Senior Physician Research Articles

Reorganisation of emergency departments: From policy to practice

Background: In 2007, a national policy of emergency department reorganisation was announced in Denmark. To obtain the expected benefits of the policy, the policy must be put into practice. The aim of this study is to assess the relation between policy and practice after this policy announcement.
 Methods: The study was designed as a cross-sectional study and we conducted a survey across all Danish emergency departments (n=21), to assess the policy implementation from 2007-2017. The questionnaire was answered by executive staff at the EDs (100% response rate). We applied the multi-contingency theory as an analytical framework to classify policy recommendations (specialised equipment, centralisation, multidisciplinary teams, triage, flow coordinator, senior physician, qualification upgrade) according to key organisational design dimensions (strategy, structure, coordination, staff, incentive structure) known to affect patient outcome. The framework further guides our analysis and expectations of the policy implementation process and ED impact.
 
 Results: The implementation rate varied across organisational dimensions: Coordination (multidisciplinary teams, triage, flow coordinator) was first implemented and terminated at the highest rates from 86-100%, whereas the implementation of structure (specialised equipment and centralisation) and staff (senior physicians and qualification upgrade) were more sluggish with implementations rates from 10-76% and 33-90%, respectively. The policy did not adhere to the multi-contingency theory and strategy and incentive structure were identified as missing organisational design dimensions of the policy.
 Conclusion: We found hesitant and heterogeneous translation from policy to practice, probably due to cooperation and recruitment challenges. According to our analytical framework, these issues might be caused by a lack of linkage between policy and theory. However, most of the Danish EDs developed new coordination strategies to resolve these issues. Since the policy did not suggest a complete design plan, it is not surprising, that the EDs have tried to develop independent solutions. It also shows that if only a partial design is specified with no time limits, the implementation may take different routes.

An Ultrasonic-Based Radiomics Nomogram for Distinguishing Between Benign and Malignant Solid Renal Masses.

ObjectivesThis study was conducted in order to develop and validate an ultrasonic-based radiomics nomogram for diagnosing solid renal masses.MethodsSix hundred renal solid masses with benign renal lesions (n = 204) and malignant renal tumors (n = 396) were divided into a training set (n = 480) and a validation set (n = 120). Radiomics features were extracted from ultrasound (US) images preoperatively and then a radiomics score (RadScore) was calculated. By integrating the RadScore and independent clinical factors, a radiomics nomogram was constructed. The diagnostic performance of junior physician, senior physician, RadScore, and radiomics nomogram in identifying benign from malignant solid renal masses was evaluated based on the area under the receiver operating characteristic curve (ROC) in both the training and validation sets. The clinical usefulness of the nomogram was assessed using decision curve analysis (DCA).ResultsThe radiomics signature model showed satisfactory discrimination in the training set [area under the ROC (AUC), 0.887; 95% confidence interval (CI), 0.860–0.915] and the validation set (AUC, 0.874; 95% CI, 0.816–0.932). The radiomics nomogram also demonstrated good calibration and discrimination in the training set (AUC, 0.911; 95% CI, 0.886–0.936) and the validation set (AUC, 0.861; 95% CI, 0.802–0.921). In addition, the radiomics nomogram model showed higher accuracy in discriminating benign and malignant renal masses compared with the evaluations by junior physician (DeLong p = 0.004), and the model also showed significantly higher specificity than the senior and junior physicians (0.93 vs. 0.57 vs. 0.46).ConclusionsThe ultrasonic-based radiomics nomogram shows favorable predictive efficacy in differentiating solid renal masses.

A KSA system for competency-based assessment of clinicians’ professional development in China and quality gap analysis

ABSTRACT Background We aim to create a holistic competency-based assessment system to measure competency evolution over time – one of the first such systems in China. Method Two rounds of self-reported surveys were fielded among the graduates from the Shantou University Medical College: June through December 2017, and May through August 2018. Responses from three cohorts of graduates specializing in clinical medicine – new graduates, resident physicians, and senior physicians – were analyzed. Gaps between respondents’ expected and existing levels of competencies were examined using a modified service quality model, SERVQUAL Results A total of 605 questionnaires were collected in 2017 for the construction of competency indicators and a 5-level proficiency rating scale, and 407 in 2018, for confirmatory factor and competency gap analysis. Reliability coefficients of all competency indicators (36) were greater than 0.9. Three competency domains were identified through exploratory factor analysis: knowledge (K), skills (S), and attitude (A). The confirmatory factor analysis confirmed the fit of the scale (CMIN/DF < 4; CFI > 0.9; IFI > 0.9; RMSEA ≤ 0.08). Within the cohorts of resident and senior physicians, the largest competency gap was seen in the domain of knowledge (K): −1.84 and −1.41, respectively. Among new graduates, the largest gap was found in the domain of skills (S) (−1.92), with the gap in knowledge (−1.91) trailing closely behind. Conclusions A competency-based assessment system is proposed to evaluate clinician’s competency development in three domains: knowledge (K), skills (S), and attitude (A). The system consists of 36 competency indicators, a rating scale of 5 proficiency levels, and a gap analysis to measure competency evolution through 3 key milestones in clinician’s professional career: new graduate, resident physician, and senior physician. The competency gaps identified can provide evidence-based guide to clinicians’ own continuous development as well as future medical curriculum improvements.

COVID-19 and Cancer Center Operations: Lessons Learned From the NCCN Best Practices Committee.

The NCCN Best Practices Committee, which is composed of senior physician, nursing, and administrative leaders from NCCN Member Institutions, evaluated the status of cancer center operations after 1 year of operating during the COVID-19 pandemic. Two major initiatives stood out: the increase in the utilization of network sites, and the gains made in telemedicine operations and reimbursement. Experts from NCCN Member Institutions participated in a webinar series in June 2021 to share their experiences, knowledge, and thoughts on these topics and discuss the impact on the future of cancer care.

Recognition of Peripheral Lung Cancer and Focal Pneumonia on Chest Computed Tomography Images Based on Convolutional Neural Network.

Introduction: Chest computed tomography (CT) is important for the early screening of lung diseases and clinical diagnosis, particularly during the COVID-19 pandemic. We propose a method for classifying peripheral lung cancer and focal pneumonia on chest CT images and undertake 5 window settings to study the effect on the artificial intelligence processing results. Methods: A retrospective collection of CT images from 357 patients with peripheral lung cancer having solitary solid nodule or focal pneumonia with a solitary consolidation was applied. We segmented and aligned the lung parenchyma based on some morphological methods and cropped this region of the lung parenchyma with the minimum 3D bounding box. Using these 3D cropped volumes of all cases, we designed a 3D neural network to classify them into 2 categories. We also compared the classification results of the 3 physicians with different experience levels on the same dataset. Results: We conducted experiments using 5 window settings. After cropping and alignment based on an automatic preprocessing procedure, our neural network achieved an average classification accuracy of 91.596% under a 5-fold cross-validation in the full window, in which the area under the curve (AUC) was 0.946. The classification accuracy and AUC value were 90.48% and 0.957 for the junior physician, 94.96% and 0.989 for the intermediate physician, and 96.92% and 0.980 for the senior physician, respectively. After removing the error prediction, the accuracy improved significantly, reaching 98.79% in the self-defined window2. Conclusion: Using the proposed neural network, in separating peripheral lung cancer and focal pneumonia in chest CT data, we achieved an accuracy competitive to that of a junior physician. Through a data ablation study, the proposed 3D CNN can achieve a slightly higher accuracy compared with senior physicians in the same subset. The self-defined window2 was the best for data training and evaluation.

L’aide au sevrage tabagique : la pratique du conseil minimal par les résidents en médecine

Smoking is a public health problem. Physicians have an important role in the fight against smoking, particularly by means of the brief advice they can give. The aim of this work was to study the prevalence of brief advice application by medical residents and to identify factors that may condition its practice. We conducted a descriptive and analytical study with prospective data collection that included 302 residents practicing in Tunisia who had agreed to respond to an online questionnaire submitted in February and March 2020. Residents' mean age was 28±2 years and the gender ratio was 0.65. Sixty-four percent of them were non-smokers. During their practice, 94% systematically identified their patients' smoking status, but 61.9% were unfamiliar with the concept of brief advice. Residents' brief advice application rate was 57.6%. In multivariate analysis, the factors impacting brief advice application were: gender (OR=0.321, p=0.0001), familiarity with brief counseling (OR=2.808, p=0.002) and having observed brief advice being given by a senior physician (OR=2.328, p=0.0001). The rate of brief advice application remains low. On this subject, improved theoretical and practical teaching during medical studies is essential.

Clinical Pearls

Almost one-third of deaths in the United States take place in intensive care units. Critical care health providers report high levels of stress and burnout when working with end-of-life (EOL) care. Although various EOL care interventions have been developed, little evidence is available on their use in practice.Palma and colleagues conducted focus groups with physicians, nurses, and nursing assistants in Chile to explore their perceptions of EOL care. The major themes include The findings show the need for interprofessional collaborative strategies to support all critical care staff. The authors suggest communication training to build care providers’ confidence in EOL care.See Article, pp 24-32. Delirium affects up to 80% of all patients in intensive care units (ICUs). This costly complication (&gt;$182 billion nationally) has been associated with long-term cognitive and functional deterioration. Standardized screening tools, such as the Confusion Assessment Method for the ICU (CAM-ICU), are widely used in practice by highly trained delirium experts and ICU providers. However, when used by bedside practitioners, the sensitivity of the tool for detecting delirium drops significantly.Sinvani and colleagues explored the feasibility of using a telehealth training program with a remotely located delirium specialist. They found Although further research is needed to examine the impact of telehealth on patient outcomes, the authors suggest use of tele-ICU platforms to share expertise from one remote location to numerous other sites.See Article, pp 73-76. Visitation of family members during the COVID-19 pandemic was not permitted in most hospitals, greatly affecting communication between the patient’s provider and the surrogate decision maker (SDM). Although many intensive care units instituted a daily telephone call between a senior physician and the SDM to provide patient-related information, perceptions of this practice are unknown.Fritz and colleagues surveyed SDMs, physicians, family members, and other health care providers to assess their experience with this practice. They found The practice was satisfactory for most physicians and SDMs; however, the authors suggest improvement with more frequent calls and use of videoconferencing.See Article, pp 77-81. Infants born with a congenital heart defect (CHD) are at risk for neurodevelopmental abnormalities such as cognitive disabilities, mental health problems, and gross motor deficits. Individualized family-centered developmental care (IFDC) interventions such as cue-based care and parent participation have been successfully used with premature infants to prevent neurodevelopmental problems; however, the practice with infants with a CHD varies.LaRonde and colleagues surveyed nurses from 25 cardiovascular programs to describe the current state of IFDC practice. They found Although most respondents described competence with IFDC, practice varied widely. The authors state that next steps should include development of guidelines for infants with CHD and then implementation and evaluation across pediatric critical care settings.See Article, pp e10-e19.

Implementation of point-of-care ultrasonography in an infectious disease ward

IntroductionPoint-of-care ultrasonography (POCUS) has emerged as an essential supplement to physical examination in many specialties. In contrast, its use by infectious diseases (ID) specialists remains anecdotal. Here, we report on the acquisition of an ultrasonography device in a French ID ward, and we describe its everyday use. MethodsA preliminary audit was conducted to evaluate the potential impact of the acquisition of an ultrasonography device. A second audit was performed during the first year following the acquisition of the device to quantify its everyday use. We also evaluated the impact of POCUS implementation on medical imaging requests by comparing the number of intra-hospital transports before and after the acquisition. ResultsAccording to the first audit, 81 of the 199 (41%) imaging examinations that were prescribed during a two-month period could have been replaced by POCUS. During the first year following the acquisition of the ultrasonography device, POCUS was performed 240 times by 31 different operators. The operators were a senior physician, an intern, and a medical student in 94 (39%), 135 (57%), and 11 (5%) cases, respectively. The organs most frequently explored were the genito-urinary tract (n=74), the joints (n=35), and the lungs/pleura (n=35). Acquisition of the device was followed by a significant decrease in the number of transports to the ultrasonography room, whereas the total number of transports to the medical imaging ward did not change. ConclusionOpportunities to use POCUS in the ID ward are numerous. POCUS training should be part of the ID specialist's curriculum.

Precision medicine in aggressive thyroid cancer: Moving beyond multitargeted tyrosine kinase inhibitors

Precision medicine in aggressive thyroid cancer: Moving beyond multitargeted tyrosine kinase inhibitors

Editorial introductions.

Current Opinion in Cardiology was launched in 1985. It is part of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of cardiology is divided into 15 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Section Editors for this issue. SECTION EDITORS Alan BravermanAlan BravermanDr Braverman is a graduate of the University of Missouri-Kansas City School of Medicine, USA. He completed a residency in internal medicine and cardiology fellowship at Brigham and Women's Hospital and Harvard Medical School, USA, and served as Chief Medical Resident. In 1991, Dr Braverman joined the faculty at Washington University School of Medicine in St. Louis, USA, where he is currently the Alumni Endowed Professor in Cardiovascular Diseases. Dr Braverman is actively involved in the education of students, house staff and fellows at Washington University and serves as a Director of the Inpatient Cardiology Firm at Barnes-Jewish Hospital, USA. He has been awarded Teacher of the Year Award by the internal medicine residents on five occasions, the Clinical Teacher of the Year Award by the Washington University Medical Students Class of 2004, and the Benico Barzilai Teaching Award by the cardiology fellows in 2016, and the Hugh McCullough Award from the American Heart Association. In 2010, Dr Braverman was bestowed the E. Grey Dimond Take Wing Award from the University of Missouri-Kansas City. He is a Clinical Cardiologist and has a particular interest in diseases of the aorta, Marfan syndrome and hereditary aneurysm conditions. He is the Director of the Marfan Syndrome Clinic at Washington University in St. Louis and serves on the Professional Advisory Board and the Board of Directors of the Marfan Foundation. He has been awarded the Antoine Marfan Award from the Marfan Foundation in 2003. Dr Braverman is actively involved in clinical research on Marfan syndrome and related aortic diseases, including genetically triggered aortopathy, aortic dissection, and bicuspid aortic valve aortopathy. Marc RuelMarc RuelDr Marc Ruel is the Head and Chair of Cardiac Surgery at the University of Ottawa, Canada. A seasoned heart surgeon, innovator and researcher, Dr Ruel is widely credited with the development of minimally invasive multivessel coronary artery bypass surgery worldwide, and with furthering other minimally invasive cardiac techniques. He has led extensive research and clinical trials in coronary and heart valve surgery. Dr Ruel has published over 400 scientific papers and book chapters, is the recipient of numerous academic and community awards, and is featured as one of the ’Giants of Cardiothoracic Surgery’. Dr Ruel is the President of the Canadian Cardiovascular Society (CCS), one of the most respected medical societies in the world. He is also the surgical Editor for the prestigious journal Circulation and the Canadian Director of the Society of Thoracic Surgeons. Peter H. StonePeter H. StonePeter H. Stone, MD, is a Professor of Medicine at Harvard Medical School, USA, Director of the Vascular Profiling Research Group, a Co-Director of the Center for Clinical Investigation, and Senior Physician at Brigham & Women's Hospital, USA. Dr Stone's research interests are in evaluating and managing patients with acute and chronic coronary artery disease. He is using new in-vivo methodologies to identify areas where human coronary disease will progress to determine if pre-emptive therapeutic strategies may avert adverse cardiac events. He received his undergraduate degree from Princeton University, USA, and his Medical Degree from Cornell University, USA. He completed internal medicine training at the University of California, San Francisco, USA, and then did a clinical cardiology fellowship at Pacific Medical Center in San Francisco, USA. He came to the Peter Bent Brigham Hospital as a Cardiology Research Fellow and he has remained at Brigham and Women's Hospital. He is past President of the Boston Chapter of the American Heart Association, past President of the International Society for Holter and Noninvasive Electrocardiology, and is a Fellow of the American College of Cardiology and the American Heart Association.

Concordance in mSEGA Tool to Frailty Diagnosis between Medical Doctors and Nurses

Introduction: It is currently considered that screening for frailty in elderly subjects is a major public health issue. Methods: a cross-sectional pilot study involving elderly subjects (over 75 years of age) admitted at the emergency department of the hospital of Troyes, France in the period from 24 August to 30 August 2017 was conducted. The patients were screened for frailty using the modified SEGA (Short Emergency Geriatric Assessment) (part A) grid (mSEGA), correlated with the subjective opinion of the triage nurse and the senior physician. Results: 100 patients were included during the pilot study period, the mean age was 84.34 years (range: 75–97), 56 patients (56%) were female, and the average CHARLSON score was 4.28 (range: 0–11). The patients’ previous medical histories were remarkable for cardiovascular diseases. The main reason for hospital admission was fall (26 subjects, 26%). Hospitalization was required for 52 subjects (52%). The average mSEGA score was 6.3 +/− 3.59. The completion time for the SEGAm (part A) score was about 5 minutes. According to Cohen’s kappa, the concordance between the subjective opinion of the triage nurse and the mSEGA grid was average, while the concordance between the subjective opinions of the senior physicians was good. Conclusion: The mSEGA score appears to be well-suited and useful in the emergency department. It is easy to use, allows an overall evaluation of the patient, and is not time-consuming.

Evaluation of thrombin generation assay in factor XI deficiency

IntroductionFactor XI (FXI) deficiency is characterized by a lack of correlation between FXI plasma levels and the occurrence of hemorrhagic events. The main objective of our study was to determine whether thrombin generation assay (TGA) could be used to assess the hemorrhagic phenotype of patients with FXI deficiency. Material and methodsAll patients had confirmed laboratory measurement of FXI < 50% in two plasma samples. Relevant bleeding history was evaluated by a senior physician. TGA was performed with Calibrated Automated Thrombography, in platelet poor plasma, from patients and healthy controls. The assay was performed with PPP low reagent (1 pM of human tissue factor). ResultsSeventy-six patients with FXI deficiency were included between 2011 and 2020. Among them, eight patients had severe deficiency (FXI < 15%). Mean age was 34 years [range: 9–77]. Endogenous thrombin potential (ETP) was significantly lower in patients with FXI deficiency and bleeding (573 nM·min [225–1214]) or no bleeding (732 nM·min [222–1435]), compared to healthy controls (1184 nM·min [933–1518]). No difference was observed for ETP and peak between patients with FXI deficiency and bleeding and patients with FXI deficiency and no bleeding. No difference was observed for ETP (923 nM·min [377–1497] vs 1063 nM·min [252–2529]), peak (82 nM [28–154] vs 131 nM [20–330]) or velocity (13.7 nM/min [3.6–29.6] vs 26.5 nM/min [2.5–90]) in women with (n = 4) and without history (n = 17) of post-partum bleeding. No difference of thrombin generation was observed in pregnant women with FXI deficiency (ETP: 1395 nM·min [351–2529]; peak: 154 nM [26–330]; velocity: 29.6 nM/min [4.1–90.0]), compared to healthy controls and a control group of healthy pregnant women. ConclusionIn conclusion, under our experimental condition, a non-significant decrease of thrombin generation was observed in plasma samples of patients with FXI deficiency and bleeding. Our results suggest an increase of coagulation parameters during pregnancy in women with FXI deficiency. A larger sample size or other experimental conditions are required to evaluate the use of TGA in FXI deficiency.

Daily Telephone Call During the COVID-19 Pandemic: Perceptions of Families and Providers.

In intensive care units (ICUs), the quality of communication with families is a key point in the caregiver-patient-family relationship. During the COVID-19 pandemic, hospital visits were prohibited, and many ICUs implemented a daily telephone call strategy to ensure continuity of communication with patients' families. To assess how family members and health care providers perceived this communication strategy. The study was conducted in a 45-bed ICU during the COVID-19 pandemic. Communication with families consisted of a single daily telephone call from the senior physician in charge of the patient to the patient's surrogate decision maker. Satisfaction was qualitatively assessed via an anonymous online questionnaire with open-ended questions. Participants completed 114 questionnaires. Forty-six percent of surrogate decision makers stated that the key medical messages were understandable, but 57% of other family members expressed that the frequency of information delivery was insufficient. Fifty-six percent of the physicians described the practice as functional for the organization of the unit. Among health care providers other than physicians, 55% felt that not having to interact with families decreased their emotional load and 50% mentioned saving time and the absence of task interruptions as positive aspects. Fixed-time, daily telephone calls in the ICU allowed satisfactory transmission of information between physicians and surrogate decision makers, as perceived by both parties. However, the telephone-based communication strategy could still be improved.

A questionnaire-based study on quality and adequacy of clinical communication between physician and family members of admitted Covid-19 patients

ObjectiveTo assess adequacy of present means of clinical communication between physicians and (Covid-19) patients’ family members, to analyse their perspectives and recommend felicitous practices for virtual conversation during ongoing pandemic. MethodsCross-sectional questionnaire-based (20 questions) anonymous online survey was conducted including patient’s relatives (Group-1) and treating physicians (Group-2), through Google Forms. ResultsResponse Rate was 82.5%. Group-1 and Group-2 included 155 and 204 respondents respectively. Group-1 preferred update by resident doctors (39%), twice a day (41.9%), daily case-summaries (80%) and hand-written document/electronic messages (53%,31%) as consent. Whereas Group-2 favored update by senior consultants (63%), daily one appraisal (55.9%) and scanned copies of hand written consent (81%) before high-risk procedures. The groups broadly agreed on the desired duration for a fruitful discussion (5–10 min) and designating one responsible person from the family for daily appraisal. ConclusionUse of modern techniques/technologies of communication (voice/video calls, texts) during the ongoing pandemic is acceptable to majority. Practice implicationsStudy proposes a senior physician should communicate to a designated responsible family member at-least once a day for stable and twice a day for critical covid patients (more if patient’s health condition changes), either by voice or video calls for 5–10 min.

Relationship between burnout and mistreatment: Who plays a role?

IntroductionSurgery residents have high burnout rates and mistreatment occurs during training. We hypothesized that residents who reported mistreatment would be more likely to experience burnout. MethodsA multi-institutional observational study asked residents to complete the Maslach Burnout Inventory and to rate how often they experienced mistreatment. Scores in the high-risk range for emotional exhaustion or depersonalization were classified as burnout. Associations between mistreatment behaviors, program, sex, post graduate year(PGY), and clinical status were measured by Spearman's correlation, linear regression, and logistic regression. ResultsWe invited 398 residents to participate; 180 responded(45%). 52%(n = 93) were female, there was an even distribution among PGY, and seven programs were represented. Almost half of the cohort (48%) reported high risk for burnout and 68% reported experiencing mistreatment. Mistreatment by senior physician team members were correlated with EE(rho = 0.184,p = 0.016) and DP(rho = 0.181,p = 0.016). ConclusionWhile overall burnout was not significantly associated with mistreatment behaviors, both burnout and mistreatment were commonly reported.

Die Assoziation von beruflicher Zufriedenheit mit selbstberichtetem Burnout bei Urologen und Urologinnen mit Migrationshintergrund tätig an deutschen Kliniken

Urologists with amigration background currently provide patient care in German hospitals. Study results on job satisfaction and burnout of this important professional group have not been available so far. Between August and October 2020, aquestionnaire (SurveyMonkey® with 101items) was conducted among urologists with migration background working in German hospitals regarding professional satisfaction and avalidated survey of burnout (Maslach Burnout Inventory), among others. The subject of this work was the association of job satisfaction with the critical thresholds of burnout in the domains of emotional exhaustion (EE), depersonalization (DP), and low personal accomplishment (PA). For this work, 68 questionnaires could be completely analyzed. Study participants were dominantly male (90%), between 30and 39years of age (69%), married (72%), and working full-time (94%). Above critical thresholds of high burnout in the EE, DP, and PA domains were 27.9% (n = 19), 35.3% (n = 24), and 73.5% (n = 50) of study participants. Asum score was formed from five of atotal of 39satisfaction items, which independently predicted the EE and DP endpoints and acombined EE and DP endpoint in well-adjusted regression models. For each individual score of the sum score (range 5-25points), the probability of acritical burnout is reduced by arelative 57% (EE), 25% (DP), and 34% (combined endpoint). In contrast, permanent employment contract, the clinic position as senior physician or chief physician, working full-time, and amarried marital status significantly reduced the critical PA domain. Several dimensions of professional satisfaction were identified, the improvement of which could contribute to adecrease in burnout among urologists with a migrant background. Future intervention studies aimed at improving job satisfaction must follow.

The age-old question: Thematic analysis of focus groups on physician experiences of aging in emergency medicine.

ObjectivesEmergency medicine has a demanding work environment. Characteristics influencing longevity among older physicians in emergency medicine have been the subject of ongoing discussion. The American College of Emergency Physicians (ACEP) released a policy statement in 2009 suggesting accommodating emergency physicians in preretirement years. We engaged emergency physicians to determine awareness of the ACEP policy and issues faced in preretirement years.MethodsWe conducted a series of online focus group discussions with a purposive sample of emergency physicians, age ≥ 50 years. The discussion guide was developed from the ACEP policy statement and relevant literature. Groups were audio recorded, transcribed, and analyzed with a thematic coding system developed iteratively by the 4‐person team. Emerging themes were identified, organized, and presented with illustrative quotations.ResultsA total of 28 emergency physicians participated in 4 focus groups, with between 6 and 9 participants in each group. These physicians had between 17 and 35 years of clinical experience (median = 27), 6 were female (21%), and the majority (n = 26, 93%) worked in academic emergency medicine. Only 1 emergency physician was fully aware of the ACEP policy. Three principal content areas were identified: workload demands that change as physicians age, wellness and physician social equity, and senior emergency physician value. Interwoven across all of these was the focus on leadership and solutions to issues. Issues facing emergency physicians in their preretirement years were identified; commitment from emergency medicine site and national leadership and buy‐in from junior colleagues was emphasized. Generational conflicts in recognizing the contribution and needs of preretirement emergency physicians was a major barrier to solutions.ConclusionsWorkload demands, wellness and physician social equity, and concerns about value as a senior physician are major themes confronting preretirement emergency physicians. Generational divides, deficits in local and national leadership, and the health detriments of rotating schedules and night shifts are barriers to longevity in emergency medicine. Further research on the value of senior physicians and the impact of hospital and departmental financial models on adopting accommodations for senior emergency physicians is needed.

Ausprägung der Beanspruchungsreaktionen während operativer Lehreingriffe und Erfassung des arbeitsbezogenen Stressempfindens bei Assistenzärzten

Characteristics of stress reactions during surgical teaching procedures and recording of workrelated stress perception among resident physicians Background: Junior surgeons are exposed to high workloads inside and outside the operating theatre early in their careers. By using different measurement tools, it is possible to gain insight into the physiological and subjective stress levels of surgical residents. Aim and Methods: The aim of this study was to investigate differences in time-based stress parameters in two cardiothoracic surgery residents during surgical teaching procedures (n = 24) for aortocoronary bypasses with and without senior physician supervision by means of heart rate variability (HRV). In addition, subjective stress perception was recorded in relation to work-related behaviour and experience patterns (AVEM). Results: The time-related HRV parameters indicate higher psychological stress during the intraoperative phases without a senior physician (Mean HR: 96.1 vs. 89.4; Mean RR: 628.7 ms vs. 675.0 ms; RMSSD: 16.9 ms vs. 20.6 ms; NN50: 120.0 vs. 189.5). The stress index (14.37 vs. 12.27), PNS (–2.17 vs. –1.81), and SNS (2.90 vs. 2.08) values based on these data confirm this. Based on the results from the AVEM, the residents studied can be classified as risk types for a health-risk behaviour and experience pattern. Conclusions: The results illustrate the high psychological stress of assistant physicians and are further evidence of the high risk of burnout in the medical profession. The presence of senior physicians during operative activities seems to have a positive effect on the stress level of junior physicians. Keywords: residents – workloads – psychological stresses – heart rate variability – stress perception

External cephalic version: Predictors for success

ObjectivesThe objective of this study was to identify the factors predictive of the success of external cephalic version (ECV). MethodsA single-centre retrospective observational study was performed in the maternity ward of the Angers University Hospital, France, between January 2010 and May 2020. The study included all patients (n = 613) for whom an ECV was performed for a breech or transverse foetus. The primary endpoint was measured by the success of the ECV, defined by the visualisation, using pelvic ultrasound, of the foetus in cephalic presentation immediately after the manoeuvre. Following to the ECV, the cohort was separated into two groups; ECV Success and ECV Failure. In order to determine the predictive factors of success, a logistic regression model was performed, including the parameters of: parity, foetal presentation during ECV, the side of the foetal back, placental location, type of operator and maternal age.The results are presented as (odds ratio [confidence intervals]; p-value). The significance threshold was defined by a p-value < 0.05. ResultsThe ECV success rate was 21.4% (131/613). The factors predictive of the success of ECV were: transverse foetal presentation (2.7 [1.3–5.6]; p<0.01); a senior physician operator (1.6 [1.2–2]; p<0.01); multiparity (1.6 [1.2–2]; p<0.01); non anterior placental localization (1.4 [1.1–2]; p<0.01). A number of attempts greater than 3 were significantly associated with reduced chances of success (0.3 [0.2–0.4]; p<0.01). ConclusionThe study shows that transverse foetal presentation, a senior physician operator, multiparity, as well as a non-anterior placental location are factors predictive of the success of ECV. Knowledge of these factors can improve the information given to patients.

RELATIONSHIP BETWEEN GLASGOW COMA SCALE AND AIRWAYS PROTECTIVE REFLEXES IN CEREBRO VASCULAR ATTACK PATIENTS

Introduction: The laryngeal cough reex (LCR) protects the supraglottic larynx from signicant aspiration of food or uids during inspiration or pharyngeal spillage during swallowing 1. The reex cough test (RCT), using nebulized tartaric acid solution, provides an effective stimulus to the receptors in the supraglottic mucosa, and, like a reex hammer or percussor, triggers a cascade of neurological activity in both craniospinal nerves and the central nervous system. The vagus nerve mediates the afferent component of the LCR. Aims And Objective:To nd the relation between glasgowcoma scale and airway protective reexes in Indian population. Materials And Methods: This study was a prospective observational study. Clinical history and examination is mandatory for selection of the eligible patients. All the procedure was done, only once a traumatically, in patients. Suction apparatus was made available all the time beside the patients in case they vomit. Procedure was done under supervision of senior physician. Result And Analysis: We found that in ≤5 GCS Group, 15(100.0%) patients had Intubation. In 6-8 GCS Group, 7(10.6%) patients had Intubation. In ≥9 GCS Group, 8(20.5%) patients had Intubation. Association of Intubation vs GCS Group was statistically signicant (p&lt;0.0001). In ≤5 GCS Group, 15(100.0%) patients had Immediate Intubation. Summary And Conclusion: In our study, 11(9.2%) patients were Attenuated/ Diminished (Absent Cough and Gag reex) air way protective reexes checked later, 19(15.8%) patients were Not Applicable (As Pt Mechanical Ventilator) air way protective reexes checked later and 90(75.0%) patients were Patent (Present Cough and Gag reex) air way protective reexes checked later. Mechanical Ventilator was more in low GCS (≤5) which was statistically signicant.