Preparation for airway management in Australia and New Zealand ICUs during the COVID -19 pandemic.

BACKGROUND: This paper aimed to describe the airway practices of intensive care units (ICUs) in Australia and New Zealand specific to patients presenting with COVID-19 and to inform whether consistent clinical practice was achieved. Specific clinical airway guidelines were endorsed in March 2020 by the Australian and New Zealand Intensive Care Society (ANZICS) and College of Intensive Care Medicine (CICM). METHODS AND FINDINGS: Prospective, structured questionnaire for all ICU directors in Australia and New Zealand was completed by 69 ICU directors after email invitation from ANZICS. The online questionnaire was accessible for three weeks during September 2020 and analysed by cloud-based software. Basic ICU demographics (private or public, metropolitan or rural) and location, purchasing, airway management practices, guideline uptake, checklist and cognitive aid use and staff training relevant to airway management during the COVID-19 pandemic were the main outcome measures. The 69 ICU directors reported significant simulation-based inter-professional airway training of staff (97%), and use of video laryngoscopy (94%), intubation checklists (94%), cognitive aids (83%) and PPE "spotters" (89%) during the airway management of patients with COVID-19. Tracheal intubation was almost always performed by a Specialist (97% of ICUs), who was more likely to be an intensivist than an anaesthetist (61% vs 36%). There was a more frequent adoption of specific airway guidelines for the management of COVID-19 patients in public ICUs (94% vs 71%) and reliance on specialist intensivists to perform intubations in private ICUs (92% vs 53%). CONCLUSION: There was a high uptake of a standardised approach to airway management in COVID-19 patients in ICUs in Australia and New Zealand, likely due to endorsement of national guidelines.

Pregnancy and parental leave among plastic surgery residents in Canada: a nationwide survey of attitudes and experiences.

SUMMARY: Small surgical residency programs like plastic surgery can be challenging environments to accommodate parental leave. This study aimed to report the experiences, attitudes and perceived support of Canadian plastic surgery residents, recent graduates and staff surgeons with respect to pregnancy and parenting during training. Residents and staff surgeons were invited via email to participate in an online survey. The results presented here explore experiences of pregnancy and parental leave of current plastic surgery residents and staff surgeons. Residents' and staff surgeons' perceptions of program director support, policies, negative comments and the impact of parental leave on the workload of others were also explored. Although the findings suggest that there may be improvements in the support of program directors, there continues to be a negative attitude in surgical culture toward pregnancy during residency. The perceived confusion of respondents with respect to programspecific policies emphasizes the need for open conversations and standardization of parental leave.

Pandemic influenza and major disease outbreak preparedness in US emergency departments: A survey of medical directors and department chairs.

STUDY OBJECTIVES: To quantify the readiness of individual academic emergency departments (EDs) in the United States for an outbreak of pandemic influenza. Methods, design, and setting: Cross-sectional assessment of influenza pandemic preparedness level of EDs in the United States via survey of medical directors and department chairs from the 135 academic emergency medicine departments in the United States. Preparedness assessed using a novel score of 15 critical preparedness indicators. Data analysis consisted of summary statistics, χ2, and ANOVA. PARTICIPANTS: ED medical directors and department chairs. RESULTS: One hundred and thirty academic emergency medicine departments contacted; 66 (50.4 percent) responded. Approximately half (56.0 percent) stated their ED had a written plan for pandemic influenza response. Mean preparedness score was 7.2 (SD = 4.0) out of 15 (48.0 percent); only one program (1.5 percent) achieved a perfect score. Respondents from programs with larger EDs (=30 beds) were more likely to have a higher preparedness score (p < 0.035), an ED pandemic preparedness plan (p = 0.004) and a hospital pandemic preparedness plan (p = 0.007). Respondents from programs with larger EDs were more likely to feel that their ED was prepared for a pandemic or other major disease outbreak (p = 0.01). Only one-third (34.0 percent) felt their ED was prepared for a major disease outbreak, and only 27 percent felt their hospital was prepared to respond to a major disease outbreak. CONCLUSIONS: Significant deficits in preparedness for pandemic influenza and other disease outbreaks exist in US EDs, relative to HHS guidelines, which appear to be related in part to ED size. Further study should be undertaken to determine the barriers to appropriate pandemic preparedness, as well as to develop and validate preparedness metrics.

Characterizing the Effect of Pass/Fail U.S. Medical Licensing Examination Step 1 Scoring in Neurosurgery: Program Directors' Perspectives.

BACKGROUND: The neurosurgery match is among the most competitive across all specialties. As a result, numerical Step U.S. Medical Licensing Examination Step 1 scores have historically played a major role in selecting applicants for interviews. With the anticipated change in Step 1 scoring to pass/fail will come significant ramifications for how program directors (PDs) screen and select applicants. The present study characterized the responses of PDs to the change in U.S. Medical Licensing Examination Step 1 scoring and its consequences on medical students applying to neurosurgery. METHODS: After receipt of an institutional review board exemption, a validated 19-item survey was electronically distributed to 99 PDs of neurosurgery training programs as a part of a national study across 30 residency specialties. Descriptive statistical analyses were performed, and statistical significance was determined by nonoverlapping 95% confidence intervals. RESULTS: A total of 48 responses were obtained (48.5%). Most PDs were men, with a mean age of 52 years, and, on average, had served 7.4 years as a PD. Most PDs (79%) disagreed with binary Step 1 scoring. Most (85%) believed the change will make objective comparison of applicants more difficult, and 83% reported they will begin to require Step 2 clinical knowledge scores with application submission. More than one half (71%) believed medical school reputation will become more important in resident selection. Only 15% believed that pass/fail Step 1 scoring will improve medical student well-being. CONCLUSION: Binary Step 1 scoring represents a significant change in medical student evaluations, with consequences for the neurosurgery residency application process. The results from the present study might help guide PD practices and prepare medical students for the anticipated changes to the application process.

Conference Didactic Planning and Structure: An Evidence-based Guide to Best Practices from the Council of Emergency Medicine Residency Directors.

Emergency medicine residency programs around the country develop didactic conferences to prepare residents for board exams and independent practice. To our knowledge, there is not currently an evidence-based set of guidelines for programs to follow to ensure maximal benefit of didactics for learners. This paper offers expert guidelines for didactic instruction from members of the Council of Emergency Medicine Residency Directors Best Practices Subcommittee, based on best available evidence. Programs can use these recommendations to further optimize their resident conference structure and content. Recommendations in this manuscript include best practices in formatting didactics, selection of facilitators and instructors, and duration of individual sessions. Authors also recommend following the Model of Clinical Practice of Emergency Medicine when developing content, while incorporating sessions dedicated to morbidity and mortality, research methodology, journal article review, administration, wellness, and professionalism.

Clinical Teaching: An Evidence-based Guide to Best Practices from the Council of Emergency Medicine Residency Directors.

Clinical teaching is the primary educational tool use to train learners from day one of medical school all the way to the completion of fellowship. However, concerns over time constraints and patient census have led to a decline in bedside teaching. This paper provides a critical review of the literature on clinical teaching with a focus on instructor teaching strategies, clinical teaching models, and suggestions for incorporating technology. Recommendations for instructor-related teaching factors include adequate preparation, awareness of effective teacher attributes, using evidence-based-knowledge dissemination strategies, ensuring good communication, and consideration of environmental factors. Proposed recommendations for potential teaching strategies include the Socratic method, the One-Minute Preceptor model, SNAPPS, ED STAT, teaching scripts, and bedside presentation rounds. Additionally, this article will suggest approaches to incorporating technology into clinical teaching, including just-in-time training, simulation, and telemedical teaching. This paper provides readers with strategies and techniques for improving clinical teaching effectiveness.

Understanding Entrustment Decision-Making by Surgical Program Directors.

BACKGROUND: The process of entrustment-placing trust in a trainee to independently execute a task-has been proposed as a complementary metric to assess competence. However, entrustment decision-making by trainee supervisors is not well understood in surgical training. We aim to explore processes underlying entrustment decision-making (EDM) by general surgery program directors. MATERIALS AND METHODS: Purposive sampling was used to recruit 20 program directors from Accreditation Council for Graduate Medical Education-accredited general surgery training programs to participate in a one-hour semistructured interview. We analyzed interviews using an iterative and inductive approach to identify novel themes associated with the process of trainee entrustment. RESULTS: Qualitative analysis identified that program directors rely on a network of faculty to make entrustment decisions regarding trainees. Perceived trainee competence to perform independent clinical tasks varies significantly in and out of the operating room (OR), with a strong emphasis on entrustment for technical competencies to the exclusion of cognitive competencies. In the OR, entrustment is informed by an attending's reflexive trust and physical presence, trainee labels, and presumed discernment. Outside of the OR, trainee labels, presumed discernment, and transference of competence were identified as critical themes. CONCLUSIONS: Modifiable components of entrustment are equally dependent on trainee and faculty behavior. Entrustment is more heavily informed by trainee performance in the OR, despite program directors uniformly stating that judgment outside of the OR is the most critical component of resident training. The inclusion of EDM to evaluate trainee progression should be considered as an important adjunct to established Accreditation Council for Graduate Medical Education milestones.

Public disclosure of hospital clinicians' performance data: insights from medical directors.

Objective This study gathered information from public hospital chief medical officers to better understand underlying mechanisms through which public reporting affects institutional behavioural change and decision making towards quality improvement. Methods This qualitative study used thematic analysis of 17 semistructured, in-depth interviews among a peak group of medical directors representing 26 health services in Victoria, Australia. Results The medical directors indicated a high level of in-principle support for public reporting of identifiable, individual clinician-level data. However, they also described varying conceptual understanding of what public reporting of performance data is. Overall, they considered public reporting of individual clinicians' performance data a means to improve health care quality, increase transparency and inform consumer healthcare decision making. Most identified caveats that would need to be met before such data should be publicly released, in particular the need to resolve issues around data quality and timeliness, context and interpretation and ethics. Acknowledgement of the public's right to access individual clinician-level data was at odds with some medical directors' belief that such reporting may diminish trust between clinicians and their employers, thus eroding rather than motivating quality improvement. Conclusions Public reporting of identifiable individual healthcare clinicians' performance data is an issue that merits robust research and debate given the effects such reporting may have on doctors and on hospital quality and safety. What is known about the topic? The public reporting of individual clinician-level data is a mechanism used in some countries, but not in Australia, for increasing health care transparency and quality. Clinician-level public reporting of doctors' performance attracts contention and debate in Australia. What does this paper add? This paper informs debate around the public reporting of individual clinician-level performance data. Among a discrete cohort of senior hospital administrators in Victoria, Australia, there was strong in-principle support for such public reporting as a means to improve hospital quality and safety. What are the implications for practitioners? Before public reporting of individual clinician performance data could occur in Australia, resolution of issues would be required relating to legality and ethics, data context and interpretation, data quality and timeliness.

Primary Care Clinician and Clinic Director Experiences of Professional Bias, Harassment, and Discrimination in an Underserved Agricultural Region of California.

Importance: Many rural and agricultural communities experience hardship from a shortage of clinicians. The aging of the clinician population threatens future supply in these areas. Developing policies to build a sustainable workforce requires the understanding of experiences from those currently in medical practice. Previous research about rural clinicians has primarily sampled non-Latinx white men, and to a lesser extent, non-Latinx white women; to date, no study has examined differences by race/ethnicity, sexual orientation, or gender identity. Objective: To describe the professional experiences of a diverse group of primary care clinicians and clinic directors in an underserved rural and agricultural region of California. Design, Setting, and Participants: In this qualitative study, semistructured in-depth qualitative interviews were performed with clinicians and clinic directors from December 1, 2017, to December 31, 2018, with a present or recent medical practice in the central San Joaquin Valley region of California. Participants (N = 26) consisted of physicians, nurse practitioners, and clinic directors practicing in primary care settings. Settings included solo and group private practice, academic training programs, community health centers, and rural health clinics. Main Outcomes and Measures: Personal experiences as primary care clinicians and clinic directors, and perceived associations with gender, race/ethnicity, sexual orientation, and gender identity. Results: Of 26 primary care clinicians and clinic directors interviewed, 16 (62%) identified as female, 12 (46%) identified as non-Latinx white, and 3 (12%) identified as a member of a sexual and gender minority group. Participants who self-identified as female, nonwhite, and of certain sexual orientation and gender identity minority groups described burnout from bias, harassment, and hostility in their professional relationships with colleagues and health care staff. These experiences intensified their feelings of community isolation and professional isolation. Harassment and institutional discrimination were factors in the decision of participants to change practices or exit the region entirely. Discriminatory acts against members of sexual and gender minority groups were the most severe, including threats to licensure and denial of hospital admitting privileges. In contrast to the minority group participants, the remaining participants expressed little to no awareness of these negative experiences, or the association between these experiences and retention. Conclusions and Relevance: Professional harassment and discrimination may hamper efforts to improve clinician and clinic director recruitment and retention in underserved rural and agricultural areas and may pose barriers to addressing health disparities within those communities. Additional investigation appears to be needed to assess the extent to which professional harassment and discrimination affect clinicians and clinic directors in similar communities across the United States.

Residency and Fellowship Program Administrator Burnout: Measuring Its Magnitude.

BACKGROUND: Little is known about the level of burnout among program administrators (PAs) working in graduate medical education. OBJECTIVE: We created a national database with baseline burnout data for PAs from residency and fellowship programs, including intention to leave their current positions. METHODS: A cross-sectional study was conducted in July 2017 to assess levels of burnout in a national cohort of PAs, who were largely members of online specialty forums. The Copenhagen Burnout Inventory (CBI) was used to measure burnout. Univariate analysis produced descriptive statistics for CBI. We performed a 2-sample t test to measure differences in average burnout scores for those who had thoughts of resigning from their positions and those who had not. RESULTS: Of the approximately 10 205 national PAs, we sampled 1126 (11%). Of the 1126 individuals who received the study information, 931 (83%) completed the baseline survey. Total mean scores for all subscales were elevated (personal: 53.7, SD 21.4; work-related: 52.0, SD 22; and client-related: 30.6, SD 20.8; each scale ranged from 0, low, to 100, high). Burnout scores differed between those contemplating leaving their jobs and those who were not, across all subscales of CBI, including personal (64.2 versus 42.4, -24.18 to -19.44 confidence interval [CI]), work-related (63.5 versus 39.7, -26.12 to -21.35 CI), and client-related (36.6 versus 24.2, -14.95 to -9.84 CI; P < .0001 for all). CONCLUSIONS: In this national survey of PAs, burnout scores measured by the CBI were higher among those who had considered leaving their positions.

Medical schools, primary care and family medicine: clerkship directors' perceptions of the current environment.

BACKGROUND: The culture at a medical school and the positive experiences in primary care clerkships influence student specialty choice. This choice is significant if the demand for primary care physicians is to be met. The aim of this study was to examine family medicine clerkship directors' perceptions of the medical school environment. METHODS: Data were collected as part of the 2015 Council of Academic Family Medicine Educational Research Alliance Family Medicine Clerkship Director survey. Questions asked included how clerkship directors perceived the environment of their medical school towards family medicine, has the environment towards family medicine changed between 2010 and 2015, do they take action to influence student attitudes towards family medicine and whether faculty members in other departments make negative comments about family medicine. RESULTS: The response rate was 79.4%. While most respondents indicated the environment of their medical school has become more positive towards family medicine, a majority of clerkship directors perceived the environment to be either very much against, slightly against or indifferent towards family medicine. Nearly one-half (41.4%) of the clerkship directors were notified more than once a year that a faculty member of another department made a negative comment about family medicine. Results varied among regions of the USA and between schools located in the USA and Canada. CONCLUSION: Family medicine clerkship directors often perceived negativity towards family medicine, a finding that may limit the effectiveness of academic health centres in their mission to better serve their community and profession.

Pediatric urgent care education: a survey-based needs assessment.

BACKGROUND: There is an increasing number of pediatric urgent care centers that are largely staffed by pediatric residency graduates. It is unclear if pediatric residency adequately prepares a physician to fully and successfully provide care in an urgent care setting. The goal of this study is to conduct an assessment of urgent care directors' perceptions of recent pediatric residency graduates' preparedness to successfully provide pediatric urgent care after graduation. METHODS: This is a 2018 cross-sectional survey of all pediatric emergency medicine division chiefs in the United States and all pediatric urgent care directors who are members of the Society for Pediatric Urgent Care. An electronic survey was distributed consisting of eight multiple choice questions regarding perceived preparedness and knowledge gaps of recent pediatric residency graduates for independent practice in urgent care. Descriptive statistics were used to analyze results and qualitative data were analyzed via an inductive thematic approach. RESULTS: Forty-two percent (65/154) of surveys were completed. No respondents believed that a recent pediatric residency graduate would be adequately prepared to independently practice in a pediatric urgent care and 81% of respondents recommended some additional training. Most respondents described this training as important (46%) or very important (35%). Most respondents recommended between 6 months and 1 year as the appropriate amount of time to achieve competency. CONCLUSIONS: Despite the growing number pediatric residency graduates staffing pediatric urgent care centers, the majority of surveyed pediatric emergency medicine division chiefs and pediatric urgent care directors do not think that pediatric residency adequately prepares graduates to successfully provide urgent care to pediatric patients. We recommend further exploration of gaps in knowledge of recent pediatric residency graduates as a next step towards developing systems for further training for pediatric residency graduates to gain competency in urgent care management.

Defining a Leader-Characteristics That Distinguish a Chair of Surgery.

BACKGROUND: Chair of the Department of Surgery, sometimes known as the Chief, holds a title that has significant historical connotations. Our goal was to assess a group of objectively measurable characteristics that unify these individuals as a group. METHODS: Utilizing publicly available data for all US teaching hospitals, demographic information was accumulated for the named chiefs/chairs of surgery. Information collected included location of their program, their medical/surgical training history, their surgical specialty, previous chair/chief titles held, and academic productivity. RESULTS: Of the 259 programs listed, data were available on 244 individuals who were trained in 19 different specialties. The top three specialties of these practitioners are General Surgery (40, 16.3%), Surgical Oncology (38, 15.5%), and Vascular Surgery (33, 13.5%). There were only 14 female chairs (5.7%) and only one chair with a doctor of osteopathic medicine degree. The majority (62.3%) had been a previous chief of a surgical subdivision with only 26% having been a previous chair/chief of the surgical department. The average chair had 72 peer-reviewed manuscripts with 28 published book chapters. Chair's at academic institutions with university affiliation had a significantly higher number of peer-reviewed manuscripts (P < 0.0001) as well as were more likely to be trained at academic institutions (P = 0.013). CONCLUSIONS: There are no set characteristics that define the Chair of a Department of Surgery. By understanding a group of baseline characteristics that unify these surgical leaders, young faculty and trainees with leadership aspirations may begin to understand what is necessary to fill these roles in the future.

Organizational constraints as root causes of role conflict.

PURPOSE: The purpose of this paper is to gain a better understanding of the difficulties encountered in the hybrid roles of physician-managers (P-Ms), examine the impact of organizational constraints on the role conflicts experienced by P-Ms and explore the different ways their two roles are integrated. DESIGN/METHODOLOGY/APPROACH: A qualitative approach was adopted, using six focus groups made up of clinical co-managers, medical directors and P-Ms. In all, 43 different people were interviewed to obtain their perceptions of the day-to-day realities of the role of the P-M. The data collected were subsequently validated. FINDINGS: Although the expectations of the different groups involved regarding the role of P-Ms are well understood and shared, there are significant organizational constraints affecting what P-Ms are able to do in their day-to-day activities, and these constraints can result in role conflicts for the people involved. Such constraints also affect the ways P-Ms integrate the two roles. The authors identify three role hybridization profiles. PRACTICAL IMPLICATIONS: The results afford a better understanding of how organizational constraints might be used as levers of organizational change to achieve a better hybridization of the dual roles of P-Ms. ORIGINALITY/VALUE: This paper seeks to reach beyond a simple identification of constraints affecting the dual roles of P-Ms by analyzing how such constraints impact on these professionals' day-to-day activities. Results also enable us to further refine Katz and Kahn's (1966) role model, in addition to identifying hybridization profiles.

Did we learn the lesson after 60 years of Management by Objectives? A survey among former physician executives in German hospitals.

BACKGROUND: Management by Objectives (MbO) has been shown to establish efficient team work in both industry and medicine. Its most important prerequisite for success is target agreements between managers and medical professionals on equal footing. In medicine, lump-sum financing urges the delivery of a health care service with minimal effort. Consequently, daily clinical life changed, with economic goals seeming to become priority over medical principles. OBJECTIVE: To determine how well MbO can still be practiced in hospitals with lumped treatment prices. METHODS: We used an anonymized questionnaire for already retired physician executives who completed their active leadership positions between 2010 and 2015 in Saxony (Germany). We asked various type of target agreements that had been used in order to achieve medical or economic targets. RESULTS AND CONCLUSIONS: Out of 111 former executives, the questionnaires of 25 respondents could be analysed. Eight respondents confirmed target agreements that were mostly set by managing directors. If used, most targets had not been adapted to the infrastructure and personnel strength, nor were they coordinated with neighbouring departments. Four respondents received financial incentives. Most medical executives were unsatisfied and preferred to abandon further goal setting. Due to the low number of cases, the representativeness of the study is limited. Nevertheless, it might be questioned if a flat-rate remuneration system facilitates the change into an authoritarian leadership concept.

Use of performance reports among trauma medical directors and programme managers in the American College of Surgeons' Trauma Quality Improvement Program: a qualitative analysis.

BACKGROUND: The American College of Surgeons' Trauma Quality Improvement Program (TQIP) provides trauma centres with performance reports on their processes and outcomes of care relative to their peers. This study explored how performance reports are used by trauma centre leaders to engage in performance improvement and perceived barriers to use. STUDY DESIGN: Qualitative focus group study with trauma medical directors (TMDs) and trauma programme managers (TPMs) in US trauma centres. Consistent with qualitative descriptive analysis, data collection and interpretation were inductively and iteratively completed. Major themes were derived using a constant comparative technique. RESULTS: Six focus groups were conducted involving 22 TMDs and 22 TPMs. Three major themes were captured: (1) technical uses of performance reports; (2) cultural uses of performance reports; (3) opportunities to enhance the role and value of TQIP. First, technical uses included using reports to assess data collection procedures, data quality and areas of poor performance relative to peers. In this domain, barriers to report use included not trusting others' data quality and challenges with report interpretation. Second, reports were used to influence practice change by fostering inter-specialty discussions, leveraging resources for quality improvement, community engagement and regional collaboratives. Perceived lack of specialist engagement was viewed as an impediment in this domain. Lastly, identified opportunities for TQIP to support report use involved clarifying the relationship between verification and performance reports, and increasing partnerships with nursing associations. CONCLUSION: Trauma centre improvement leaders indicated practical and social uses of performance reports that can affect intention and ability to change. Recommendations to optimise programme participation include a focus on data quality, adequate resource provision and enhanced support for regional collaboratives.