Resident Teams Research Articles

Narcotic Prescriptions for Benign Gynecologic Procedures in a Tertiary Care Facility [30H

INTRODUCTION: Narcotic addiction has been linked to legal prescription of narcotics by physicians. Narcotic prescriptions for gynecologic surgical procedures vary widely and little data exist to quantify prescribing practices. The present study aimed to describe narcotic prescription practices in gynecologic surgeries. METHODS: We examined gynecologic cases in a retrospective chart review of 8 months from 2014 to 2015. Patient characteristics (age, weight, insurance status, prior narcotic prescription, race, ethnicity, resident team or private physician) and discharge prescription data were collected from 549 cases. Prescriptions were converted into equivalent oral morphine doses for comparison (e.g. 5 mg oxycodone equals 7.5 mg oral morphine). RESULTS: Prescriptions associated with open gynecologic procedures were significantly larger than all other procedure types (P < .001); inpatient laparoscopy prescriptions were larger than any outpatient procedures (P < .001). Mean total prescriptions for surgery categories (in milligrams of oral morphine) were: vulvar and cervical - 90; uterine (e.g. hysteroscopy, dilation and curettage) - 50; outpatient laparoscopy - 137; inpatient laparoscopy and vaginal surgery - 267; and open - 323. No significant differences were correlated to age, weight, race, insurance, or care team. Of note, 43% of patients had a narcotic prescription in the five years preceding surgery. CONCLUSION: Narcotic prescription practices are widely varied, and significantly different between procedure types. Many patients have prescription narcotic exposure prior to a gynecologic procedure. More study is needed to evaluate how much narcotic patients utilize for gynecologic procedures to avoid excessive prescribing.

MP22: The impact of collaborative social media promotion on the dissemination of CJEM articles

Introduction: The CJEM Social Media Team was created in 2014 to assist the journal with the dissemination of its research online. It consists of two Social Media Editors (Junior and Senior) and a team of volunteer medical students and residents to assist their work. Collaborative promotional agreements were developed to promote CJEM articles on the Skeptics’ Guide to Emergency Medicine (SGEM) podcast through the ‘Hot off the Press’ (HOP) series and the CanadiEM blog through an infographic series. Methods: CJEM papers were selected for promotion by the Team based on their perceived interest to the online community of emergency physicians. Altmetric scores, which are a measure of online dissemination derived from a weighted algorithm of social media metrics, were collated for articles promoted using the SGEM HOP or CanadiEM blogs. A control group was created using the articles with the top two Altmetric scores in each CJEM issue in 2015 and 2016. Erratum, Letters, and articles written by the social media editors were excluded from the control groups. The success of the social media promotion was quantified through the measurement of Altmetric scores as of January 1, 2017. Unpaired two-tailed t-tests with unequal variance were used to test for significant differences. Results: 106 and 82 eligible articles were published in 2015 and 2016, respectively. Four articles in 2015 and two articles in 2016 were excluded from the control groups because they were written by the social media editors. SGEM HOP podcasts promoted one article in 2015 and five articles in 2016. CanadiEM infographics promoted three articles in 2015 and eight articles in 2016. No articles were promoted in both series. The average Altmetric score was higher for SGEM HOP (61.0) than CanadiEM Infographics (31.5, p<0.04), 2015 controls (15.8, p<0.01), and 2016 controls (13.6, p<0.01). The average Altmetric score for CanadiEM Infographics was higher than 2015 controls (p<0.04) and 2016 controls (p<0.02). There was no significant difference between the control groups. Conclusion: The results suggest that collaborating with established social media websites to promote CJEM articles using podcasts and infographics increases their social media dissemination. Given the nonrandomized design of these results, causative conclusions cannot be drawn. A randomized study of the impact of social media promotion on readership is underway.

Use of a 90-Minute Admission Window and Front-Fill System to Reduce Work Compression on a General Medicine Inpatient Teaching Service.

Duty hour limits have shortened intern shifts without concurrent reductions in workload, creating work compression. Multiple admissions during shortened shifts can result in poor training experience and patient care. To relieve work compression, improve resident satisfaction, and improve duty hour compliance in an academic internal medicine program. In 2014, interns on general ward services were allotted 90 minutes per admission from 3 pm to 7 pm, when the rate of admissions was high. Additional admissions arriving during the protected period were directed to hospitalists. Resident teams received 2 patients admitted by the night float team to start the call day (front-fill). Of the 51 residents surveyed before and after the implementation of the intervention, 39 (77%) completed both surveys. Respondents reporting an unmanageable workload fell from 14 to 1 (P < .001), and the number of residents reporting that they felt unable to admit patients in a timely manner decreased from 14 to 2 (P < .001). Reports of adequate time with patients increased from 16 to 36 (P < .001), and residents indicating that they had time to learn from patients increased from 19 to 35 (P < .001). Reports of leaving on time after call days rose from 12 to 33 (P < .01), and overall satisfaction increased from 26 to 35 (P = .002). Results were similar when residents were resurveyed 6 months after the intervention. Call day modifications improved resident perceptions of their workload and time for resident learning and patient care.

The University of North Carolina Medical Center pharmacy resident leadership certificate program.

The development and implementation of a certificate program for pharmacy residents are described. University of North Carolina (UNC) Medical Center met the call for increased efforts in the area of pharmacy residency leadership training through the design, implementation, and evaluation of a leadership certificate program. The purpose of the UNC certificate program is to develop leaders who will serve others, improve their communities, and advance the profession. The program is designed to (1) foster self-awareness, social awareness, and altruism, (2) provide transferable and individualized leadership experiences, (3) enrich other residency components through integration of leadership development opportunities, and (4) create role models for departmental leadership. A team of preceptors and residents implemented the certificate program by integrating program components into the existing pharmacy residency infrastructure. The certificate program includes required and flexible components to allow residents to set and achieve their determined leadership development goals. Overall, residents are satisfied with the program and perceive it as worthwhile. During the first 3 years since implementation of the certification initiative, program facilitators improved the feasibility of, participant engagement in, and sustainability of the program. Future directions include an effectiveness evaluation and a "scale-up" to other institutions. The need for a pharmacy residency leadership certificate was met by designing, implementing, and evaluating such a program at UNC. Through its first 3 years, the program was feasible, sustainable, and valued by program participants.

Hematology and oncology patient perceptions of inpatient care coordination at an urban academic teaching center.

109 Background: Outpatient doctors increasingly defer inpatient care to hospital-based physicians. At academic medical centers, inpatient care coordination is further complicated by frequent handoffs between resident teams. Breaks in inpatient care continuity may disproportionately affect hematology and oncology patients, given their often complicated longitudinal histories and specialized problems. We sought to understand hematology and oncology patient perceptions of inpatient care coordination at Massachusetts General Hospital (MGH). Methods: Between July 2014 and June 2015, patients admitted to any MGH service were randomly selected to complete a survey about their perception of inpatient care coordination. In total, 1,783 patients responded. Of these, 158 were admitted to hematology or oncology. Hematology and oncology patient responses were compared to all MGH patient responses using chi-squared analysis, with p values less than or equal to 0.05 used as the threshold for statistical significance. Responses reflect the percentage of patients who chose the “top box” option. Results: Compared to all MGH patients, hematology and oncology patients were significantly more likely to recognize a clearly identified doctor responsible for their care while in the hospital (85% vs 74%, p = 0.003) and to perceive the presence of a responding clinician at all times (79% vs 66%, p = 0.001). Hematology/oncology patients were also much more likely to report seeing their longitudinal MGH doctors while admitted (77% vs 57%, p &lt; 0.001). However, despite more frequent in-person visits by outpatient physicians, significantly fewer hematology/oncology patients reported perceiving that their outpatient doctor receives discharge information (47% vs 64%, p = 0.005). Conclusions: MGH hematology and oncology patients reported stronger inpatient care coordination and higher frequency of outpatient physician visits than MGH patients overall. Nevertheless, patients perceived less frequent coordination of discharge information with outpatient physicians. More research is needed to understand whether patient perceptions of care coordination correlates with clinical and utilization outcomes.

Using Simulation to Conduct a Usability Study of Wearable Technology

BackgroundThis study had two purposes. First, to assess the usability and perceived ease of use (PEU) of a head-mounted display (HMD) in the health care environment. Second, to assess whether the use of a remote teleconsultant intensivist via a HMD improves the management of a simulated cardiac arrest. The use of technology, specifically HMDs (such as Google Glass™), is becoming more popular, especially in health care. However, the efficacy, usability, and PEU have not been studied to any great extent. Assessing new technology is an important step when considering potential implementation in a patient care setting. Using simulation to assess the usability and the PEU is one method that can provide insight into the viability of new technology. MethodsNine teams of internal medicine residents (31 individuals) participated in this study conducted in a simulation center with a high-technology patient simulator. Resident teams were randomized to the availability of a remote intensivist via teleconsultation using a HMD. The residents were asked to provide care to a patient and had the opportunity to activate the HMD for assistance. ResultsThe main outcome measure was the PEU and usefulness of the HMD during a cardiac arrest. Although the PEU and perceived usefulness of the HMD were not different between the teams, the team leaders, who used the HMD during the scenario, scored the device as more useful than other team members. The second outcome of proper management of a critical patient was not improved with the use of a HMD. ConclusionsReal-time video communication via a HMD was seen as potentially useful by the team leaders, but not by team members. In addition, the use of a HMD for communication did not improve the management of a simulated patient. New technologies, including wearable, HMDs may have their role in health care, but must first be tested for efficacy, ease of use, and perceived usefulness in realistic simulated patient environments. Introducing new technology in a simulated environment may aide in their adoption in clinical environments or prevent dangerous and costly missteps.

Validity of ultrasound in diagnosis of tendon injuries in penetrating extremity trauma

BackgroundTendon ruptures are common musculoskeletal injuries all around the world. Correct and timely diagnosis of tendon injuries is obviously important for improving the treatment and minimizing the community costs. Ultrasound is now being considered as one of useful modalities in this area. ObjectiveThe preset study is going to validate the diagnostic ability of ultrasound in tendon injuries induced by penetrating extremity trauma. MethodsIn this prospective, observational study, patients with penetrating extremity trauma and suspicion of tendon injuries were enrolled in our study. A team of emergency medicine (EM) residents performed ultrasound examination in these cases after attending the specific workshop and acquiring necessary skills in normal and abnormal tendon ultrasound examination. Then another team of either EM or orthopedic residents explored patients' wounds and determined intact or injured tendons under direct visual observation. The results were analyzed to validate sensitivity and specificity of ultrasound as an alternative diagnostic test. ResultsSeventy-one patients were enrolled in our study and 11 patients were excluded during one year in 2014. Sixty patients, 11 with lower extremity and 49 with upper limb injuries were evaluated, among them 32 patients had extensor zone and 28 patients had flexure zone injuries. The overall sensitivity and specificity were calculated 94.4% (95% CI 72.7–99.8%) and 100% (95% 91.5–100.0%) respectively. ConclusionsOur results were similar to previous findings. Ultrasound can effectively differentiate injured from intact tendons in penetrating extremity trauma.

MULTIFAMILY AFFORDABLE HOUSING THAT IS HEALTHY, EFFICIENT, COST EFFECTIVE AND LEED PLATINUM

INTRODUCTION A developer who had chronic asthma as a child built the first LEED® (Leadership in Energy and Environmental Design) Platinum certified apartment complex in Idaho. He has also heard from two residents that their asthma no longer resulted in attacks due to eliminating triggers in the interior environment. Eight years and a dozen multifamily affordable housing projects later, the LEED consultant on these projects has gathered insight on best practices, lessons learned and strategies that result in resident, owner and project team satisfaction. Ten projects have achieved LEED Platinum certification (two more are still under construction, but are on track for Platinum), and the HERS (Home Energy Rating System) scores are as low as 48. Feedback has been collected on what works, what doesn't and what matters most: from low energy bills to living in a healthy home and not having asthma attacks. These projects debunk the assumptions that energy efficiency adds too much cost or that green homes are only for the wealthy.

Professionalism in the Twilight Zone: A Multicenter, Mixed-Methods Study of Shift Transition Dynamics in Surgical Residencies.

Duty hours rules sparked debates about professionalism. This study explores whether and why general surgery residents delay departures at the end of a day shift in ways consistent with shift work, traditional professionalism, or a new professionalism. Questionnaires were administered to categorical residents in 13 general surgery programs in 2014 and 2015. The response rate was 76% (N = 291). The 18 items focused on end-of-shift behaviors and the frequency and source of delayed departures. Follow-up interviews (N = 39) examined motives for delayed departures. The results include means, percentages, and representative quotations from the interviews. A minority (33%) agreed that it is routine and acceptable to pass work to night teams, whereas a strong majority (81%) believed that residents exceed work hours in the name of professionalism. Delayed departures were ubiquitous: Only 2 of 291 residents were not delayed for any of 13 reasons during a typical week. The single most common source of delay involved a desire to avoid the appearance of dumping work on fellow residents. In the interviews, residents expressed a strong reluctance to pass work to an on-call resident or night team because of sparse night staffing, patient ownership, an aversion to dumping, and the fear of being seen as inefficient. Resident behavior is shaped by organizational and cultural contexts that require attention and reform. The evidence points to the stunted development of a new professionalism, little role for shift-work mentalities, and uneven expression of traditional professionalism in resident behavior.

Assessing the Impact and Cost of Short-Term Health Workforce in Remote Indigenous Communities in Australia: A Mixed Methods Study Protocol.

BackgroundRemote Australia is a complex environment characterized by workforce shortages, isolated practice, a large resident Indigenous population, high levels of health need, and limited access to services. In recent years, there has been an increasing trend of utilizing a short-term visiting (fly-in/fly-out) health workforce in many remote areas. However, there is a dearth of evidence relating to the impact of this transitory workforce on the existing resident workforce, consumer satisfaction, and the effectiveness of current services.ObjectiveThis study aims to provide rigorous empirical data by addressing the following objectives: (1) to identify the impact of short-term health staff on the workload, professional satisfaction, and retention of resident health teams in remote areas; (2) to identify the impact of short-term health staff on the quality, safety, and continuity of patient care; and (3) to identify the impact of short-term health staff on service cost and effectiveness.MethodsMixed methods will be used. Administrative data will be extracted that relates to all 54 remote clinics managed by the Northern Territory Department of Health, covering a population of 35,800. The study period will be 2010 to 2014. All 18 Aboriginal Community-Controlled Health Services in the Northern Territory will also be invited to participate. We will use these quantitative data to describe staffing stability and turnover in these communities, and then utilize multiple regression analyses to determine associations between the key independent variables of interest (resident staff turnover, stability or median survival, and socioeconomic status, community size, and per capita funding) and dependent variables related to patient care, service cost, quality, and effectiveness. The qualitative component of the study will involve in-depth interviews and focus groups with staff and patients, respectively, in six remote communities. Three communities will be high staff turnover communities and three characterized by low turnover. This will provide information on service quality, impact on resident and visiting staff, and patient satisfaction with the services. The research team will work with staff, patients, and a key stakeholder group of senior policymakers to develop workforce strategies to maintain or attain remote health workforce stability.ResultsThe study commenced in 2015. As of October 2016, fieldwork has been almost completed and quantitative analysis has commenced. Results are expected to be published in 2017.ConclusionsThe study has commenced, but it is too early to provide results or conclusions.

Improving Colorectal Cancer Screening and Surveillance Compliance with a Multidisciplinary Approach in the Outpatient Setting

Introduction: Colorectal cancer (CRC) is a common and preventable malignancy. Studies have shown that removal of premalignant adenomas can prevent cancer and cancer-related deaths. Screening tools have improved the incidence and mortality rates of CRC, along with shifting from late to early stage disease. Therefore, it is important to encourage preventative CRC screening (CRCS) and surveillance by primary care physicians. In this internal medicine outpatient office, compliance rate for CRCS and surveillance was below average at 53% in June 2015. The aim for this project was to develop and implement a tool to improve CRCS and surveillance compliance by 5% within a 12-month time frame among this practice's patients. Methods: We identified barriers to compliance which included lack of health literacy among this patient population, inability to do proper CRCS counseling in a 20-min office visit, and lack of knowledge about fecal immunochemical tests (FIT) as options among medical assistants (MA). We formed a multidisciplinary team of case manager, residents, faculty, and MAs to develop a Plan-Do-Study-Act (PDSA) for performance improvement. We used a quality assessment metrics program called Dashboard to assess compliance. Any patient who was non-compliant in both first and subsequent CRCS were identified. Interventions included educating the MAs on how to use FIT so they are motivated and empowered to provide this to patients, increasing educational information for patients about colonoscopy procedures and offering the option of FIT tests to non-compliant patients, and creating a preventative care form for each visit in order to alert physicians if patients are not up to date on preventative screening. The team met every month to evaluate ongoing progress. Compliance was measured monthly through Dashboard. Results: Since the implementation of the PDSA, compliance for CRCS in the internal medicine outpatient office has continued to improve 1-2% every month. In a 7-month period the compliance rate rose 12% from 53% to 65%. The result of the PDSA accomplished and then surpassed our initial clear aim. Conclusion: The team is continuing to meet on monthly bases to evaluate and modify our metrics to further improve our compliance rate. The implementation of the PDSA with the resulting rapid improvement demonstrates how a multidisciplinary approach for preventative care can improve patients' compliance for CRCS. We hope that this plan can be extrapolated to other gaps in preventative healthcare.Figure 1

Factors Associated With Resident Continuity in Ambulatory Training Practices.

Continuity of care is a critical element of residents' educational experience in primary care programs. We examined how continuity in resident practices compares to nonteaching practices, identified factors associated with increased continuity, and explored the association between continuity and quality measures. We analyzed 117 235 patient visits to 4 resident practices (26 resident teams in internal medicine, pediatrics, family medicine, and medicine-pediatrics) and 270 242 visits to nonteaching community practices between July 2013 and May 2014. We defined continuity from both clinician and patient perspectives, and used logistic regression models to examine the influence of factors on continuity while controlling for postgraduate year, patient age, gender, race, and insurance. Continuity was greater at nonteaching sites compared to resident practices (87.3% versus 56.2%, P < .001). Resident continuity ranged from 33.1% to 83.7% among resident sites. Factors associated with improved resident continuity included absence of advanced practice providers (71.5% versus 52.3%); consistent use of scheduling protocols (77.5% versus 33.1%); rescheduling policies (71.5% versus 41.3%); increased faculty clinical time (71.5% versus 46.3%); and dismissal policies for excessive missed appointments (71.5% versus 62.5%, P < .001 for all). Increased continuity was associated with improved rates of diabetic control (62.8% versus 54.6%); hypertension control (82.8% versus 57.5%); screening colonoscopy (69.2% versus 31.9%); and mammography (74.8% versus 38.2%, P < .001 for all). Increased clinical faculty time, scheduling protocols, and absence of advanced practice providers were most strongly associated with increasing continuity. Increased continuity was associated with improved quality measures.

The Battle of the Bulb

Albany Bulb, a former landfill, is a thirty-one-acre battleground for the Bay Area’s competing progressive movements for social justice, environmental conservation, and politically engaged art. Street protest, lawsuits, regulatory jockeying, anarchist camp-ins, and art have all been deployed in the name of saving this oddball spit of land from and for its users of many species. Drawing from information collected over sixteen years of visits to the Bulb, including scores of hours of interviews beginning in 2013, this essay brings together work from an interdisciplinary team of UC Berkeley students and Bulb residents to apply techniques of ethnography, contemporary archaeology, oral history, participatory mapping, mobile apps, botany, architecture, landscape architecture, and urban planning to the study of the Bulb.

Gendered Innovations in Orthopaedic Science: Family Planning: An Orthopaedic Issue.

Gendered Innovations in Orthopaedic Science: Family Planning: An Orthopaedic Issue.

Effects of adding a new PCMH block rotation and resident team to existing longitudinal training within a certified PCMH: primary care residents' attitudes, knowledge, and experience.

BackgroundAlthough the patient-centered medical home (PCMH) model is considered important for the future of primary care in the USA, it remains unclear how best to prepare trainees for PCMH practice and leadership. Following a baseline study, the authors added a new required PCMH block rotation and resident team to an existing longitudinal PCMH immersion and didactic curriculum within a Level 3-certified PCMH, aiming for “enhanced situated learning”. All 39 residents enrolled in a USA family medicine residency program during the first year of curricular implementation completed this new 4-week rotation. This study examines the effects of this rotation after 1 year.MethodsA total of 39 intervention and 13 comparison residents were eligible participants. This multimethod study included: 1) individual interviews of postgraduate year (PGY) 3 intervention vs PGY3 comparison residents, assessing residents’ PCMH attitudes, knowledge, and clinical experience, and 2) routine rotation evaluations. Interviews were audiorecorded, transcribed, and analyzed using immersion/crystallization. Rotation evaluations were analyzed using descriptive statistics and qualitative analysis of free text responses.ResultsAuthors analyzed 23 interviews (88%) and 26 rotation evaluations (67%). Intervention PGY3s’ interviews revealed more nuanced understanding of PCMH concepts and more experience with system-level PCMH tasks than those of comparison PGY3s. More intervention PGY3s rated themselves “extremely prepared” to implement PCMH than comparison PGY3s; however, most self-rated “somewhat prepared”. Their reflections demonstrated deeper understanding of PCMH implementation and challenges than comparison PGY3s but inadequate experience to directly see the results of successful solutions. Rotation evaluations from PGY1, PGY2, and PGY3s revealed strengths and several areas for improvement.ConclusionAdding one 4-week block rotation to existing longitudinal training appears to improve residents’ PCMH knowledge, skills, and experience from “basic” to “intermediate”. However, this training level appears inadequate for PCMH leadership or for teaching junior learners. Further study is needed to determine the optimum training for different settings.

Industry-academic partnerships: an approach to accelerate innovation

BackgroundBiotechnology companies are process-driven organizations and often struggle with their ability to innovate. Universities, on the other hand, thrive on discovery and variation as a source of innovation. As such, properly structured academic-industry partnerships in medical technology development may enhance and accelerate innovation. Through joint industry-academic efforts, our objective was to develop a technology aimed at global cervical cancer prevention. MethodsOur Center for Medical Innovation assembled a multidisciplinary team of students, surgical residents, and clinical faculty to enter in the University of Utah's annual Bench-to-Bedside competition. Bench-to-Bedside is a university program centered on medical innovation. Teams are given access to university resources and are provided $500.00 for prototype development. Participation by team members are on a volunteer basis. Our industry partner presented the validated need and business mentorship. The team studied the therapeutic landscape, environmental constraints, and used simulation to understand human factors design and usage requirements. A physical device was manufactured by first creating a digital image (SOLIDWORKS 3D CAD). Then, using a 3-dimensional printer (Stratasys Objet30 Prime 3D printer), the image was translated into a physical object. Tissue burn depth analysis was performed on raw chicken breasts warmed to room temperature. Varying combinations of time and temperature were tested, and burn depth and diameter were measured 30 min after each trial. An arithmetic mean was calculated for each corresponding time and temperature combination. User comprehension of operation and sterilization was tested via a participant validation study. Clinical obstetricians and gynecologists were given explicit instructions on usage details and then asked to operate the device. Participant behaviors and questions were recorded. ResultsOur efforts resulted in a functional battery-powered hand-held thermocoagulation prototype in just 72 d. Total cost of development was <$500. Proof of concept trials at 100°C demonstrated an average ablated depth and diameter of 4.7 mm and 23.3 mm, respectively, corresponding to treatment efficacy of all grades of precancerous cervical lesions. User comprehension studies showed variable understanding with respect to operation and sterilization instructions. ConclusionsOur experience with using industry-academic partnerships as a means to create medical technologies resulted in the rapid production of a low-cost device that could potentially serve as an integral piece of the “screen-and-treat” approach to premalignant cervical lesions as outlined by World Health Organization. This case study highlights the impact of accelerating medical advances through industry-academic partnership that leverages their combined resources.

Examining the July Effect: A National Survey of Academic Leaders in Medicine

BackgroundWhether the “July Effect” affects perspectives or has prompted changes in US Internal Medicine residency programs is unknown. MethodsWe designed a survey-based study to assess views and efforts aimed at preventing harm in July. A convenience sampling strategy (email listserv and direct messages to program leaders via the Electronic Residency Application Service) was used to disseminate the survey. ResultsThe response rate was 16% (65/418 programs); however, a total of 262 respondents from all 50 states where residency programs are located were included. Most respondents (n = 201; 77%) indicated that errors occur more frequently in July compared with other months. The most common identified errors included incorrect or delayed orders (n = 183, 70% and n = 167, 64%, respectively), errors in discharge medications (n = 144, 55%), and inadequate information exchange at handoffs (n = 143, 55%). Limited trainee experience (n = 208, 79%), lack of understanding hospital workflow, and difficulty using electronic medical record systems (n = 194; 74% and n = 188; 72%, respectively) were reported as the most common factors contributing to these errors. Programs reported instituting several efforts to prevent harm in July: for interns, additional electronic medical record training (n = 178; 68%) and education on handoffs and discharge processes (n = 176; 67% and n = 108; 41%, respectively) were introduced. Similarly, for senior residents, teaching sessions on how to lead a team (n = 158; 60%) and preferential placement of certain residents on harder rotations (n = 103; 39%) were also reported. Most respondents (n = 140; 53%) also solicited specific “July attendings” using a volunteer system or highest teaching ratings. ConclusionResidency programs in Internal Medicine appear to have instituted various changes to mitigate harm in July. Further evaluation to understand the impact of these interventions on trainee education and patient safety is necessary.

A Time Study of Plastic Surgery Residents.

Resident work hours are under scrutiny and have been subject to multiple restrictions. The studies supporting these changes have not included data on surgical residents. We studied the workday of a team of plastic surgery residents to establish prospective time-study data of plastic surgery (PRS) residents at a single tertiary-care academic medical center. Five trained research assistants observed all residents (n = 8) on a PRS service for 10 weeks and produced minute-by-minute activity logs. Data collection began when the team first met in the morning and continued until the resident being followed completed all non-call activities. We analyzed our data from 3 perspectives: 1) time spent in direct patient care (DPC), indirect patient care, and didactic activities; 2) time spent in high education-value activities (HEAs) versus low education-value activities; and 3) resident efficiency. We defined HEAs as activities that surgeons must master; other activities were LEAs. We quantified resident efficiency in terms of time fragmentation and time spent waiting. A total of 642.4 hours of data across 50 workdays were collected. Excluding call, residents worked an average of 64.2 hours per week. Approximately 50.7% of surgical resident time was allotted to DPC, with surgery accounting for the largest segment of this time (34.8%). Time spent on HEAs demonstrated trended upward with higher resident level (P = 0.086). Time in spent in surgery was significantly associated with higher resident levels (P < 0.0001); 57.7% of activities require 4 minutes or less, suggesting that resident work was highly fragmented. Residents spent 10.7% of their workdays waiting for other services. In this first-time study of PRS residents, we found that compared with medicine trainees, surgical residents spent 3.23 times more time on DPC. High education-value activities comprised most of our residents' workdays. Surgery was the leading component of both DPC and HEAs. Our residents were highly efficient and fragmented, with the majority of all activities requiring 4 minutes or less. Residents spent a large portion of their time waiting for other services. In light of these data, we suggest that future changes to residency programs be pilot tested, with preimplantation and postimplementation time studies performed to quantify the changes' impact.

P054: Development of a hospital-wide program for simulation-based training in trauma care and management

Introduction: The Queen Elizabeth II Health Sciences Centre (QEII HSC) is a Level I trauma center that provides tertiary care services to the province of Nova Scotia (pop. 940,592) and quaternary care services to Atlantic Canada (population &gt; 2.4 million). The objective of this study was to describe and evaluate the development of an inter-professional hospital-wide trauma simulation that was performed at the QEII HSC in June of 2015. Methods: The simulation was performed in the dedicated trauma resuscitation bay in the emergency department of the trauma centre using SimMan equipment. The scenario involved a 35-year-old male pedestrian versus car at approximately 70 km. The patient required immediate resuscitation and transfer to the operating room for an emergency laparotomy. Evaluation of the simulation was through video feedback, time stamping, piloting of resident Trauma Team Activation evaluation, observation for latent safety issues, and participant feedback. Trauma team members were unaware of simulation prior to arrival. Results: Feedback received from simulation participants indicated that this exercise was incredibly “real” for them. Using the usual emergency department patient registration proved difficult in this simulation exercise, both for activation of the massive transfusion protocol and transfer of the patient to the operating room. Latent safety issues identified included a lack of communication with the operating room and unavailability of some resuscitation equipment. Debriefing after the event was felt to be important by all participants of the simulation. Having evaluators dedicated to observing specific aspects of the simulation would facilitate these exercises. Patient care was not interrupted in the emergency department or the operating room. Conclusion: The in situ simulation was a valuable experience for the trauma program, stakeholders, and all participants. Based on this trial simulation, additional simulations will be held within our trauma program. Further research is required to validate long-term retention of skills and knowledge, and to evaluate the impact of simulation training on staff performance and trauma patient outcomes.

A Few Good Words.

On Being a Doctor19 April 2016A Few Good WordsChristopher Moriates, MDChristopher Moriates, MDFrom University of California, San Francisco, San Francisco, California.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M15-2198 Audio Reading - “A Few Good Words” Audio. Michael A. LaCombe, MD, Annals Associate Editor, reads "A Few Good Words," by C. Moriates. Your browser does not support the audio element. Audio player progress bar Step backward in current audio track Play current audio trackPause current audio track Step forward in current audio track Mute current audio trackUnmute current audio track 00:00/ SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail “Do you have any questions?” I asked. My team of residents and medical students standing around the bed began to slump a bit. We had 10 more patients to see this morning, and we were already falling behind. As I asked the question, my brain immediately began chanting, “Please don't, please don't, please don't.” I thought the chant was quiet enough that only I could hear it, but my patient seemed to read my mind. She was an elderly woman with cancer, admitted with shortness of breath due to fluid that had built up around her lung. This stubbornly progressive ... Author, Article, and Disclosure InformationAffiliations: From University of California, San Francisco, San Francisco, California.Corresponding Author: Christopher Moriates, MD, University of California, San Francisco, 505 Parnassus Avenue, M1287, San Francisco, CA 94143-0131; e-mail, [email protected]ucsf.edu. PreviousarticleNextarticle Advertisement Audio Reading - “A Few Good Words” Audio. Michael A. LaCombe, MD, Annals Associate Editor, reads "A Few Good Words," by C. Moriates. Your browser does not support the audio element. Audio player progress bar Step backward in current audio track Play current audio trackPause current audio track Step forward in current audio track Mute current audio trackUnmute current audio track 00:00/ FiguresReferencesRelatedDetails Metrics Cited byTrust-Based Partnerships Are Essential — and Achievable — in Health Care ServiceRole of Kindness in Cancer CareWhen Patients and Their Families Feel Like Hostages to Health CareWhat Adult Cancer Care Can Learn From Pediatrics 19 April 2016Volume 164, Issue 8Page: 566-567KeywordsArmed forcesBrainDyspneaElderlyHabitsLung and intrathoracic tumorsPatientsPerceptionPleural effusionShoulders ePublished: 19 April 2016 Issue Published: 19 April 2016 Copyright & PermissionsCopyright © 2016 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...