Firearm-Related Injuries and the US Opioid and Other Substance Use Epidemic: A Nationwide Evaluation of Emergency Department Encounters.

INTRODUCTION: There has been a sharp climb in the Unites States' death rate among opioid and other substance abuse patients, as well as an increased prevalence in gun violence. We aimed to investigate the association between substance abuse and gun violence in a national sample of patients presenting to US emergency departments (EDs). METHODS: We queried the 2018-2019 Nationwide Emergency Department Sample for patients ≥18 years with substance abuse disorders (opioid and other) using International Classification of Diseases, 10th Revision, Clinical Modification codes. Within this sample, we analyzed characteristics and outcomes of patients with firearm-related injuries. The primary outcome was mortality; secondary outcomes were ED charges and length of stay. RESULTS: Among the 25.2 million substance use disorder (SUD) patients in our analysis, 35,306 (0.14%) had a firearm-related diagnosis. Compared to other SUD patients, firearm-SUD patients were younger (33.3 versus 44.7 years, P < 0.001), primarily male (88.6% versus 54.2%, P < 0.001), of lower-income status (0-25th percentile income: 56.4% versus 40.5%, P < 0.001), and more likely to be insured by Medicaid or self-pay (71.6% versus 53.2%, P < 0.001). Firearm-SUD patients had higher mortality (1.4% versus 0.4%, P < 0.001), longer lengths of stay (6.5 versus 4.9 days, P < 0.001), and higher ED charges ($9269 versus $5,164, P < 0.001). Firearm-SUD patients had a 60.3% rate of psychiatric diagnoses. Firearm-SUD patients had 5.5 times greater odds of mortality in adjusted analyses (adjusted odds ratio: 5.5, P < 0.001). CONCLUSIONS: Opioid-substance abuse patients with firearm injuries have higher mortality rates and costs among these groups, with limited discharge to postacute care resources. All these factors together point to the urgent need for improved screening and treatment for this vulnerable group of patients.

Impact of a coaching program on resident perceptions of communication confidence and feedback quality.

BACKGROUND: While communication is an essential skill for providing effective medical care, it is infrequently taught or directly assessed, limiting targeted feedback and behavior change. We sought to evaluate the impact of a multi-departmental longitudinal residency communication coaching program. We hypothesized that program implementation would result in improved confidence in residents' communication skills and higher-quality faculty feedback. METHODS: The program was implemented over a 3-year period (2019-2022) for surgery and neurology residents at a single institution. Trained faculty coaches met with assigned residents for coaching sessions. Each session included an observed clinical encounter, self-reflection, feedback, and goal setting. Eligible residents completed baseline and follow-up surveys regarding their perceptions of feedback and communication. Quantitative responses were analyzed using paired t-tests; qualitative responses were analyzed using content analysis. RESULTS: The baseline and follow-up survey response rates were 90.0% (126/140) and 50.5% (46/91), respectively. In a paired analysis of 40 respondents, residents reported greater confidence in their ability to communicate with patients (inpatient: 3.7 vs. 4.3, p < 0.001; outpatient: 3.5 vs. 4.2, p < 0.001), self-reflect (3.3 vs. 4.3, p < 0.001), and set goals (3.6 vs. 4.3, p < 0.001), as measured on a 5-point scale. Residents also reported greater usefulness of faculty feedback (3.3 vs. 4.2, p = 0.001). The content analysis revealed helpful elements of the program, challenges, and opportunities for improvement. Receiving mentorship, among others, was indicated as a core program strength, whereas solving session coordination and scheduling issues, as well as lowering the coach-resident ratio, were suggested as some of the improvement areas. CONCLUSIONS: These findings suggest that direct observation of communication in clinical encounters by trained faculty coaches can facilitate long-term trainee growth across multiple core competencies. Future studies should evaluate the impact on patient outcomes and workplace-based assessments.

Tips for developing a coaching program in medical education.

This article provides structure to developing, implementing, and evaluating a successful coaching program that effectively meets the needs of learners. We highlight the benefits of coaching in medical education and recognize that many educators desiring to build coaching programs seek resources to guide this process. We align 12 tips with Kern's Six Steps for Curriculum Development and integrate theoretical frameworks from the literature to inform the process. Our tips include defining the reasons a coaching program is needed, learning from existing programs and prior literature, conducting a needs assessment of key stakeholders, identifying and obtaining resources, developing program goals, objectives, and approach, identifying coaching tools, recruiting and training coaches, orienting learners, and evaluating program outcomes for continuous program improvement. These tips can serve as a framework for initial program development as well as iterative program improvement.

Perceptions of Use of Names, Recognition of Roles, and Teamwork After Labeling Surgical Caps.

Importance: Communication failures in perioperative areas are common and have negative outcomes for both patients and clinicians. Names and roles of teammates are difficult to remember or discern contributing to suboptimal communication, yet the utility of labeled surgical caps with names and roles for enhancing perceived teamwork and connection is not well studied. Objective: To evaluate the use of labeled surgical caps in name use and role recognition, as well as teamwork and connection, among interprofessional perioperative teammates. Design, Setting, and Participants: In this quality improvement study, caps labeled with names and roles were distributed to 967 interprofessional perioperative clinicians, along with preimplementation and 6-month postimplementation surveys. Conducted between July 8, 2021, and June 25, 2022, at a single large, academic, quaternary health care center in the US, the study comprised surgeons, anesthesiologists, trainees, and all interprofessional hospital staff who work in adult general surgery perioperative areas. Intervention: Labeled surgical caps were offered cost-free, although not mandatory, to each interested clinician. Main Outcome and Measure: Quantitative survey of self-reported frequency for name use and role recognition as well as postimplementation sense of teamwork and connection. The surveys also elicited free response comments. Results: Of the 1483 eligible perioperative clinicians, 967 (65%; 387 physicians and 580 nonphysician staff; 58% female) completed preimplementation surveys and received labeled caps, and 243 of these individuals (51% of physicians and 8% of staff) completed postimplementation surveys. Pre-post results were limited to physicians, due to the low postsurvey staff response rate. The odds of participants reporting that they were often called by their name increased after receiving a labeled cap (adjusted odds ratio [AOR], 13.37; 95% CI, 8.18-21.86). On postsurveys, participants reported that caps with names and roles substantially improved teamwork (80%) and connection (79%) with teammates. Participants who reported an increased frequency of being called by their name had higher odds for reporting improved teamwork (AOR, 3.46; 95% CI, 1.91-6.26) and connection with teammates (AOR, 3.21; 95% CI, 1.76-5.84). Free response comments supported the quantitative data that labeled caps facilitated knowing teammates' names and roles and fostered a climate of wellness, teamwork, inclusion, and patient safety. Conclusions and Relevance: The findings of this quality improvement study performed with interprofessional teammates suggest that organizationally sponsored labeled surgical caps was associated with improved teamwork, indicated by increased name use and role recognition in perioperative areas.

Developing an Inpatient Relationship Centered Communication Curriculum (I-RCCC) rounding framework for surgical teams.

BACKGROUND: Morning rounds by an acute care surgery (ACS) service at a level one trauma center are uniquely demanding, given the fast pace, high acuity, and increased patient volume. These demands notwithstanding, communication remains integral to the success of surgical teams. Yet there are limited published curricula that address trauma inpatient communication needs. Observations at our institution confirmed that the surgical team lacked a shared mental model for communication. We hypothesized that creating a relationship-centered rounding conceptual framework model would enhance the provider-patient experience. STUDY DESIGN: A mixed-methods approach was used for this study. A multi-pronged needs assessment was conducted. Provider communion items for Press Ganey and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys were used to measure patients' expressed needs. Faculty with experience in relationship-centered communication observed morning rounds and documented demonstrated behaviors. A five-hour workshop was designed based on the identified needs. A pre-and post-course Assessment and course evaluation were conducted. Provider-related patient satisfaction items were measured six months before the course and six months after the workshop. RESULTS: Needs assessment revealed a lack of a shared communication framework and a lack of leadership skills for senior trauma residents. Barriers included: time constraints, patient load, and interruptions during rounds. The curriculum was very well received. The self-reflected behaviors that demonstrated the most dramatic change between the pre and post-workshop surveys were: I listened without interrupting; I spoke clearly and at a moderate pace; I repeated key points; and I checked that the patient understood. All these changed from being performed by 50% of respondents "about half of the time" to 100% of them "always". Press Ganey top box likelihood to recommend (LTR) and provider-related top box items showed a trend towards improvement after implementing the training with a percentage difference of up to 20%. CONCLUSION: The Inpatient Relationship Centered Communication Curriculum (I-RCCC) targeting senior residents and Nurse Practitioners (NP) was feasible, practical, and well-received by participants. There was a trend of an increase in LTRs and provider-specific patient satisfaction items. This curriculum will be refined based on the study results and potentially scalable to other surgical specialties.

A National Evaluation of Emergency General Surgery Outcomes Among Hospitalized Cardiac Patients.

INTRODUCTION: Emergency general surgery among cardiac surgery patients is increasingly common and consequential. We sought to characterize the true burden of emergency general surgery among hospitalized complex cardiac patients. METHODS: We performed a retrospective analysis of the 2016-2017 National Inpatient Sample. We included adult patients with a primary diagnosis of complex cardiac disease. We then compared patients who underwent emergency general surgery (GS-OR) with those who did not (non-GS-OR). The primary outcome was mortality; secondary outcomes included length of stay and hospitalization costs. RESULTS: We identified 10.2 million patients with a primary diagnosis of complex cardiac disease, of which 148,309 (1.4%) underwent GS-OR. Mortality rates were significantly higher in the GS-OR group (11.0% versus 5.0%, P < 0.001). Among all cardiac patients, GS-OR was associated with 2.2 times increased odds of death (aOR: 2.2, P < 0.001). GS-OR patients also had longer length of stays (14.1 versus 5.8 d, P < 0.001). Among all cardiac patients, GS-OR was associated with an 8.1-day longer length of stay (P < 0.001). GS-OR patients were less often routinely discharged home (31.7% versus 45.3%, P < 0.001) and incurred higher inpatient costs ($46,136 versus $16,303, P < 0.001). Among all cardiac patients, GS-OR patients incurred $30,102 higher hospitalization costs (P < 0.001). CONCLUSIONS: Emergency general surgery among cardiac surgery patients is associated with a greater than two-fold increase in mortality, longer length of stays, higher rates of nonroutine discharge, and higher hospitalization costs. Emergency general surgery complications account for 4.0% of total inpatient costs of cardiac surgery patients and merit further study.

Introducing advanced surgical tasks simulation for surgical training.

Acquiring surgical skills is one of the major objectives of surgical training. Trainees face increasing challenges to meet the continuously evolving surgical techniques and approaches during the limited time course of their surgical training. The limited availability of training tools for teaching advanced surgical skills is an additional barrier. Educators have increasingly used simulation tools for surgical skills training around the globe. However, current simulation training modules and curricula focus mainly on basic surgical skills. Hence, the development of advanced virtual simulation modules offers a precious laparoscopic training opportunity. This article provides an educational technology-based review and proposal (with selected examples) of simulation training modules on advanced surgical skills that can be used for advanced surgical training approaches.

Building a Trainee-led Research Community to Propel Academic Productivity in Health Services Research.

Academic productivity is an increasingly important asset for trainees pursuing academic careers. Medical schools and graduate medical education programs offer structured research programs, but providing longitudinal and individualized health services research education remains challenging. Whereas in basic science research, members at multiple training levels support each other within a dedicated community (the laboratory), health services research projects frequently occur within individual faculty-trainee relationships. An optimal match of expertise, availability, and interest may be elusive for an individual mentor-mentee pair. We aimed to share our experience building Surgeons Writing about Trauma (SWAT), a trainee-led research community that propels academic productivity by facilitating peer collaboration and opportunities to transition into independent researchers. We highlight challenges of health services research for trainees, present how structured mentorship and a peer community can address this challenge, and detail SWAT's operational structure to guide replication at peer institutions.

Developing a multi-departmental residency communication coaching program.

Background: Local needs assessments in our institution's surgery and neurology residency programs identified barriers to effective communication, such as no shared communication framework and limited feedback on nontechnical clinical skills. Residents identified faculty-led coaching as a desired educational intervention to improve communication skills. Three university departments (Surgery, Neurology, and Pediatrics) and health-care system leaders collaborated closely to develop an innovative communication coaching initiative generalizable to other residency programs. Innovation: Coaching program development involved several layers of collaboration between health-care system leaders, faculty educators, and departmental communication champions. The efforts included: (1) creating and delivering communication skills training to faculty and residents; (2) hosting frequent meetings among various stakeholders to develop program strategy, discuss opportunities and learnings, and engage other medical educators interested in coaching; (3) obtaining funding to implement the coaching initiative; (4) selecting coaches and providing salary and training support. Evaluation: A multi-phased mixed-methods study utilized online surveys and virtual semi-structured interviews to assess the program's quality and impact on the communication culture and the satisfaction and communication skills of residents. Quantitative and qualitative data have been integrated during data collection and analysis using embedding, building, and merging strategies. Discussion and Implications: Establishing a multi-departmental coaching program may be feasible and can be adapted by other programs if similar resources and focus are present. We found that stakeholders' buy-in, financial support, protected faculty time, flexible approach, and rigorous evaluation are crucial factors in successfully implementing and sustaining such an initiative.

Education research - Understanding the factors involved in inpatient communication for orthopedic trainees.

BACKGROUND: "Interpersonal and Communication Skills" (ICS) is a core competency set forth by the ACGME. No structured curriculum exists to train orthopedics residents in ICS. METHODS: Twenty-four out of thirty-five orthopedics residents completed the survey (69%). The survey had the following domains: [1] Demographics, [2] Communication Needs/Goals, and [3] Communication Barriers. RESULTS: Eighty-three percent of respondents wanted to improve their communication skills and their patient's experience. Interns-PGY4s wanted to improve on similar specific communication skills. All residents desired training in conflict management. CONCLUSION: There is a need among orthopedics residents for a communication skills curriculum early in residency training, specifically in conflict management.

Virtual reality (VR) as a simulation modality for technical skills acquisition.

Efforts continue to facilitate surgical skills training and provide accessible and safe training opportunities. Educational technology has played an essential role in minimizing the challenges facing traditional surgical training and providing feasible training opportunities. Simulation and virtual reality (VR) offer an important innovative training approach to enhance and supplement both technical and non-technical skills acquisition and overcome the many training challenges facing surgical training programs. To maximize the effectiveness of simulation modalities, an in-depth understanding of the cognitive learning theory is necessary. Knowing the stages and mental processes of skills acquisition when integrated with simulation applications can help trainees achieve maximal learning outcomes. This article aims to review important literature related to VR effectiveness and discuss the leading theories of technical skills acquisition related to VR simulation technologies.

Feasibility and acceptability of virtually coaching residents on communication skills: a pilot study.

BACKGROUND: Developing communication skills is a key competency for residents. Coaching, broadly accepted as a training modality in medical education, has been proven a successful tool for teaching communication skills. Little research is available thus far to investigate virtual coaching on communication skills for telemedicine encounters. The purpose of the study was to test the hypothesis that virtually coaching residents on communication skills is feasible and acceptable. We surveyed 21 resident-faculty pairs participating in a "fully virtual" coaching session (patient, coach, and resident were virtual). METHODS: We asked 50 neurology resident-faculty coach pairs to complete one "fully virtual" coaching session between May 20 and August 31, 2020. After each session, the resident and coach completed a 15-item survey, including Likert-style scale and open-ended questions, assessing feasibility and acceptability. Descriptive statistics and qualitative content and thematic analyses were performed. RESULTS: Forty-two percent (21/50) of all eligible residents completed "fully virtual" coaching sessions. The overall survey response rate was 91 % (38/42). The majority of respondents agreed that the direct observation and debriefing conversation were easy to schedule and occurred without technical difficulties and that debriefing elements (self-reflection, feedback, takeaways) were useful for residents. Ninety-five percent of respondents rated the coach's virtual presence to be not at all disruptive to the resident-patient interaction. Virtual coaching alleviated resident stress associated with observation and was perceived as an opportunity for immediate feedback and a unique approach for resident education that will persist into the future. CONCLUSIONS: In this pilot study, residents and faculty coaches found virtual coaching on communication skills feasible and acceptable for telemedicine encounters. Many elements of our intervention may be adoptable by other residency programs. For example, residents may share their communication goals with clinic faculty supervisors and then invite them to directly observe virtual encounters what could facilitate targeted feedback related to the resident's goals. Moreover, virtual coaching on communication skills in both the in-person and telemedicine settings may particularly benefit residents in challenging encounters such as those with cognitively impaired patients or with surrogate decision-makers.

Applying Bloom's taxonomy in clinical surgery: Practical examples.

Bloom's cognitive learning taxonomy is widely used in medical education. The revised taxonomy published by David Kathwohl (1956) and his group describes the levels in action forms: Remember, Understand, Apply, Analyze, Evaluate, and Innovate. The taxonomy has been commonly used to design and structure educational goals and objectives. However, most uses occur at the course or program curriculum level, as was originally described. Whereas applying the taxonomy at the level of individual educational activities remained limited for different reasons. Hence, the aim of this article is to promote applying the taxonomy in daily clinical teaching by providing practical clinical examples in a simplified way.

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.

Actions to enhance interactive learning in surgery.

INTRODUCTION: Many educational institutions and academic organizations provide concise and highly organized educational material for the trainees and training programs, while others do not. The role of interactive technology-enhanced learning in surgical education is not entirely explored and disseminated despite common knowledge of such interactive educational technology. Utilizing such technology in the place of textbooks could replace a peer trainee and a teacher examiner. EVIDENCE: Maximizing involvement, participation, and interactivity from both surgical trainees and their faculty has been shown to improve the quality and outcomes of surgical education. Given that there is an increasing trend towards shifting from traditional unidirectional teaching to learner-centered interactive teaching. Improving the educational activities setting from the traditional - didactic unidirectional lecture to multi-directional, interactive, engaging, and stimulating activity can enhance learners' educational outcomes. With the advent of educational technology, interactive and shared learning became more feasible and creative. Various educational technology platforms, instructional designs, and tools serve different educational purposes guided by educational activity's objective. Educational systems have integrated numerous widely technologies such as smartphones, tablets, and cloud-based services that greatly facilitate instructional strategies and teaching methods. Many institutions and programs have embraced the new technologies to enhance the overall learning process. Educational technology offers new concepts and applications in learning beyond faster communication or storage of digital resources. Furthermore, active and interactive learning in surgical education has been found to carry a strong and implied impact depending on how it is structured. To enhance and promote interactive surgical education on a broad scale, the following initiatives will be reviewed; interactive adult learning worldwide, wide sharing of knowledge and skills, and use of educational technology where it is pertinent. CONCLUSION: Residents and surgical training programs need assistance with the process of learning amid ongoing technological innovations. This guidance would leverage the training programs' educational efforts toward effective surgery training. Interactive educational learning technology is expected to fulfill this need by promoting knowledge sharing, skills learning to enhance educational outcomes.

Students and faculty perception of distance medical education outcomes in resource-constrained system during COVID-19 pandemic. A cross-sectional study.

INTRODUCTION: The COVID-19 pandemic has imposed significant challenges on medical education worldwide, particularly in experience- and resource-limited regions of the world. Collaborative efforts of educators and academic institutions are necessary to facilitate the adaptation to the new educational reality. In this study, challenges and outcomes of a newly implemented distance education curriculum are examined to share findings and provide recommendations. METHODS: An alternative distance education curriculum with online resources and virtual lectures was developed and implemented in February 2020 at the Wasit University College of Medicine in Iraq. A post-implementation survey was developed for both faculty instructors and students to evaluate the program's effectiveness and perception. Results were compared between both groups. The study was approved by the University's Dean and exempted by the research committee for anonymity. RESULTS: A total of 636 students and 81 instructors were surveyed. Approximately 33% of students and 51% of instructors found online education equivalent or superior to traditional face-to-face teaching methods. Almost 69% of students and 51% of instructors reported increased difficulties with virtual learning, primarily due to challenges with the available technology, unreliable internet connectivity, as well as perceive fatigue when listening to online lectures. CONCLUSIONS: Distance education provides a worthwhile alternative during the COVID-19 pandemic, including in regions of limited experience. Adequate preparation, good quality audio-visuals and Internet, and student engagement activities are recommended to improve the quality of education.