Trainee Status Research Articles

Moving Violations: Pairing an Illegitimate Learning Hierarchy with Trainee Status Mobility for Acquiring New Skills When Traditional Expertise Erodes

We explore how members of a community of practice learn new tools and techniques when environmental shifts undermine existing expertise. In our 20-month comparative field study of medical assistants and patient-service representatives learning to use new digital technology in five primary care sites, we find that the traditional master-apprentice training model worked well when established practices were being conferred to trainees. When environmental change required introducing new tools and techniques with which the experienced members had no expertise, third-party managers selected newer members as trainers because managers judged them to be agile learners who were less committed to traditional hierarchies and more willing to deviate from traditional norms. This challenged community members’ existing status, which was based on the historical distinctions of long tenure and expertise in traditional tasks. In three sites, the introduction of this illegitimate learning hierarchy sparked status competition among trainees and trainers, and trainees collectively resisted learning new tools and techniques. In the other two sites, managers paired the new, illegitimate learning hierarchy with the opportunity for trainee status mobility by rotating the trainer role; here, trainees embraced learning in order to exit the lower-status trainee group and join the higher-status trainer group. Drawing on ideas of status group legitimacy and mobility, we suggest that managers’ pairing of an illegitimate learning hierarchy with the opportunity for trainee status mobility is a mechanism for enabling the situated learning of new techniques when traditional expertise erodes.

Introducing a Measurement Feedback System for Youth Mental Health: Predictors and Impact of Implementation in a Community Agency.

Measurement feedback systems (MFSs) that routinely collect and report client progress to mental health therapists have demonstrated beneficial impact on outcomes in numerous studies, with evidence that there is a dose-response relationship related to the implementation of the MFS. The current study examined the impact of MFS implementation (Implementation Index) on youth symptom outcomes separately by caregiver and youth self-report. Additionally, we tested the extent to which Implementation Index rates varied by individual therapists and clients, and whether therapist and client characteristics predicted MFS implementation. Methods: Administrative data (client charts, youth- and caregiver-reported Youth Outcome Questionnaires) for 229 youth (52.83% Latinx, 42.79% girls, M age = 10.33) treated during a 1-year period at a community mental health organization in Central Texas were analyzed using multi-level modeling. Caregiver-reported symptoms decreased faster for those with a higher MFS Implementation Index. Between-group differences among therapists accounted for a significant proportion of variance in the Implementation Index for caregiver report, whereas client differences accounted for most of the variance in the Implementation Index for youth self-report. Therapist trainee status predicted a significant increase in the Implementation Index for caregiver-report data. Youth symptom improvement as reported by caregivers varied with the extent of MFS implementation fidelity, and MFS implementation fidelity was higher for clients treated by trainees relative to staff therapists for caregiver report of symptoms.

Overcoming the challenges of role transition for trainee advanced clinical practitioners

Advanced clinical practitioners (ACPs) are being recruited in England to improve care continuity and safety, meet complex needs and ease workforce pressures. These roles are open to experienced, registered health professionals from a variety of backgrounds. This significant career change typically involves a transitional training programme. This article explores the challenges presented by this transition and how they can be overcome. Attaining the postgraduate qualification can be daunting for those who have been outside academic education, especially the initial degree module. The generalist ACP role can be confused with that of clinical nurse specialist, and an ambiguous role identity can cause problems for management, expectations and morale. Trainee ACPs gain wide experience from ward rotations, although they can specialise in some areas. Thus, trainees experience de-skilling as they go from being an expert in one role to a novice in another, as well as potentially developing imposter syndrome. Trainees may be anxious about being expected to fulfil the competencies of a qualified ACP, and their trainee status should be evident in their uniform. Those entering advanced practice can face interpersonal hostility and institutional resistance. Any bullying should be addressed directly, and potential misconceptions should be clarified. There is no overarching national regulatory body for ACPs, and relevant guidelines can diverge. While a clinical supervision assesses a trainee's performance, a separate mentor should support their learning and develop their competence and confidence, especially in the first year. Mentorships should be defined and structured. Trainees can be supported by experienced qualified ACPs. Flexible individual induction plans, with information spaced throughout the year, can help overcome these challenges, and these should make the most of the trainee's achievements in their previous role.

Insight into the methodology and uptake of EAES guidelines: a qualitative analysis and survey by the EAES Consensus & Guideline Subcommittee.

Over the past 25years, the European Association for Endoscopic Surgery (EAES) has been issuing clinical guidance documents to aid surgical practice. We aimed to investigate the awareness and use of such documents among EAES members. Additionally, we conceptually appraised the methodology used in their development in order to propose a bundle of actions for quality improvement and increased penetration of clinical practice guidelines among EAES members. We invited members of EAES to participate in a web-based survey on awareness and use of these documents. Post hoc analyses were performed to identify factors associated with poor awareness/use and the reported reasons for limited use. We further summarized and conceptually analyzed key methodological features of clinical guidance documents published by EAES. Three distinct consecutive phases of methodological evolvement of clinical guidance documents were evident: a "consensus phase," a "guideline phase," and a "transitional phase". Out of a total of 254 surgeons who completed the survey, 72% percent were aware of EAES guidelines and 47% reported occasional use. Young age and trainee status were associated with poor awareness and use. Restriction by colleagues was the primary reason for limited use in these subgroups. The methodology of EAES clinical guidance documents is evolving. Awareness among EAES members is fair, but use is limited. Dissemination actions should be directed to junior surgeons and trainees.

Stressors and Coping Mechanisms Related to Burnout Within Urology

To identify factors and stress coping mechanisms associated with burnout within the field of urology. A survey study was completed using the abbreviated Maslach Burnout Inventory to evaluate emotional exhaustion, depersonalization, and low personal achievement. Demographic information, training status, practice setting, work hours, and mechanisms used to cope with stress were evaluated. Participants were also asked to comment on contributors to burnout in an open-ended question. Univariate analysis and multivariate regression identified factors associated with measures of burnout. A total of 476 survey responses from 377 practicing urologists and 99 residents/fellows were included. Burnout was identified in 49.6% of all participants. Burnout through high emotional exhaustion was seen in 40.7%, high depersonalization in 30.7%, and low personal achievement in 18.3%. Trainees exhibited higher levels of depersonalization and lower levels of personal achievement. Higher levels of emotional exhaustion were identified in urologists in the middle of their careers and those in private practice. Urologists identified documentation, insurance and reimbursement, government regulations, medical practice expectations, and patient expectations as stressors contributing to burnout. Exercising and socializing were consistently associated with lower measures of burnout whereas stress eating and alcohol use were associated with higher measures of burnout on multivariate analysis. Burnout in urology was associated with trainee status, years in practice, and practice setting. Exercising and socializing were protective against burnout whereas stress eating and alcohol consumption were associated with higher rates of burnout.

What's in a Name? a Gender-Based Analysis of Speaker Introductions at the American Society of Hematology Annual Meeting

Introduction: Several recent studies have shown a gender disparity in professional doctoral introductions at major medical conferences, with female speakers being less likely to be introduced with a professional title. We sought to examine whether a similar disparity existed at the American Society of Hematology (ASH) Annual Meeting. Methods: In this retrospective observational study, 8 investigators reviewed available presentations from video archives of the 2018 ASH Annual Meeting. Presentations were excluded if gender could not be identified and/or speaker did not have a doctoral degree. We collected data on speaker gender, speaker academic/non-academic rank, speaker geographic location, speaker training status, speaker session type and introducer gender were all collected. A "professional address" was defined as either "Dr. [First and Last Name]" or "Dr. [Last Name]." Descriptive statistics and regression modelling were used to analyze the data. Results:Of the videos reviewed, 645 presentations were eligible for analysis; 380 (59%) speakers were men and 264 (41%) were women. A comparison of male and female speaker cohorts is seen in Table 1. Forty-eight percent of both men and women held a Medical Doctor degree (MD), and the rest were MD/PhD or PhD graduates. Substantially more men (28%) were full professors compared to women (13%). Almost half (47%) of session types for both men and women speakers were designated as "basic science." In an adjusted analysis, more women (N=174, 66%) compared to men (N=225, 59%) received a professional address (P<.01). 43% of women were introduced by a female introducer and 42% of men were introduced by a female introducer (P=.79). In addition, 48 of the introducers (19%) for women and 68 of the introducers (18%) for men had a PhD or MD/PhD. In a logistic regression model adjusting for session type, academic rank, degree, geographic location, trainee status, and gender of introducer, there were no significant gender-based differences in professional introduction [Table 1; Odds Ratio (OR) 0.71, P=.06]. In addition, speakers with MD introducers were more likely to have a professional introduction compared to PhD introducers (OR 2.15, P=.03) regardless of sex. Conclusions: Our study demonstrates that women were at least as likely as men to receive a professional address at the 2018 ASH Annual Meeting. These results differ from previous studies of other professional medical conferences. These findings may reflect the strong presence of PhD graduates as both speakers and introducers. Both forms of bias (gender and degree-based) merit further study and interventions including speaker training to ensure combatting unconscious bias. Disclosures Velazquez: Midatech: Other: Husband owns stock in this company; Portola Pharmaceuticals: Other: Husband owns stock in this company; Corbus Pharmaceuticals: Other: Husband owns stock in this company; Johnson & Johnson: Other: Husband is employed by this company.

The Impact of Surgeon Volume and Training Status on Implant Alignment in Total Knee Arthroplasty.

Implant malalignment may predispose patients to prosthetic failure following total knee arthroplasty (TKA). A more thorough understanding of the surgeon-specific factors that contribute to implant malalignment following TKA may uncover actionable strategies for improving implant survival. The purpose of this study was to determine the impact of surgeon volume and training status on malalignment. In this retrospective multicenter study, we performed a radiographic analysis of 1,570 primary TKAs performed at 4 private academic and state-funded centers in the U.S. and U.K. Surgeons were categorized as high-volume (≥50 TKAs/year) or low-volume (<50 TKAs/year), and as a trainee (fellow/resident under the supervision of an attending surgeon) or a non-trainee (attending surgeon). On the basis of these designations, 3 groups were defined: high-volume non-trainee, low-volume non-trainee, and trainee. The postoperative medial distal femoral angle (DFA), medial proximal tibial angle (PTA), and posterior tibial slope angle (PSA) were radiographically measured. Outlier measurements were defined as follows: DFA, outside of 5° ± 3° of valgus; PTA, >±3° deviation from the neutral axis; and PSA, <0° or >7° of flexion for cruciate-retaining or <0° or >5° of flexion for posterior-stabilized TKAs. "Far outliers" were defined as measurements falling >± 2° outside of these ranges. The proportions of outliers were compared between the groups using univariate and multivariate analyses. When comparing the high and low-volume non-trainee groups using univariate analysis, the proportions of knees with outlier measurements for the PTA (5.3% versus 17.4%) and PSA (17.4% versus 28.3%) and the proportion of total outliers (11.8% versus 20.7%) were significantly lower in the high-volume group (all p < 0.001). The proportions of DFA (1.9% versus 6.5%), PTA (1.8% versus 5.7%), PSA (5.5% versus 12.6%), and total far outliers (3.1% versus 8.3%) were also significantly lower in the high-volume non-trainee group (all p < 0.001). Compared with the trainee group, the high-volume non-trainee group had significantly lower proportions of DFA (12.6% versus 21.6%), PTA (5.3% versus 12.0%), PSA (17.4% versus 33.3%), and total outliers (11.8% versus 22.3%) (all p < 0.001) as well as DFA (1.9% versus 3.9%; p = 0.027), PSA (5.5% versus 12.6%; p < 0.001), and total far outliers (3.1% versus 6.4%; p = 0.004). No significant differences were identified when comparing the low-volume non-trainee group and the trainee group, with the exception of PTA outliers (17.4% versus 12.0%; p = 0.041) and PTA far outliers (5.7% versus 2.6%; p = 0.033). Findings from multivariate analysis accounting for the effects of patient age, body mass index, and individual surgeon demonstrated similar results. Low surgical volume and trainee status were risk factors for outlier and far-outlier malalignment in primary TKA, even when accounting for differences in individual surgeon and patient characteristics. Trainee surgeons performed similarly, and certainly not inferiorly, to low-volume non-trainee surgeons. Even among high-volume non-trainees, the best-performing cohort in our study, the proportion of TKA alignment outliers was still high. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Workplace Harassment and Discrimination in Gynecology: Results of the AAGL Member Survey

To characterize workplace and sexual harassment and discrimination among physicians in gynecology. A beta-tested Internet survey was distributed by e-mail using the REDCap platform. All responses were anonymous. The survey was distributed to the 7026 physician members of an international gynecologic society (AAGL), including faculty and trainees. Not applicable. The survey was distributed on 3 occasions between July and September 2018. The survey contained questions on demographics, attitudes, experiences, and sequelae regarding harassment and discrimination in the workplace. Frequency distributions and nonparametric tests were performed to determine the percentages and types of harassment and discrimination among respondents. A total of 907 physicians responded, including 603 US physicians and 304 non-US physicians; 59% identified as female and 40% as male, and 20% were trainees. Females were more likely than males to think the #MeToo movement was "justified and overdue" (p < .05), independent of age or trainee status. More females than males reported experiencing workplace discrimination (67% vs 39%; p < .001); gender-based discrimination was the most common basis for both. Females indicated decreased self-confidence and lower salary; males indicated fewer employment opportunities and lower patient volume. Harassment was reported by more females than males (53% vs 17%; p < .001), including sexual harassment (39% vs 11%, p <.05). Most experienced loss of self-confidence, felt the offender was in a position of power, and did not report the incident, often due to fear of reprisal. Multiple respondents experienced workplace-related sexual assault. Workplace harassment and discrimination are commonly experienced by female and male gynecologists and are usually related to a power differential. Improvements must be made in the workplace environment to achieve equity and a safe workplace free of harassment and discrimination.

Correlation Between Polyp and Adenoma Detection Rate in Trainee Endoscopists

Introduction: The adenoma detection rate (ADR) is a widely accepted quality benchmark for screening colonoscopy, but calculation requires labor-intensive manual confirmation of histology. Previous studies have shown that the polyp detection rate (PDR) correlates well with ADR and may serve as a surrogate benchmark, although the ADR/PDR ratio may vary by colonic segment. In this study, we assessed the relationship between PDR and ADR in colonoscopies performed by trainees, for whom a surrogate benchmark may be a more practical method of tracking performance. Additionally, we evaluated the relationship between PDR and sessile serrated polyp (SSPDR) and advanced adenoma detection rates (AADR). Methods: We examined all outpatient colonoscopies performed by trainees at a VA facility from 8/16/16-12/29/17. We excluded incomplete procedures and those with Boston Bowel Preparation Scale scores less than 2 in any segment. Variables collected included patient demographics, year of fellowship, and endoscopic and histologic findings. Results: Table 1 shows patient characteristics, trainee status, and overall findings in 814 colonoscopies. Our population was predominantly (44%) black. The majority (88%) of procedures were performed for screening or surveillance, and most (47%) were performed by second-year fellows. The overall PDR, ADR, SSPDR, and AADR were 77%, 57%, 3%, and 17%. Table 2 shows the PDR, ADR, SSPDR, AADR, and the respective ratios overall as well as by colonic segment and year of training. The overall ADR/ PDR ratio was 0.74. The ratio was similar in the right (0.77) and transverse colon (0.75) but lower in the left colon (0.52). The same pattern was seen for the overall SSPDR/PDR and AADR/PDR ratios. When stratified by year of training, the overall ratios were consistent and a similar decline in ratios from the right to the left colon was observed in most cases. Notably, the AADR/PDR ratio in the right colon was substantially higher for third-year fellows, which suggests training may improve the efficiency of detecting advanced adenomas in the right colon. Conclusion: The overall ADR/PDR ratio in our study was higher than previously reported, which may reflect the predominantly male veteran population and the presence of a supervising physician. The overall ratios did not vary by year of training and but did decrease in the left colon. These results provide valuable preliminary data for how the PDR can be used to calculate the ADR, SSPDR, and AADR for trainee endoscopists.222_A Figure 1. Abbreviation: IQR, inter-quartile range a Advanced adenoma: any adenoma ≥10 mm in size, with villous component, or with high grade dysplasia OR any sessile serrated polyp ≥10 mm in size or with dysplasia222_B Figure 2. Abbreviations: ADR, adenoma detection rate; PDR, polyp detection rate; SSPDR, sessile serrated polyp detection rate; AADR, advanced adenoma detection rate.

How do trainee doctors introduce themselves to patients?

ObjectivesTo identify how trainee doctors introduce themselves to patients.DesignSurvey.SettingChelsea and Westminster Hospital, London.ParticipantsOne hundred trainee doctors, of mixed grades and specialties.Main outcome measuresIntroducing oneself by name, using their professional title...

Impact of a Commercially Available Clinical Decision Support Program on Provider Ordering Habits

PurposeClinical decision support (CDS) software designed around the ACR Appropriateness Criteria assists health care providers in choosing appropriate imaging studies at the time of order entry. The goal of this study was to determine the impact of commercially available CDS on the ordering habits of inpatient and emergency providers. MethodsIn 2014, ACR Select was integrated into our electronic health record, though without displaying appropriateness scores in a “silent” mode for 6 months. Then, feedback regarding examination appropriateness was “turned on” at order entry for adult patients in the emergency and inpatient settings for 24 months. We retrospectively compared the appropriateness scores of imaging tests before and after displaying feedback at order entry and evaluated these data by modality and attending versus trainee status. ResultsThe commercially available CDS-generated scores for 34% and 20.4% of pre- and postintervention studies, respectively. After feedback, the relative frequency of low utility studies decreased to 5.4% from 11%, and the relative frequency of indicated studies increased to 82% from 64.5%. This was most pronounced in trainees for whom the percentage of low utility studies decreased from 10.8% (95% confidence interval [CI]: 10.0%, 11.7%) to 4.8% (95% CI: 4.4%, 5.2%) and the percentage of indicated studies increased from 65.6% (95% CI: 64.3%, 66.9%) to 83.7% (83.0%, 84.3%). ConclusionsAfter implementation of a commercially available decision support tool integrated into the electronic health record, there was a significant improvement in imaging study appropriateness scores, more pronounced in studies ordered by trainees.

Needlestick Injuries in Interventional Radiology Are Common and Underreported.

Purpose To determine the prevalence of and risk factors for needlesticks in interventional radiology physicians, as well as the attitudes, behaviors, and conditions that promote or interfere with reporting of these injuries. Materials and Methods A total of 3889 interventional radiologists from academic and private practice in the United States were surveyed by emailing all interventional radiologist members of the Society of Interventional Radiology, including attending-level physicians and trainees (April-August 2016). The institutional review board waived the need for consent. Questions inquired about the nature, frequency, and type of needlestick and sharps injuries and whether and to whom these incidents were reported. Stepwise regression was used to determine variables predicting whether injuries were reported. Results In total, 908 (23%) interventional radiologists completed at least a portion of the survey. Eight hundred fourteen (91%) of 895 respondents reported a prior needlestick injury, 583 (35%) of 895 reported at least one injury while treating an HIV-positive patient, and 626 (71%) of 884 reported prior training regarding needlestick injury. There was, on average, one needlestick for every 5 years of practice. Most needlestick or sharps injuries were self inflicted (711 [87%] of 817) and involved a hollow-bore device (464 [56%] of 824). Only 566 (66%) of 850 injuries were reported. The most common reasons for not reporting included perceived lack of utility of reporting (79 [28%] of 282), perceived low risk for injury (56 [20%] of 282), noncontaminated needle (53 [19%] of 282), too-lengthy reporting process (37 [13%] of 282), and associated stigma (23 [8%] of 282). Only 156 (25%) of 624 respondents informed their significant other. Stepwise regression assessing variables affecting the likelihood of reporting showed that male sex (P = .009), low-risk patient (P < .0001), self injury (P = .010), trainee status (P < .0001), and the total number of prior injuries (P = .019) were independent predictors of not reporting. Conclusion Needlestick injuries are ubiquitous among interventional radiologists and are often not reported. © RSNA, 2017 Online supplemental material is available for this article.

Compliance Is Contagious: Using Informatics Methods to Measure the Spread of a Documentation Standard From a Preoperative Clinic

Preoperative documentation is essential to coordinated care and has the potential for standardization, which may facilitate downstream clinical management. An observational pre/post standardization design was used. We analyzed the implementation of a preoperative documentation standardization intervention in Vanderbilt's Preoperative Evaluation Clinic (VPEC) and its impact outside VPEC. A phased intervention consisted of clinician education with monthly feedback, followed by the development of a compliance dashboard and inclusion in Ongoing Professional Performance Evaluation system by VPEC. A follow-up survey was administered to measure the impact on clinical management. Adherence to standardization was improved with the addition of electronic feedback. Implementation of this system in the preoperative clinic had significant impact outside VPEC. Trainee status was a significant predictor of adoption of the standardized format. Adoption of a preoperative documentation standard in a clinic had a positive impact on standardization practices in a perioperative system.

Outcome of Pediatric Critical Care Medicine Abstracts Presented at North American Academic National Meetings.

Pediatric critical care medicine abstracts presented at North American national academic meetings have not been followed up to determine their publication outcomes. Our objective was to determine the following: 1) the proportion of these presentations that are published in peer-reviewed journals within 5 years; 2) the impact of trainee status on time to and success of publication; and 3) the quality of the research as reflected in the publishing journal's impact factor. Four years of abstracts (2007-2011) were reviewed from the American Academy of Pediatrics, Pediatric Academic Societies, and Society of Critical Care Medicine national meetings. Pediatric critical care medicine abstracts were delineated by the meeting or identified by keyword search. Data included mode of presentation, trainee status of first author, publication status within 5 years based on a PubMed search, trainee position in the journal of publication authorship list, and the impact factor of journal of publication. We evaluated 267 pediatric critical care medicine abstracts, 85-94 from each meeting. Overall, 41% were published, with the highest rate in Pediatric Academic Societies abstracts (54% Pediatric Academic Societies, 38% Society of Critical Care Medicine, and 33% American Academy of Pediatrics; p = 0.011). Mean time to publication was 22 (± 3) months and did not differ by conference or presentation mode. Journal first authorship was retained in 84%. Journal impact factor was highest in Society of Critical Care Medicine abstracts (3.38 Society of Critical Care Medicine, 2.64 Pediatric Academic Societies, and 1.92 American Academy of Pediatrics; p = 0.006). First author trainee status was not associated with publication rate, time to publication, and impact factor. A total of 100% of trainees but only 79% of nontrainees who published retained first authorship. Less than half of pediatric critical care medicine research abstracts presented at North American national academic meetings culminate in articles. Pediatric Academic Societies had the highest publication success rate, and Society of Critical Care Medicine abstracts were published in journals with the highest impact factors. All trainees who were first authors retained that status in the journal publications.

Brief Online Mindfulness Training: Immediate Impact.

Online training is feasible, but the impact of brief mindfulness training on health professionals needs to be better understood. We analyzed data from health professionals and trainees who completed self-reflection exercises embedded in online mindfulness training between May 2014 and September, 2015; their changes in mindfulness were measured using standardized scales. Participants included nurses (34%), physicians (24%), social workers and psychologists (10%), dietitians (8%), and others (25%); 85% were women, and 20% were trainees. The most popular module was Introduction to Mindfulness (n = 161), followed by Mindfulness in Daily Life (n = 146), and Mindful Breathing and Walking (n = 129); most (68%) participants who took 1 module took all 3 modules. There were no differences in participation in any module by gender, trainee status, or profession. Completing modules was associated with small but significant improvements on the Cognitive and Affective Mindfulness Scale-Revised, the Mindful Attention Awareness Scale, and the Five Facet Mindfulness Questionnaire (P < 0.001 for all). Online training reaches diverse health professionals and is associated with immediate improvements in mindfulness. Additional research is warranted to compare the long-term cost-effectiveness of different doses of online and in-person mindfulness training on clinician burnout and quality of care.

Perceptions of orthodontic specialist training in the United Kingdom: a national survey of postgraduate orthodontic student opinion.

Postgraduate orthodontic education is highly challenging. There is a lack of evidence regarding orthodontic postgraduates' perceptions of their orthodontic education in the United Kingdom. In addition, no study has been conducted to compare the postgraduate orthodontic training experience between UK trainees and international postgraduates. (1) To investigate orthodontic UK trainees' and international postgraduates' perception and satisfaction of their orthodontic education. (2) To compare postgraduate orthodontic training experience between UK trainees and international postgraduates. (3) To compare orthodontic caseload between UK trainees and international postgraduates. Utilizing a descriptive, cross-sectional survey, conducted through a web-based self-administered questionnaire, the sample population consisted of all 189 orthodontic postgraduates in the United Kingdom. One hundred and twenty-five questionnaires were completed resulting in a response rate of 66.1%. All three academic years were evenly represented. Ninety five (76%) respondents rated the quality of their postgraduate orthodontic education as excellent. Over 90% of third year postgraduates felt the quality of their education was excellent. The majority of orthodontic trainees (n = 98, 78.4%) were satisfied with the number of cases. Apart from the first year postgraduates, other postgraduates regardless of UK trainee or international postgraduate status reported a high number of cases in treatment, with 45 (36%) respondents treating more patients than the recommended range of 80-120. Postgraduates' responses were less positive regarding their ability to influence the delivery of their programme, whether their programme represented value for money and the fairness of their training. Most of the respondents believed that UK trainees had an advantage in communicating with patients. The majority of orthodontic postgraduates rated the quality of their postgraduate education as excellent. Apart from first year postgraduates, other postgraduates irrespective of UK trainee or international postgraduate status reported a high number of cases in treatment. There was no difference in caseload between UK trainee and international postgraduate groups.

92: The effect of hindsight and outcome bias on the interpretation and management of intrapartum fetal heart rate (FHR) tracings: A randomized trial

To determine whether obstetricians who are asked to evaluate management decisions regarding abnormal FHR patterns will be more likely to assess the quality of medical care as negligent if they are told that there was an adverse, rather than normal, neonatal outcome. Obstetricians from four institutions were invited to participate in a research study regarding intrapartum management. Each case included clinical details, segments of the intrapartum FHR tracing, and outcomes including umbilical artery pH and presence or absence of neonatal morbidity (Table 1). Reviewers were asked to categorize the FHR tracing, assess the timing for the decision for cesarean delivery (CD), and finally rate the quality of care as either “below standard of care” or “acceptable practice.” All participants received the same clinical data and outcomes for both Case #1 and Case #2. Case #1 involved a scenario with a normal umbilical pH, whereas case #2 resulted in an abnormal umbilical pH (< 7.00). For Case #3, all participants received the same opening clinical vignette and FHR tracings; but then were randomly allocated to receive one of two alternative outcomes (Scenario A = normal umbilical pH and no neonatal complications or Scenario B = metabolic acidemia and neonatal encephalopathy). We estimated that N= 84 would be needed to show a 30% difference in the frequency of the judgment of obstetrical management as “below standard of care” between those receiving alternative outcomes (90% power and 2-sided alpha = 0.05). A total of 128 obstetricians participated; 70 were randomly allocated to Scenario A and 58 to Scenario B for Case #3. There were no differences in the assessment of the appropriateness and quality of care for the first 2 cases (Table 2). For Case #3, belief that there was an adverse outcome resulted in a worse categorization of the FHR tracing, more frequent perception that CD was performed too late, and more likely judgment that the standard of care had been violated (Table 2). The findings were similar regardless of academic institution, attending or trainee status, or MFM subspecialty. This study confirms the significant impact of hindsight and outcome bias on the interpretation of FHR tracings and the retrospective assessment of the quality of obstetrical care.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Embryo Transfer by Reproductive Endocrinology Fellows Versus Attending Physicians

Significant heterogeneity exists among the various methods used for training reproductive endocrinology and infertility (REI) fellows to perform embryo transfer (ET) for in vitro fertilization (IVF). The findings of a recent survey of current REI fellows and recent fellowship graduates indicated that almost half of them did not perform ET while in training. Many programs do not allow fellows to perform ET and restrict its performance to attending physicians largely because of fear that pregnancy rates will be compromised. There is no evidence supporting this restriction. In a recent study, ET pregnancy rates were comparable between fellows and attending physicians both before and after the institution of a mandatory minimal intrauterine insemination policy. The aim of this retrospective cohort study was to compare live birth rates following ultrasound-guided ET performed by REI fellows versus attending physicians. The study was conducted at a single academic institution between 2005 and 2011. All participants underwent first day-3, fresh, nondonor ET. Day 3 embryos with 8 cells, less than 10% fragmentation, and no asymmetry were deemed to be high quality. Fellows performed ET under direct ultrasound guidance by the attending physician, using the afterload method. The χ2 test was used to evaluate categorical variables and Student t test for continuous variables. The relationship between ET trainee status and live birth rate was assessed with multivariate logistic regression, adjusting for potential confounders. A total of 760 ETs were performed by attending physicians and 104 by fellows. Baseline patient characteristics were similar in the 2 groups. There was no difference in the live birth rate between groups: 31% following ET by an attending physician versus 34% following ET by a fellow; the odds ratio was 0.99, with a 95% confidence interval of 0.63 to 1.55. Adjusting for potential confounders did not affect the results. These findings show no significant difference in live birth rates following ultrasound-guided ET by fellows or attending physicians at a single institution. The data suggest that fellows can be trained to perform ET using the afterload method and ultrasound guidance without compromising success rates.

Emotional exhaustion and workload predict clinician-rated and objective patient safety.

Aims: To investigate the role of clinician burnout, demographic, and organizational characteristics in predicting subjective and objective indicators of patient safety.Background: Maintaining clinician health and ensuring safe patient care are important goals for hospitals. While these goals are not independent from each other, the interplay between clinician psychological health, demographic and organizational variables, and objective patient safety indicators is poorly understood. The present study addresses this gap.Method: Participants were 1425 physicians and nurses working in intensive care. Regression analysis (multilevel) was used to investigate the effect of burnout as an indicator of psychological health, demographic (e.g., professional role and experience) and organizational (e.g., workload, predictability) characteristics on standardized mortality ratios, length of stay and clinician-rated patient safety.Results: Clinician-rated patient safety was associated with burnout, trainee status, and professional role. Mortality was predicted by emotional exhaustion. Length of stay was predicted by workload. Contrary to our expectations, burnout did not predict length of stay, and workload and predictability did not predict standardized mortality ratios.Conclusion: At least in the short-term, clinicians seem to be able to maintain safety despite high workload and low predictability. Nevertheless, burnout poses a safety risk. Subjectively, burnt-out clinicians rated safety lower, and objectively, units with high emotional exhaustion had higher standardized mortality ratios. In summary, our results indicate that clinician psychological health and patient safety could be managed simultaneously. Further research needs to establish causal relationships between these variables and support to the development of managerial guidelines to ensure clinicians’ psychological health and patients’ safety.

Training surgeon status is not associated with an increased risk of early or late mortality after isolated aortic valve replacement surgery

Few studies have addressed the effect of "trainee surgeon" status on outcomes after isolated aortic valve replacement (AVR). A retrospective analysis of data, collected by the Australasian Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database Program between June 2001 and December 2009 was performed. Patient demographics, intra-operative characteristics and early morbidity were compared between trainee and staff cases. Multivariate analyses were used to determine the independent association of training status with 30-day and late mortality. Isolated AVR was performed in 2747 patients; of these, 369 (13.4%) were by trainees. Compared to staff cases, trainee cases were less likely to present with renal failure (1.1% vs. 3.7%, p = 0.010) or in a critical preoperative state (1.4% vs. 3.7%, p = 0.020). The mean EuroSCORE was lower in trainee patients, compared to staff patients (8.11 ± 2.80 vs. 8.81 ± 3.09, p < 0.001). Trainee cases had longer mean perfusion (117.9 min vs. 98.9 min, p < 0.001) and cross-clamp (88.8 min vs. 73.2 min, p < 0.001) times. The incidence of early complications was similar between the two groups, except for post-operative myocardial infarction (1.1% vs. 0.3%, p = 0.008) and red blood cell transfusion (43.9 vs. 40.0%, p = 0.006). On multivariate analysis, trainee status was not associated with an increased risk of 30-day mortality (2.2% vs. 2.4%, p = 0.823). Moreover, there was no significant difference in long-term outcomes and 5-year survival was comparable in both groups (89.9% vs. 84.8%, p = 0.274). Isolated AVR can be safely and effectively performed by trainee surgeons who are strictly supervised in the operating theatre especially during the technically complex parts of the procedure.