 2.2 months as PGY-4 and 1.1 months as PGY-5. PGY-5 residents spent a mean of 1 month in SCC, trauma, and burn rotations. PGY-4/5 residents spent the majority of this total time in trauma rotations, whereas junior residents (PGY-1 to 3) in SCC and trauma rotations. ConclusionsThere is significant variability in total duration of SCC, trauma, and burn rotations and PGY level in US general surgery residency programs, which may result in significant variability in the fund of knowledge and clinical experience of the trainee completing general surgery residency training. As acute care surgery programs have begun to integrate emergency general surgery with SCC, trauma, and burn rotations, it is an ideal time to determine the optimal curriculum and duration of these important rotations for general surgery residency training.

A Web-Based Operating Room Management Educational Tool

In 2010, our department instituted a nonclinical, administrative rotation in operating room management for anesthesiology residents. Subsequently, we mandated the rotation for all senior anesthesiology residents in 2013. In 2014, under the auspices of the American Society of Anesthesiologists, we developed a web-based module covering the basics of finance, accounting, and operating room management. A multiple-choice test was given to residents at the beginning and end of the rotation, and we compared the mean scores between residents who took the traditional course and residents who took the web-based module. We found no significant difference between the groups of residents, suggesting that the web-based module is as effective as traditional didactics.

Uniting Evidence-Based Evaluation with the ACGME Plastic Surgery Milestones: A Simple and Reliable Assessment of Resident Operative Performance

Milestones evaluations in plastic surgery reflect a shift toward competency-based training but have created a number of challenges. The authors have incorporated the smartphone application evaluation tool, System for Improving and Measuring Procedural Learning (SIMPL), that was recently developed by a multi-institutional research collaborative. In this pilot study, the authors hypothesize that SIMPL can improve resident evaluation and also collect granular performance data to simplify compliance with the plastic surgery Milestones. SIMPL was prospectively piloted with a plastic surgery resident and faculty surgeon at Massachusetts General Hospital in this institutional review board-approved study. The study period was a 2-month interval corresponding to the resident's rotation. The resident-faculty combination performed 20 cases together. All cases were evaluated with SIMPL. SIMPL evaluations uniformly took under 1 minute to submit. The average time to completed evaluation from surgery completion was 5 hours (<0.5 hour to 12 hours). Concrete, objective, and specific data about resident performance were collected for every case and presented in a concise format. SIMPL is an innovative, evidence-based evaluation system that makes performance assessment feasible for every procedure in which a plastic surgery resident participates. SIMPL's competency-based framework can be easily scaled to facilitate data collection and reporting of mandatory Milestones evaluations at the program and national levels. This technology will support a shared vocabulary between residents and faculty to enhance intraoperative education.

Formal Empathy Training During a Two-Week Patient Experience Rotation for Residents

Formal Empathy Training During a Two-Week Patient Experience Rotation for Residents