Optimizing the integration of advanced practitioners in a department of surgery: An operational improvement model.

Physician assistants (PAs) and nurse practitioners (NPs) have established themselves as key members of the healthcare team to supplement practicing physicians in patient care. PAs and NPs are collectively referred to as "advanced providers" (APs) and work not only in primary care but in general surgery and surgical subspecialties. Studies have addressed AP integration into the profession of medicine and have examined cost and efficacy of APs, attitudes about APs among residents, and educational impact of APs, but very little literature exists that describes a formalized approach to AP integration into a department of surgery, specifically with AP/resident integration. The purpose of this paper is to describe an initiative for developing an operational improvement model for APs working with residents on surgical inpatient services in a large academic health center. The model consists of four components and each component is described in detail from discovery state towards continuous improvement. Formal professional development opportunities for APs as well as appointing a Clinical Director for Surgical APs have positively impacted AP integration into the department of surgery.

Ranking Surgical Residency Programs: Reputation Survey or Outcomes Measures?

OBJECTIVE: The release of general surgery residency program rankings by Doximity and U.S. News & World Report accentuates the need to define and establish measurable standards of program quality. This study evaluated the extent to which program rankings based solely on peer nominations correlated with familiar program outcomes measures. DESIGN: Publicly available data were collected for all 254 general surgery residency programs. To generate a rudimentary outcomes-based program ranking, surgery programs were rank-ordered according to an average percentile rank that was calculated using board pass rates and the prevalence of alumni publications. A Kendall τ-b rank correlation computed the linear association between program rankings based on reputation alone and those derived from outcomes measures to validate whether reputation was a reasonable surrogate for globally judging program quality. RESULTS: For the 218 programs with complete data eligible for analysis, the mean board pass rate was 72% with a standard deviation of 14%. A total of 60 programs were placed in the 75th percentile or above for the number of publications authored by program alumni. The correlational analysis reported a significant correlation of 0.428, indicating only a moderate association between programs ranked by outcomes measures and those ranked according to reputation. Seventeen programs that were ranked in the top 30 according to reputation were also ranked in the top 30 based on outcomes measures. CONCLUSIONS: This study suggests that reputation alone does not fully capture a representative snapshot of a program's quality. Rather, the use of multiple quantifiable indicators and attributes unique to programs ought to be given more consideration when assigning ranks to denote program quality. It is advised that the interpretation and subsequent use of program rankings be met with caution until further studies can rigorously demonstrate best practices for awarding program standings.

Clinical Assessment and Management Examination--Outpatient (CAMEO): its validity and use in a surgical milestones paradigm.

OBJECTIVES: Clinical Assessment and Management Examination--Outpatient (CAMEO) is a metric for evaluating the clinical performance of surgery residents. The aim of this study was to investigate the measurement characteristics of CAMEO and propose how it might be used as an evaluation tool within the general surgery milestones project. DESIGN: A total of 117 CAMEO evaluations were gathered and used for analysis. Internal consistency reliability was estimated, and item characteristics were explored. A Kruskal-Wallis procedure was performed to discern how well the instrument discriminated between training levels. An exploratory factor analysis was also conducted to understand the dimensionality of the evaluation. SETTING: CAMEO evaluations were collected from 2 departments of surgery geographically located in the Midwestern United States. Combined, the participating academic institutions graduate approximately 18 general surgery residents per year. PARTICIPANTS: In this retrospective data analysis, the number of evaluations per resident ranged from 1 to 7, and evaluations were collected from 2006 to 2013. For the purpose of data analysis, residents were classified as interns (postgraduate year 1 [PGY1]), juniors (PGY2-3), or seniors (PGY4-5). RESULTS: CAMEO scores were found to have high internal consistency (Cronbach's α = 0.96), and all items were highly correlated (≥ 0.86) to composite CAMEO scores. Scores discriminated between senior residents (PGY4-5) and lower level residents (PGY1-3). Per an exploratory factor analysis, CAMEO was revealed to measure a single dimension of "clinical competence." CONCLUSIONS: The findings of this research aligned with related literature and verified that CAMEO scores have desirable measurement properties, making CAMEO an attractive resource for evaluating the clinical performance of surgery residents.

Impact of a competency-based curriculum on medical student advancement: a ten-year analysis.

BACKGROUND: In 1999, the Indiana University School of Medicine implemented a new curriculum based on the attainment of core competencies beyond medical knowledge. PURPOSE: The objective was to document how the Student Promotions Committee (SPC) has adjudicated students' competency-related deficiencies over the past decade. METHODS: Using SPC records, the authors determined the frequency of competency-related deficiencies reported to the SPC over time, the nature of those deficiencies, and how the deficiencies were remediated. For the purposes of this study, traditional knowledge-related deficiencies like course failures were excluded from analysis. RESULTS: From 1999 to 2009, 191 students (138 male, 53 female) were referred to the SPC for competency-related deficiencies in 8 performance domains involving communication, basic clinical skills, lifelong learning, self-awareness, social context, ethics, problem solving, and professionalism. By comparison, 1,090 students were referred to the SPC for knowledge-related deficiencies during this time. Collectively, the 191 students were cited for 317 separate competency-related deficiencies (M ± SD = 1.7 ± 1.3; range = 1-10). Of these 317 deficiencies, the most prevalent were in the competencies of professionalism (29.3%), basic clinical skills (28.4%), and self-awareness (17.7%). Each of the remaining competencies constituted less than 10% of the total. Successful remediation utilized 12 methods ranging from a simple warning letter to repeating the year under close monitoring. Remediation was unsuccessful for 17 students (8.9%) who were dismissed from medical school primarily due to unprofessional behaviors and poor self-awareness. CONCLUSIONS: Competency-related deficiencies can be identified and remediated in most cases, but deficiencies in professionalism and self-awareness are especially challenging.

Do personality differences between teachers and learners impact students' evaluations of a surgery clerkship?

OBJECTIVE: Historically, the surgery clerkship at the Indiana University School of Medicine (IUSM) has received poor evaluations from medical students, and the authors of this article hypothesized that this negative feedback may reflect, at least in part, inherent differences in the personality styles of the learners compared with those of the surgery teachers (faculty and residents). Differences between teachers and learners could impede effective communication and impact adversely students' perception of, and satisfaction with, the learning environment. The objective of this study was to compare the inherent personality styles of surgery teachers and medical students. DESIGN: Using the Myers-Briggs Type Indicator (MBTI) to assess personality styles, we administered the instrument to 154 teachers in the surgery department and to 1395 medical students. Aggregate MBTI data for teachers and learners were analyzed based on four dichotomous scales. Chi square tests of independence were performed to examine the relationship between teachers and learners on the MBTI scales. SETTING: The study was undertaken at IUSM, which has been engaged in a process of cultural change for over 10 years, in part to ensure that both the formal curriculum and the learning environment support the development of self-awareness and professionalism among our graduates. RESULTS: We found that teachers were similar to learners on the Introversion/Extraversion scale and dissimilar from learners on the three remaining scales: Sensing/Intuition scale (p < 0.008), Thinking/Feeling scale (p < 0.000), and the Judging/Perceiving scale (p < 0.022). CONCLUSIONS: These results suggest that differences in personality styles may affect the teacher-learner interaction during the surgery clerkship and may influence negatively students' perception of the learning environment.

Practices and Perceptions of Family Practice Residency Directors toward International Medical Graduate Applicants: A National Survey.

Purpose - International Medical Graduates (IMGs) are increasingly filling Family Medicine residency positions. (1) To what extent are residency programs recruiting and accepting IMG applicants? (2) What are program directors' perceptions of IMG applicants? (3) What program characteristics are associated with their practices and perceptions? Methods - A 2002 national survey of Family Medicine program directors assessed program demographics and directors' recruiting practices and perceptions regarding IMG applicants. Results - Although 88% of respondents would rank IMG applicants, only 40% agreed that they would perform as well as U.S. graduates. Programs with IMG faculty were more likely to have IMG residents (p˂0.01). Program directors with IMG faculty or more IMG residents reported more positive perceptions of IMG residents' performance (p˂0.01). Conclusion - More experience with IMGs, such as having IMG faculty or higher numbers of IMG residents, is associated with recruitment of IMG residents and may contribute to more positive beliefs about their performance.