Language-discordant care in pediatric neurosurgery: parent and provider perspectives on challenges and multilevel solutions to reduce disparities.

OBJECTIVE: In the United States, Spanish is the second most spoken language, with nearly 42 million individuals speaking Spanish at home. Spanish speakers have been noted to have higher rates of unfavorable neurosurgical outcomes; however, to the authors' knowledge, no study has explored the experiences of patients, caregivers, and providers receiving or delivering neurosurgical care in language-discordant settings. In this study, the authors sought to identify challenges faced by pediatric neurosurgery providers and Spanish-speaking parents communicating with a language barrier and propose solutions to address those challenges. METHODS: Spanish-speaking parents and pediatric neurosurgery providers were invited to participate in semistructured interviews. Purposeful sampling was used to recruit Spanish-speaking parents whose child had recently undergone neurological surgery at the authors' institution and to identify pediatric neurosurgery clinical team members to interview, including physicians, advanced practice providers, and interpreters. Codes were inductively developed and applied to transcripts by two researchers. Thematic analysis was conducted to identify challenges faced by parents and providers. RESULTS: Twenty individuals were interviewed, including parents (n = 8), advanced practice providers (n = 5), physicians (n = 3), interpreters (n = 2), a social worker (n = 1), and a nurse (n = 1). Three challenges were identified. 1) Compared with English-speaking parents, providers noted that Spanish-speaking parents were less likely to ask questions or raise new concerns. Concurrently, Spanish-speaking parents expressed a desire to better understand their child's future medical needs, care, and development. 2) There is a dearth of high-quality resources available in the Spanish language to supplement patient and parent neurosurgical education. 3) Both parents and providers invariably prefer in-person interpreters; however, their availability is limited. CONCLUSIONS: Three challenges were identified by Spanish-speaking parents of pediatric neurosurgery patients and providers when receiving or delivering care through a language barrier. The authors discuss multilevel solutions that, if deployed, could directly address these shared challenges. Furthermore, optimizing communication may help mitigate the disparities experienced by non-English-speaking Hispanic/Latino individuals when receiving neurosurgical care.

A Novel Serious Illness Communication Curriculum Improves Neurology Residents' Confidence and Skills.

Background and Purpose: Competency in serious illness communication is mandated by the Accreditation Council of Graduate Medical Education. Previous efforts to teach communication skills have been hampered by intensive time requirements. In this study, we developed and evaluated a brief goals-of-care communication curriculum for neurology residents. Methods: We developed and implemented a two-part curriculum based on themes identified from a needs assessment: (1) fundamental physician-patient communication skills; and (2) counseling surrogate decision makers and providing neuroprognostication. We used a three-pronged pre-post study design to evaluate the impact of the curriculum: resident self-assessment surveys, direct observations of resident-patient interactions, and patient perception surveys using the Communication Assessment Tool. Results: Residents reported a significant increase in mean scores [standard deviation] of confidence practicing fundamental communication skills, such as offering opportunities for emotion (3.84 [0.9] vs. 4.54 [0.6], p = 0.002), and goals-of-care communication skills, such as using triggers for serious conversations (2.65 [0.7] vs. 3.29 [0.5], p = 0.004). Observed resident-patient interactions showed significant improvement in fundamental communication skills, such as involving the patient in decision making (1.89 [0.6] vs. 4.0 [0.9], p < 0.001). There was no significant impact on patient perception of resident communication skills in the three months following the intervention. Conclusions: A brief, learner-centered curricular intervention improved neurology residents' confidence in serious illness communication and improved their skills as judged by trained observers.

Motivations and Barriers Toward Implementation of a Rectal Cancer Synoptic Operative Report: A Process Evaluation.

BACKGROUND: The use of synoptic reporting has been shown to improve documentation of critical information and provide added value related to data access and extraction, data reliability, relevant detail, and completeness of information. Surgeon acceptance and adoption of synoptic reports has lagged behind other specialties. OBJECTIVE: This study aimed to evaluate the process of implementing a synoptic operative report. DESIGN: This study was a mixed-methods process evaluation including surveys and qualitative interviews. SETTINGS: This study focused on colorectal surgery practices across the United States. PATIENTS: Twenty-eight board-certified colorectal surgeons were included. INTERVENTIONS: The synoptic operative report for rectal cancer was implemented. MAIN OUTCOME MEASURES: Acceptability, feasibility, and usability were measured by Likert-type survey questions and followed up with individual interviews to elicit experiences with implementation as well as motivations and barriers to use. RESULTS: Among all study participants, 28 surgeons completed the electronic survey (76% response rate) and 21 (57%) completed the telephone interview. Mean usability was 4.14 (range, 1-5; SE, 0.15), mean feasibility was 3.90 (SE, 0.15), and acceptability was 3.98 (SE, 0.18). Participants indicated that substantial administrative and technical support were necessary but not always available for implementation, and many were frustrated by the need to change their workflow. LIMITATIONS: Most surgeon participants were male, white, had >12 years in practice, and used Epic electronic medical record systems. Therefore, they may not represent the perspectives of all US colon and rectal surgeons. In addition, as the synoptic operative report is implemented more broadly across the United States, it will be important to consider variations in the process by electronic medical record system. CONCLUSIONS: The synoptic operative report for rectal cancer was easy to implement and incorporate into workflow, in general, but surgeons remained concerned about additional burden without immediate and tangible value. Despite recognizing benefits, many participants indicated they only implemented the synoptic operative report because it was mandated by the National Accreditation Program for Rectal Cancer. See Video Abstract at http://links.lww.com/DCR/B735MOTIVACIONES Y BARRERAS HACIA LA IMPLEMENTACIÓN DE UN INFORME OPERATIVO SINÓPTICO DE CÁNCER RECTAL: UNA EVALUACIÓN DEL PROCESOANTECEDENTES:Se ha demostrado que el uso de informes sinópticos mejora la documentación de información crítica y proporciona un valor agregado relacionado con el acceso y extracción de datos, la confiabilidad de los datos, los detalles relevantes y la integridad de la información. La aceptación y adopción de informes sinópticos por parte de los cirujanos se ha quedado rezagada con respecto a otras especialidades.OBJETIVO:Evaluar el proceso de implementación de un informe operativo sinóptico.DISEÑO:Evaluación de procesos de métodos mixtos que incluyen encuestas y entrevistas cualitativas.AJUSTES:Prácticas de cirugía colorrectal en los Estados Unidos.PACIENTES:Veintiocho cirujanos colorrectales certificados por la junta.INTERVENCIONES:Implementación del informe operatorio sinóptico de cáncer de recto.PRINCIPALES MEDIDAS DE RESULTADO:Aceptabilidad, viabilidad y usabilidad medidas por preguntas de encuestas tipo Likert y seguidas con entrevistas individuales para obtener experiencias con la implementación, así como motivaciones y barreras para el uso.RESULTADOS:Entre todos los participantes del estudio, 28 cirujanos completaron la encuesta electrónica (tasa de respuesta del 76%) y 21 (57%) completaron la entrevista telefónica. La usabilidad media fue 4,14 (rango = 1-5, error estándar (EE) = 0,15), la factibilidad media fue 3,90 (EE = 0,15) y la aceptabilidad fue 3,98 (EE = 0,18). Los participantes indicaron que se necesitaba un apoyo administrativo y técnico sustancial, pero que no siempre estaba disponible para la implementación y muchos se sintieron frustrados por la necesidad de cambiar su flujo de trabajo.LIMITACIONES:La mayoría de los cirujanos participantes eran hombres, blancos, tenían >12 años en la práctica y usaban sistemas de registros médicos electrónicos de Epic. Por lo tanto, es posible que no representen las perspectivas de todos los cirujanos de colon y recto de EE. UU. Además, a medida que el informe operativo sinóptico se implemente de manera más amplia en los EE. UU., Será importante considerar las variaciones en el proceso por sistema EMR.CONCLUSIONES:El informe quirúrgico sinóptico para el cáncer de recto fue en general fácil de implementar e incorporar en el flujo de trabajo, pero los cirujanos seguían preocupados por la carga adicional sin valor inmediato y tangible. A pesar de reconocer los beneficios, muchos participantes indicaron que solo implementaron el informe operativo sinóptico porque era un mandato del Programa Nacional de Acreditación para el Cáncer de Recto. Consulte Video Resumen en http://links.lww.com/DCR/B735 (Traducción-Dr. Xavier Delgadillo).

COVID-19 Impact on Surgical Resident Education and Coping.

BACKGROUND: Healthcare systems and surgical residency training programs have been significantly affected by the novel coronavirus disease 2019 (COVID-19) pandemic. A shelter-in-place and social distancing mandate went into effect in our county on March 16, 2020, considerably altering clinical and educational operations. Along with the suspension of elective procedures, resident academic curricula transitioned to an entirely virtual platform. We aimed to evaluate the impact of these modifications on surgical training and resident concerns about COVID-19. MATERIALS AND METHODS: We surveyed residents and fellows from all eight surgical specialties at our institution regarding their COVID-19 experiences from March to May 2020. Residents completed the survey via a secure Qualtrics link. A total of 38 questions addressed demographic information and perspectives regarding the impact of the COVID-19 pandemic on surgical training, education, and general coping during the pandemic. RESULTS: Of 256 eligible participants across surgical specialties, 146 completed the survey (57.0%). Junior residents comprised 43.6% (n = 61), compared to seniors 37.1% (n = 52) and fellows 19.3% (n = 27). Most participants, 97.9% (n = 138), anticipated being able to complete their academic year on time, and 75.2% (n = 100) perceived virtual learning to be the same as or better than in-person didactic sessions. Participants were most concerned about their ability to have sufficient knowledge and skills to care for patients with COVID-19, and the possibility of exposure to COVID-19. CONCLUSIONS: Although COVID-19 impacted residents' overall teaching and clinical volume, residency programs may identify novel virtual opportunities to meet their educational and research milestones during these challenging times.

"Making It Work": A Preliminary Mixed Methods Study of Rural Trauma Care Access and Resources in New Mexico.

Introduction Patients in the rural western United States face challenges accessing trauma and surgical services and are more likely to succumb to their injuries. New Mexico, a rural and medically underresourced state, is a salient space to study these disparities. We examine how travel distance from trauma centers impacts injured patient outcomes and describe care delivery obstacles. Materials and Methods We conducted an explanatory mixed methods study by creating geospatial maps of New Mexico's trauma data, incorporating linear regression analyses on patient outcomes as a function of estimated travel distance from trauma centers. We also conducted qualitative semi-structured interviews with trauma providers to illuminate and provide context for the geospatial findings utilizing a systematic, collaborative, iterative transcript analysis process. We constructed a conceptual framework describing rural trauma care delivery obstacles. Results Geospatial analyses revealed that most New Mexicans face long travel times to trauma centers. Comparing regression analyses using different data sources suggests that solely hospital-derived data may undercount rural trauma deaths. Interviews with 10 providers suggest that elements that may contribute to these findings include on-the-ground resource-based challenges and those related to broader healthcare systems-based issues. Our conceptual framework denotes how these elements collectively may impact rural trauma outcomes and proposes potential solutions. Conclusions In addressing rural patients' needs, healthcare policy decision-makers should ensure that their datasets are comprehensive and inclusive. They must also take into account the particular challenges of underserved rural patients and providers who care for them by eliciting their perspectives, as presented in our conceptual framework.

Clinical Uses and Impacts of Emergency Manuals During Perioperative Crises.

BACKGROUND: Performing key actions efficiently during crises can determine clinical outcomes, yet even expert clinicians omit key actions. Simulation-based studies of crises show that correct performance of key actions dramatically increases when emergency manuals (EMs) are used. Despite widespread dissemination of EMs, there is a need to understand in clinical contexts, when, how, and how often EMs are used and not used, along with perceived impacts. METHODS: We conducted interviews with the anesthesia professionals involved in perioperative crises, identified with criterion-based sampling, occurring between October 2014 and May 2016 at 2 large academic medical centers with a history of EM training and implementation. Our convergent, mixed-methods study of the interview data extracted quantitative counts and qualitative themes of EM use and nonuse during clinical crises. RESULTS: Interviews with 53 anesthesia professionals yielded 80 descriptions of applicable clinical crises, with varying durations and event types. Of 69 unique patients whose cases involved crises, the EM was used during 37 (54%; 95% confidence interval [CI], 41-66). Impacts on clinician team members included decreased stress for individual anesthesia professionals (95%), enabled teamwork (73%), and calmed atmosphere (46%). Impacts on delivery of patient care included specific action improvements, including catching errors of omission, for example, turning off anesthetic during cardiac arrest, only after EM use (59%); process improvements, for example, double-checking all actions were completed (41%); and impediments (0%). In 8% of crises, EM use was associated with potential distractions, although none were perceived to harm delivery of patient care. For 32 EM nonuses (46%; 95% CI, 34-59), participants self-identified errors of omission or delays in key actions (56%), all key actions performed (13%), and crisis too brief for EM to be used (31%). CONCLUSIONS: This study provides evidence that EMs in operating rooms are being used during many applicable crises and that clinicians perceive EM use to add value. The reported negative effects were minimal and potentially offset by positive effects.

Creation and implementation of a novel clinical workflow based on the AAST uniform anatomic severity grading system for emergency general surgery conditions.

OBJECTIVE: Emergency general surgery (EGS) conditions encompass a variety of diseases treated by acute care surgeons. The heterogeneity of these diseases limits infrastructure to facilitate EGS-specific quality improvement (QI) and research. A uniform anatomic severity grading system for EGS conditions was recently developed to fill this need. We integrated this system into our clinical workflow and examined its impact on research, surgical training, communication, and patient care. METHODS: The grading system was integrated into our clinical workflow in a phased fashion through formal education and a written handbook. A documentation template was also deployed in our electronic medical record to prospectively assign severity scores at the time of patient evaluation. Mixed methods including a quantitative survey and qualitative interviews of trainees and attending surgeons were used to evaluate the impact of the new workflow and to identify obstacles to its adoption. RESULTS: We identified 2291 patients presenting with EGS conditions during our study period. The most common diagnoses were small bowel obstruction (n=470, 20.5%), acute cholecystitis (n=384, 16.8%), and appendicitis (n=370, 16.1%). A total of 21 qualitative interviews were conducted. Twenty interviewees (95.2%) had a positive impression of the clinical workflow, citing enhanced patient care and research opportunities. Fifteen interviewees (75.0%) reported the severity grading system was a useful framework for clinical management, with five participants (25.0%) indicating the system was useful to facilitate clinical communication. Participants identified solutions to overcome barriers to adoption of the clinical workflow. CONCLUSIONS: The uniform anatomic severity grading system can be readily integrated into a clinical workflow to facilitate prospective data collection for QI and research. The system is perceived as valuable by users. Educational initiatives that focus on increasing familiarity with the system and its benefits will likely improve adoption of the classification system and the clinical workflow that uses it. LEVEL OF EVIDENCE: Level III.

A Mixed Methods Approach to Understanding Curricular Impact of a Capstone Course on the Self-Efficacy of Fourth-Year Medical Students.

Background Capstone, or bootcamp, courses have been shown to increase the knowledge, skills, and self-efficacy of students prior to starting intern year and have been recommended by the Alliance for Clinical Education (ACE) to be incorporated into the fourth-year medical school curricula. However, a paucity of research exists regarding the exploration of the student perspective on critical curricular content and teaching strategies in a capstone course. Self-efficacy, one's subjective task-specific judgment of capability, has served in the literature as a framework for capstone outcomes and is derived from four sources of experiences: practice, observation of others, feedback, and one's emotional reaction to difficult situations. Utilizing this framework, we aimed to evaluate the impact of our capstone curriculum on students' self-efficacy and to identify critical curricular content and teaching strategies that affected students' self-efficacy and their transition into residency. Methods We designed a mixed methods study of our institution's capstone course in May 2019. Students were invited to participate in the retrospective pre- and post- self-efficacy survey and focus group immediately after the capstone and in semi-structured interviews four months after they began the intern year. Themes were identified via qualitative analysis using inductive coding to allow participants' voices to guide code development and deductive analysis using codes derived from the self-efficacy framework. Results  Nine enrolled students participated in the study (surveys n=8, focus group n=7, follow-up interview n=6). Students reported the capstone was a very valuable educational experience (median 4.5 [interquartile range, or IQR 4-5]), increased their preparedness for intern year (median 5 [IQR 4.25-5]) and increased self-efficacy in multiple domains. Qualitative analysis revealed the critical curricular elements that most impacted students' self-efficacy were practical and communication skills to which students previously had limited exposure, in particular managing acute clinical needs, overnight cross-cover pages, inpatient pharmacology, daily intern communication (handoffs, consults, consenting), and end-of-life communication (goals of care, code status, pronouncing death). While all four sources contributed to self-efficacy, students reported that instructor and peer feedback were fundamental to providing context and substance to their performance. Students preferred practice-based learning via high-fidelity simulation and small groups for familiar tasks (daily intern communication, overnight pages, pharmacology) and observation of peers for new tasks (end-of-life communication and acute clinical deterioration). Conclusions This is the first study describing students' perspectives on critical curricular content and teaching strategies for a capstone course derived from qualitative analysis. Practical and communication skills with previously limited clerkship exposure and task-specific learning strategies increased the students' self-efficacy. Constructive feedback provided an important source of self-efficacy for all tasks, augmenting the benefits of practice and observation. This data provides preliminary groundwork for future research as multi-institutional studies are necessary to better understand students' needs around the curriculum to address residency transition.

Medical Student Values Inform Career Plans in Service & Surgery-A Qualitative Focus Group Analysis.

BACKGROUND: Diversifying the surgical workforce is a critical component of improving care for underserved patients. To recruit surgeons from diverse backgrounds, we must understand how medical students choose their specialty. We investigate how preclinical students contemplate entering a surgical field. MATERIALS AND METHODS: We conducted semistructured focus groups during two iterations of a seminar class called Service Through Surgery. Discussion goals included identifying student values and assessing how they inform early career decisions. We used a systematic, collaborative, and iterative process for transcript analysis, including developing a codebook, assessing inter-rater reliability, and analyzing themes. RESULTS: Twenty-four preclinical medical students from diverse backgrounds participated in seven focus groups; most were women (16; 67%), in their first year of medical school (19; 79%), and interested in surgery (17; 71%). Participants ranked professional fulfillment, spending time with family, and serving their communities and/or underserved populations among their most important values and agreed that conducting groundbreaking research, working long hours, and finding time for leisure activities were the least important. We constructed a framework to describe student responses surrounding their diverse visions for service in future surgical careers through individual doctoring interactions, roles in academia, and broader public service. CONCLUSIONS: Our framework provides a basis for greater understanding and study of the ways in which preclinical medical students think about their personal values and visions for service in potential future surgical careers. This research can guide early interventions in medical education to promote diversity and care for the underserved in surgery.

What constitutes a 'successful' recovery? Patient perceptions of the recovery process after a traumatic injury.

BACKGROUND: As the number of patients surviving traumatic injuries has grown, understanding the factors that shape the recovery process has become increasingly important. However, the psychosocial factors affecting recovery from trauma have received limited attention. We conducted an exploratory qualitative study to better understand how patients view recovery after traumatic injury. METHODS: This qualitative, descriptive study was conducted at a Level One university trauma center. Participants 1-3 years postinjury were purposefully sampled to include common blunt-force mechanisms of injuries and a range of ages, socioeconomic backgrounds and injury severities. Semi-structured interviews explored participants' perceptions of self and the recovery process after traumatic injury. Interviews were transcribed verbatim; the data were inductively coded and thematically analyzed. RESULTS: We conducted 15 interviews, 13 of which were with male participants (87%); average hospital length of stay was 8.9 days and mean injury severity score was 18.3. An essential aspect of the patient experience centered around the recovery of both the body and the 'self', a composite of one's roles, values, identities and beliefs. The process of regaining a sound sense of self was essential to achieving favorable subjective outcomes. Participants expressed varying levels of engagement in their recovery process, with those on the high end of the engagement spectrum tending to speak more positively about their outcomes. Participants described their own subjective interpretations of their recovery as most important, which was primarily influenced by their engagement in the recovery process and ability to recover their sense of self. DISCUSSION: Patients who are able to maintain or regain a cohesive sense of self after injury and who are highly engaged in the recovery process have more positive assessments of their outcomes. Our findings offer a novel framework for healthcare providers and researchers to use as they approach the issue of recovery after injury with patients. LEVEL OF EVIDENCE: III-descriptive, exploratory study.

Validity Evidence for a Knowledge Assessment Tool for a Mastery Learning Scrub Training Curriculum.

PURPOSE: To examine the validity evidence for a scrub training knowledge assessment tool to demonstrate the utility and robustness of a multimodal, entrustable professional activity (EPA)-aligned, mastery learning scrub training curriculum. METHOD: Validity evidence was collected for the knowledge assessment used in the scrub training curriculum at Stanford University School of Medicine from April 2017 to June 2018. The knowledge assessment had 25 selected response items that mapped to curricular objectives, EPAs, and operating room policies. A mastery passing standard was established using the Mastery Angoff and Patient-Safety approaches. Learners were assessed pre curriculum, post curriculum, and 6 months after the curriculum. RESULTS: From April 2017 to June 2018, 220 medical and physician assistant students participated in the scrub training curriculum. The mean pre- and postcurriculum knowledge scores were 74.4% (standard deviation [SD] = 15.6) and 90.1% (SD = 8.3), respectively, yielding a Cohen's d = 1.10, P < .001. The internal reliability of the assessment was 0.71. Students with previous scrub training performed significantly better on the precurriculum knowledge assessment than those without previous training (81.9% [SD = 12.6] vs 67.0% [SD = 14.9]; P < .001). The mean item difficulty was 0.74, and the mean item discrimination index was 0.35. The Mastery Angoff overall cut score was 92.0%. CONCLUSIONS: This study describes the administration of and provides validity evidence for a knowledge assessment tool for a multimodal, EPA-aligned, mastery-based curriculum for scrub training. The authors support the use of scores derived from this test for assessing scrub training knowledge among medical and physician assistant students.

Qualitative outcomes of Clean Cut: implementation lessons from reducing surgical infections in Ethiopia.

BACKGROUND: Clean Cut is a six month, multi-modal, adaptive intervention aimed at reducing surgical infections through improving six critical perioperative processes: 1) handwashing/skin preparation, 2) surgical gown/drape integrity, 3) antibiotic administration, 4) instrument sterility, 5) gauze counts, and 6) WHO Surgical Safety Checklist use. The aim of this study was to elucidate themes across Clean Cut implementation sites in Ethiopia to improve implementation at future hospitals. METHODS: We conducted semi-structured interviews of 20 clinicians involved in Clean Cut at four hospitals. Participation was limited to Clean Cut team members and included surgeons, anesthetists, operating room (OR) nurses, ward nurses, OR managers, quality improvement personnel, and hospital administrators. Audio recordings were transcribed and coded using qualitative software. A codebook was inductively and iteratively derived between two researchers, tested for inter-rater reliability, and applied to all transcripts. We conducted thematic analysis to derive our final qualitative results. RESULTS: The interviews revealed barriers and facilitators to the implementation of Clean Cut, as well as strategies for future implementation sites. Key barriers included material resource limitations, feelings of job burden, existing gaps in infection prevention education, and communication errors during data collection. Common facilitators included strong hospital leadership support, commitment to improved patient outcomes, and organized Clean Cut training sessions. Future strategies include resource assessments, creating a sense of responsibility among staff, targeted training sessions, and incorporating new standards into daily routine. CONCLUSIONS: The findings of this study highlight the importance of engaging hospital leadership, providers and staff in quality improvement programs, and understanding their work contexts. The identified barriers and facilitators will inform future initiatives in the field of perioperative infection prevention.

Unavoidable Risks: Local Perspectives on Water Contact Behavior and Implications for Schistosomiasis Control in an Agricultural Region of Northern Senegal.

Human schistosomiasis is a snail-borne parasitic disease affecting more than 200 million people worldwide. Direct contact with snail-infested freshwater is the primary route of exposure. Water management infrastructure, including dams and irrigation schemes, expands snail habitat, increasing the risk across the landscape. The Diama Dam, built on the lower basin of the Senegal River to prevent saltwater intrusion and promote year-round agriculture in the drought-prone Sahel, is a paradigmatic case. Since dam completion in 1986, the rural population-whose livelihoods rely mostly on agriculture-has suffered high rates of schistosome infection. The region remains one of the most hyperendemic regions in the world. Because of the convergence between livelihoods and environmental conditions favorable to transmission, schistosomiasis is considered an illustrative case of a disease-driven poverty trap (DDPT). The literature to date on the topic, however, remains largely theoretical. With qualitative data generated from 12 focus groups in four villages, we conducted team-based theme analysis to investigate how perception of schistosomiasis risk and reported preventive behaviors may suggest the presence of a DDPT. Our analysis reveals three key findings: 1) rural villagers understand schistosomiasis risk (i.e., where and when infections occur), 2) accordingly, they adopt some preventive behaviors, but ultimately, 3) exposure persists, because of circumstances characteristic of rural livelihoods. These findings highlight the capacity of local populations to participate actively in schistosomiasis control programs and the limitations of widespread drug treatment campaigns. Interventions that target the environmental reservoir of disease may provide opportunities to reduce exposure while maintaining resource-dependent livelihoods.

Education Research: Understanding barriers to goals of care communication for neurology trainees.

OBJECTIVE: To describe the perspectives of neurology residents regarding barriers to effective goals of care discussions and to identify residents' current and desired educational strategies to improve goals of care communication. METHODS: All neurology residents at our institution were invited to voluntarily participate in focus groups. Residents were organized into 3 focus groups by year of training. Moderators asked residents open-ended questions about current goals of care communication practice and ideas for improving the frequency and effectiveness of goals of care discussions. All responses were audiorecorded, transcribed, and de-identified. Transcripts of the focus groups were independently read and coded by members of the research team. We performed thematic analysis to identify and systematize relationships across coded data. RESULTS: Twenty out of 29 neurology residents participated in the focus groups. We identified 3 overarching domains impeding goals of care communication: patient factors, resident factors, and systems factors. Residents proposed specific desired strategies to address these 3 domains with the goal of improving the frequency and efficacy of goals of care communication. The desired strategies included receiving feedback from patients and families, developing resident-focused educational opportunities through direct observation and coaching, and systems changes by documenting goals of care discussions. CONCLUSIONS: Neurology residents identify multiple barriers to effective goals of care communication and propose specific desired strategies for improvement. This detailed input from residents will be incorporated into future curricular interventions to improve confidence and skill in leading goals of care discussions.

Challenges of infertility genetic counseling: Impact on counselors' personal and professional lives.

Infertility genetic counselors (GCs) work with patients struggling to become pregnant who desire genetic testing of embryos and preconception genetic testing or carrier screening. Because personal and professional challenges have not been examined in this relatively new genetic counseling specialty, we investigated the difficulties infertility GCs face in their professional roles. Past and present infertility GCs in patient-facing roles were recruited through the National Society of Genetic Counselors. Purposive sampling ensured participants were diverse in clinical setting, reproductive history, and other demographics. Nineteen participants completed a semi-structured interview, at which time data saturation occurred. Thematic analysis revealed infertility GCs consider their patients more emotionally stressed than patients in other specialties. Infertility GCs relate easily to patients, build long-term patient relationships, and feel invested in the reproductive successes of patients. Participants reported heightened concern for their own fertility, leading to high personal uptake of preconception genetic and fertility tests. Participants described discomfort when counseling while visibly pregnant and reluctance to disclose their own reproductive histories. Further research is needed on the complex interactions of GCs' personal and professional lives. Peer support groups and professional dialogue about the personal effects of the role may be beneficial for infertility GCs.

Attending Surgeons Differ From Other Team Members in Their Perceptions of Operating Room Communication.

BACKGROUND: The Joint Commission has repeatedly recognized inadequate communication as a top contributing factor to medical error in the operating room (OR). The goal of this qualitative study was to develop a deeper and more nuanced understanding of OR communication dynamics, specifically across different interdisciplinary roles and to recommend specific interventions based on these findings. METHODS: We performed a two-phase qualitative study at one academic institution to explore contributors and barriers to optimal OR communication. The first phase consisted of interviews with OR team members, including surgery and anesthesiology attending faculty and residents, medical students, and OR staff. We qualitatively analyzed the transcripts of these interviews using a deductive approach. We additionally verified the findings through subsequent focus groups. RESULTS: Most OR team members, independent of role, noted that team familiarity, clear role expectations, and formal communication are vital for effective OR communication. There was a disconnect between attending surgeons and the rest of the OR team: Whereas the majority of team members noted the importance of procedural-focused discussions, team hierarchy, and the attending surgeon's mood as major contributors to successful OR communication, the attending surgeons did not recognize their own ability to contribute to optimal OR communication in these regards. CONCLUSIONS: Although team familiarity was important to all participants in the OR, we noted that attending surgeons differed in their perceptions of OR communications from other members of the team, including attending anesthesiologists, residents, medical students, and nurses. Our findings support the need for (1) improved awareness of the impact of a team members's content and character of communication, particularly by attending surgeons; and (2) targeted initiatives to prioritize team familiarity in OR scheduling.

Use of an Emergency Manual During an Intraoperative Cardiac Arrest by an Interprofessional Team: A Positive-Exemplar Case Study of a New Patient Safety Tool.

BACKGROUND: An emergency manual (EM) is a set of evidence-based crisis checklists, or cognitive aids, that can improve team performance. EMs are used in other safety-critical industries, and health care simulation studies have shown their efficacy, but use in clinical settings is nascent. A case study was conducted on the use of an EM during one intraoperative crisis, which entailed the assessment of the impact of the EM's use on teamwork and patient care and the identification of lessons for effectively using EMs during future clinical crises. METHODS: In a case study of a single crisis, an EM was used during a cardiac arrest at a tertiary care hospital that had systematically implemented perioperative EMs. Semistructured interviews were conducted with all six clinicians present, interview transcripts were iteratively coded, and thematic analysis was performed. RESULTS: All clinician participants stated that EM use enabled effective team functioning via reducing stress of individual clinicians, fostering a calm work environment, and improving teamwork and communication. These impacts in turn improved the delivery of patient care during a clinical crisis and influenced participants' intended EM use during future appropriate crises. CONCLUSION: In this positive-exemplar case study, an EM was used to improve delivery of evidence-based patient care through effective clinical team functioning. EM use must complement rather than replace good clinician education, judgment, and teamwork. More broadly, understanding why and how things go well via analyzing positive-exemplar case studies, as a converse of root cause analyses for negative events, can be used to identify effective applications of safety innovations.

Exploring the Medical and Psychosocial Concerns of Adolescents and Young Adults With Craniofacial Microsomia: A Qualitative Study.

OBJECTIVE: This study explores the experiences of adolescents and young adults with craniofacial microsomia, including the impact of growing up with this craniofacial condition on daily life and sense of self. The results may guide future research on optimally supporting individuals with craniofacial microsomia during this critical life phase. DESIGN AND SETTING: Participants were recruited through a craniofacial center, online patient support groups, and social media sites. Eleven individual semistructured interviews with participants between 12 and 22 years old were conducted by a single interviewer, transcribed, iteratively coded, and thematically analyzed. RESULTS: Five themes were evident in the data: (1) impact on personal growth and character development, (2) negative psychosocial impact, (3) deciding to hide or reveal the condition, (4) desire to make personal surgical decisions, and (5) struggles with hearing loss. CONCLUSIONS: We identified both medical and psychosocial concerns prevalent among adolescents with craniofacial microsomia. Although adolescents with craniofacial microsomia exhibit considerable resilience, the challenges they face impact their sense of self and should be addressed through psychosocial support and counseling. Further research should investigate the potential benefit of the wider use of hearing aids, as well as the involvement of patients in decision-making about reconstructive ear surgery.

Medical student perceptions of a mistreatment program during the surgery clerkship.

BACKGROUND: Medical student mistreatment remains a concern, particularly in the surgery clerkship. This is a single academic institution's report of medical student perceptions of a mistreatment program embedded in the surgery clerkship. METHODS: Students who completed the surgery clerkship and the mistreatment program volunteered to be interviewed individually or in focus groups. The interviews were transcribed and qualitatively analyzed. RESULTS: Twenty-four medical students were interviewed and nine transcripts were obtained. Codes were identified independently then nested into four codes: Student Growth, Faculty Champion and Team, Student Perspectives on Surgical Culture, and Program Methods. Rank orders were then calculated for each major code. CONCLUSION: Our mistreatment program has shown that providing students with an opportunity to define mistreatment, a safe environment for them to debrief, and staff to support and advocate for them empowers them with the knowledge and skillset to confront what is too often considered part of the hidden curriculum.

Introductory Surgical Skills Course: Technical Training and Preparation for the Surgical Environment.

Introduction: Early exposure to surgery in a positive learning environment can contribute to increased student interest. The primary objectives of this study included developing increased comfort in the operating room (OR) environment, confidence in surgical skills, and mentorship for students interested in surgery. Methods: The course comprised seven 2-hour sessions covering both nontechnical and technical skills facilitated by attending and resident surgeons. Sessions included nontechnical skills training, basic knot tying and suturing, laparoscopic surgical skills, and high-fidelity operative simulations on animal and cadaver models. The curriculum also matched students with faculty mentors in order to scrub into operative cases. Surveys assessing self-reported comfort in the OR, confidence levels in surgical skills, and whether students had mentors in surgery were distributed before and after the course. Results: Thirty preclinical medical students were enrolled in the course in 2016 and an additional 41 students in 2017. Results showed increased confidence in all skills and in comfort in the OR, as well as increased surgeon mentorship. Thirty-two students who completed the course entered clinical rotations in 2018 and, when surveyed, reported increased confidence in the aforementioned domains and in their preparedness for their surgery clerkship, compared to 49 peers who had not completed the course. Discussion: The course successfully increased comfort in the OR, increased confidence in performing surgical skills, and provided students with mentors in surgery, all of which will hopefully foster positive experiences during their surgery clerkship and ultimately increase their consideration of surgery as a career.