Maximizing Learning in the Operating Room: Residents' Perspectives.

BACKGROUND: Few studies examine how residents can optimize their educational experience in the OR on their terms. This study aimed to examine residents' perceptions of how learners can maximize their education in the OR. METHOD: Using constructivist grounded theory methodology, the authors conducted focus groups with general surgery residents, PGY1-5, followed by semi-structured interviews with attending surgeons from a single, academic medical center. Constant comparison was used to identify themes and explore their relationships. Theoretical sampling was used until saturation was achieved. RESULTS: Residents and attendings participated. Two phases of OR learning were identified, intra-operative and inter-operative. Characters that made optimized learning included control, struggling, and reflection. Residents who practiced self-reflection with their experiences, and were able to articulate this awareness to attendings, felt the OR was an ideal learning environment. Attendings echoed similar findings. CONCLUSIONS: Providing residents with a method of maximizing OR learning is critical to postgraduate clinical education. Currently, observation passively morphs into active learning and eventually independent operating in the OR. However, residents who practice self-regulated learning, and are able to discuss their educational goals with attendings, seem to find the OR a better learning environment and progress to independence more quickly. This was echoed by practicing attendings. Providing residents with a generalizable, self-regulated learning framework specific to operative educational experiences could maximize learning potential and expedite resident progression in the OR.

The educators' experience: Learning environments that support the master adaptive learner.

BACKGROUND: The Master Adaptive Learner (MAL) theoretical framework describes an integrated approach to learning that combines features of educational theory on self-regulated learning and aspects of quality improvement. In order to develop MAL students, it is important to pay attention to the learning environment. PURPOSE: To describe educators' perspectives about the learning environment needed to promote the development of master adaptive learners. METHODS: Thematic analysis of reports by medical educators who were workshop participants at a national presentation on creating effective learning environment to develop MAL in undergraduate medical education. RESULTS: Three themes educators considered important in the development of the Master Adaptive Learner were Adaptive Educator, Support for Learning, and Institutional Commitment. These findings suggest that in order to support the MAL, an educational setting should provide faculty who can be flexible and adapt to the developing MAL, learning experiences that support active learning, focused on groups as well as developing individual learners. Leaders in the educational setting should demonstrate a commitment to creating a culture to support learning and provide appropriate resources to that end. CONCLUSION: Learning environments to develop master adaptive learners need to have adaptive educators, teaching, learning, and institutional culture to support challenge and grow Master Adaptive Learners.

Learning to balance efficiency and innovation for optimal adaptive expertise.

It is critical for health professionals to continue to learn and this must be supported by health professions education (HPE). Adaptive expert clinicians are not only expert in their work but have the additional capacity to learn and improve in their practices. The authors review a selective aspect of learning to become an adaptive expert: the capacity to optimally balance routine approaches that maximize efficiency with innovative ones where energy and resources are used to customize actions for novel or difficult situations. Optimal transfer of learning, and hence the design of instruction, differs depending on whether the goal is efficient or innovative practice. However, the task is necessarily further complicated when the aspiration is an adaptive expert practitioner who can fluidly balance innovation with efficiency as the situation requires. Using HPE examples at both the individual and organizational level, the authors explore the instructional implications of learning to shift from efficient to innovative expert functioning, and back. They argue that the efficiency-innovation tension is likely to endure deep into the future and therefore warrants important consideration in HPE.

Unprofessional behavior by specialty: a qualitative analysis of six years of student perceptions of medical school faculty.

BACKGROUND: Unprofessional behavior has well documented negative effects both on the clinical care environment and on the learning environment. If unprofessional behavior varies by department or specialty, this has implications both for faculty development and for undergraduate and graduate level training. AIMS: We sought to learn which unprofessional behaviors were endemic in our school, and which were unique to particular departments. METHODS: Students graduating from medical school between 2007 and 2012 were asked to complete a questionnaire naming the most professional and least professional faculty members they encountered in during school. For the least professional faculty members, they were also asked to provide information about the unprofessional behavior. RESULTS: Students noted several types of unprofessional behavior regardless of the department faculty were in; however, there were some behaviors only noted in individual departments. The unprofessional behavior profiles for Surgery and Obstetrics/Gynecology were markedly similar, and were substantially different from all other specialties. CONCLUSION: Undergraduate, graduate, and faculty education focused on unprofessional behavior that may occur in various learning environments may provide a feasible, practical, and an effective approach to creating a culture of professional behavior throughout the organization.

Biomedical knowledge, clinical cognition and diagnostic justification: a structural equation model.

CONTEXT: The process whereby medical students employ integrated analytic and non-analytic diagnostic strategies is not fully understood. Analysing academic performance data could provide a perspective complementary to that of laboratory experiments when investigating the nature of diagnostic strategy. This study examined the performance data of medical students in an integrated curriculum to determine the relative contributions of biomedical knowledge and clinical pattern recognition to diagnostic strategy. METHODS: Structural equation modelling was used to examine the relationship between biomedical knowledge and clinical cognition (clinical information gathering and interpretation) assessed in Years 1 and 2 of medical school and their relative contributions to diagnostic justification assessed at the beginning of Year 4. Modelling was applied to the academic performance data of 133 medical students who received their md degrees in 2011 and 2012. RESULTS: The model satisfactorily fit the data. The correlation between biomedical knowledge and clinical cognition was low-moderate (0.26). The paths between these two constructs and diagnostic justification were moderate and slightly favoured biomedical knowledge (0.47 and 0.40 for biomedical knowledge and clinical cognition, respectively). CONCLUSIONS: The findings suggest that within the first 2 years of medical school, students possessed separate, but complementary, cognitive tools, comprising biomedical knowledge and clinical pattern recognition, which contributed to an integrated diagnostic strategy at the beginning of Year 4. Assessing diagnostic justification, which requires students to make their thinking explicit, may promote the integration of analytic and non-analytic processing into diagnostic strategy.

Academic and professional career outcomes of medical school graduates who failed USMLE Step 1 on the first attempt.

This study sought to determine the academic and professional outcomes of medical school graduates who failed the United States Licensing Examination Step 1 on the first attempt. This retrospective cohort study was based on pooled data from 2,003 graduates of six Midwestern medical schools in the classes of 1997-2002. Demographic, academic, and career characteristics of graduates who failed Step 1 on the first attempt were compared to graduates who initially passed. Fifty medical school graduates (2.5 %) initially failed Step 1. Compared to graduates who initially passed Step 1, a higher proportion of graduates who initially failed Step 1 became primary care physicians (26/49 [53 %] vs. 766/1,870 [40.9 %]), were more likely at graduation to report intent to practice in underserved areas (28/50 [56 %] vs. 419/1,939 [ 21.6 %]), and more likely to take 5 or more years to graduate (11/50 [22.0 %] vs. 79/1,953 [4.0 %]). The relative risk of first attempt Step 1 failure for medical school graduates was 13.4 for African Americans, 7.4 for Latinos, 3.6 for matriculants >22 years of age, 3.2 for women, and 2.3 for first generation college graduates. The relative risk of not being specialty board certified for those graduates who initially failed Step 1 was 2.2. Our observations regarding characteristics of graduates in our study cohort who initially failed Step 1 can inform efforts by medical schools to identify and assist students who are at particular risk of failing Step 1.

Future focus for professional development.

Professional development has evolved from individually focused sabbaticals and professional leaves to institutionally focused programs with an interest in developing faculty members' ability to teach in various environments as well as to succeed in the many endeavors they undertake. We address various issues related to professional development in the medical school arena. Professional development in medical school takes place in a context where faculty are stretched to engage in research and service not only for their own sake but also to financially support their institutions. This obligates professional developers to acknowledge and address the environments in which teaching faculty work, and to use approaches to professional development that honor the time and efforts of teaching faculty. These approaches may be brief interventions that make use of principles of education, and may include online offerings. Professional development will be most effective when professional developers acknowledge that most faculty members aspire to excellence in teaching, but they do so in an environment that pushes them to address competing concerns. Offering professional development opportunities that fit within the workplace environment, take little time, and build upon faculty's existing knowledge will assist in enhancing faculty success.

The case of the entitled resident: a composite case study of a resident performance problem syndrome with interdisciplinary commentary.

BACKGROUND: Residents with performance problems create substantial burden on programs and institutions. Understanding the nature and quality of performance problems can help in learning to address performance problems. AIM: We sought to illuminate the effects of resident performance problems and the potential solutions for those problems from the perspectives of people with various roles in health care. METHODS: We created a composite portrait from several residents who demonstrated a cluster of common performance characteristics and whose chronic or serious maladaptive behavior and response to situations created problems for themselves, for their clinical colleagues, and for faculty of their residency program. The composite was derived from in-depth interviews of program directors and review of resident records. We solicited practitioners from multiple fields to respond to the portrait by answering a series of questions about severity, prognosis, and how and whether one could reliably remediate a person with these performance characteristics. We present their perspectives in a manner borrowed from the New England Journal of Medicine's "Case Records of the Massachusetts General Hospital." RESULTS: We created a composite portrait of a resident whose behavior suggested he felt entitled to benefits his peers were not entitled to. Experts reflecting on his behavior varied in their opinion about the effect the resident would have on the health care system. They suggested approaches to remediation that required substantial time and effort from the faculty. CONCLUSION: Programs must balance the needs of individual residents to adjust their behaviors with the needs of the health care system and other people within it.

Defining the "Problem Resident" and the Implications of the Unfixable Problem: The Rationale for a "Front-door" Solution.

INTRODUCTION: Problem residents are common in graduate medical education, yet little is known about their characteristics, deficits, and the consequences for emergency medicine (EM) residencies. The American Board of Internal Medicine (ABIM) defines a problem resident as "a trainee who demonstrates a significant enough problem that requires intervention by someone of authority, usually the program director [PD] or chief resident." Although this is a comprehensive definition, it lacks specificity. Our study seeks to add granularity and nuance to the definition of "problem resident," which can be used to guide the recruitment, selection, and training of residents. METHODS: We conducted semi-structured interviews with a convenience sample of EM PDs between 2011 and 2012. We performed qualitative analysis of the resulting transcripts with our thematic analysis based on the principles of grounded theory. We reached thematic sufficiency after 17 interviews. Interviews were coded as a team through consensus. RESULTS: The analysis identified diversity in the type, severity, fixability, and attribution of problems among problem residents. PDs applied a variety of thresholds to define a problem resident with many directly rejecting the ABIM definition. There was consistency in defining academic problems and some medical problems as "fixable." In contrast, personality problems were consistently defined as "non-fixable." Despite the diversity of the definition, there was consensus that residents who caused "turbulence" were problem residents. CONCLUSION: The ABIM definition of the problem resident captures trainees who many PDs do not consider problem residents. We propose that an alternative definition of the problem resident would be "a resident with a negative sphere of influence beyond their personal struggle." This combination acknowledges the identified themes of turbulence and the diversity of threshold. Further, the combination of PDs' unwillingness to terminate trainees and the presence of non-fixable problems implies the need for a "front-door" solution that emphasizes personality issues at the potential expense of academic potential. This "front-door" solution depends on the commitment of all stakeholders including medical schools, the Association of American Medical Colleges, and PDs.

A sampling strategy for promoting and assessing medical student retention of physical examination skills.

BACKGROUND: Skill acquisition and maintenance requires spaced deliberate practice. Assessing medical students' physical examination performance ability is resource intensive. The authors assessed the nature and size of physical examination performance samples necessary to accurately estimate total physical examination skill. METHOD: Physical examination assessment data were analyzed from second year students at the University of Illinois College of Medicine at Chicago in 2002, 2003, and 2004 (N = 548). Scores on subgroups of physical exam maneuvers were compared with scores on the total physical exam, to identify sound predictors of total test performance. RESULTS: Five exam subcomponents were sufficiently correlated to overall test performance and provided adequate sensitivity and specificity to serve as a means to prompt continued student review and rehearsal of physical examination technical skills. CONCLUSIONS: Selection and administration of samples of the total physical exam provide a resource-saving approach for promoting and estimating overall physical examination skills retention.

Learning in the real place: medical students' learning and socialization in clerkships at one medical school.

PURPOSE: To understand medical students' learning experiences in clerkships: learning expectations (what they expect to learn), learning process (how they learn), and learning outcomes (what they learn). METHOD: Using a longitudinal qualitative research design, the authors followed the experiences of 12 participants across their clerkship year (2011-2012) at the Southern Illinois University School of Medicine. Interview data from each participant were collected at three points (preclerkship, midclerkship, and postclerkship) and analyzed using a grounded theory approach. Additionally, the authors observed participants through a full clerkship day to augment the interviews. RESULTS: Before clerkships, students expected to have more hands-on experiences and become more knowledgeable by translating textbook knowledge to real patients and practicing diagnostic thinking. During clerkships, students experienced ambiguity and subjectivity of attending physicians' expectations and evaluation criteria. They perceived that impression management was important to ensure that they received learning opportunities and good evaluations. After clerkships, students perceived that their confidence increased in navigating the health care environments and interacting with patients, attendings, and residents. However, they felt that there were limited opportunities to practice diagnostic thinking. Students could not clearly discern the decision-making processes used by attending physicians. Although they saw many patients, they perceived that their learning was at the surface level. CONCLUSIONS: Students' experiential learning in clerkships occurred through impression management as a function of dynamic social and reciprocal relationships between students and attendings or residents. Students reported that they did not learn comprehensive clinical reasoning skills to the degree they expected in clerkships.

Feedback matters: the impact of an intervention by the dean on unprofessional faculty at one medical school.

PURPOSE: Unprofessional behavior by faculty can result in poor patient care, poor role modeling, and mistreatment of trainees. To improve faculty or institutional behavior, unprofessional faculty must be given direct feedback. The authors sought to determine whether annually surveying medical students for their nominations of most and least professional faculty, coupled with direct feedback to unprofessional faculty from the dean, improved faculty's professional behavior. METHOD: From 2007 to 2012, senior medical students at Southern Illinois University School of Medicine completed an anonymous survey naming the "most professional" and "least professional" faculty in each department. Students described unprofessional behaviors, and their descriptions were qualitatively analyzed. The most unprofessional faculty met with the dean to discuss their behavior. The authors examined differences between faculty named most professional in their department versus those named least professional and whether behavior as measured by student nominations changed following feedback. RESULTS: The response rate overall for six graduating classes was 92.5% (385/416). Faculty named most professional were highly associated with receiving teaching and humanism awards. Faculty named most unprofessional were shown to either leave the institution or improve their behavior after receiving feedback. CONCLUSIONS: Attitudes and behaviors of teachers create the culture of their institution, and unprofessional behavior by these educators can have a profound, negative effect. Direct involvement by the dean may be an effective tool to improve the learning environment of a single institution, but universal application of such a program is needed if the profession as a whole is to improve its culture.

The impact of brief team communication, leadership and team behavior training on ad hoc team performance in trauma care settings.

BACKGROUND: Communication breakdowns and care coordination problems often cause preventable adverse patient care events, which can be especially acute in the trauma setting, in which ad hoc teams have little time for advanced planning. Existing teamwork curricula do not address the particular issues associated with ad hoc emergency teams providing trauma care. METHODS: Ad hoc trauma teams completed a preinstruction simulated trauma encounter and were provided with instruction on appropriate team behaviors and team communication. Teams completed a postinstruction simulated trauma encounter immediately afterward and 3 weeks later, then completed a questionnaire. Blinded raters rated videotapes of the simulations. RESULTS: Participants expressed high levels of satisfaction and intent to change practice after the intervention. Participants changed teamwork and communication behavior on the posttest, and changes were sustained after a 3-week interval, though there was some loss of retention. CONCLUSIONS: Brief training exercises can change teamwork and communication behaviors on ad hoc trauma teams.

Using the hidden curriculum to teach professionalism during the surgery clerkship.

BACKGROUND: It has been shown that medical student professionalism is influenced by the hidden curriculum, although the extent to which this occurs during the surgery clerkship is unknown. Furthermore, the processes within the hidden curriculum have been used to teach professionalism to medical students, but this strategy has not been used during the surgery clerkship. The purpose of this study was to review a 2-year experience with a surgery clerkship instructional session where the hidden curriculum was used to teach professionalism to medical students. STUDY DESIGN: Medical student essays were analyzed to evaluate the influence of the hidden curriculum on their ideas about professionalism and to identify specific behaviors that they regarded as professional and unprofessional. The instructional session was evaluated using the average satisfaction session ratings and through an analysis of medical student session evaluation comments. RESULTS: Seventy-five percent of medical students reported that their ideas about professionalism changed. This change involved their general concepts about professionalism, identifying specific behaviors that they planned to adopt or avoid, or developing opinions about the professionalism of surgeons. The average satisfaction rating was consistently high throughout the study period, and the most helpful session feature was reported as the opportunity to share and discuss their observations. CONCLUSIONS: The hidden curriculum has a substantial influence on the development of professionalism of medical students during the surgery clerkship. It was possible to illuminate and use the hidden curriculum to create an instructional session devoted to professionalism for medical students on the surgery clerkship.

Capturing the teachable moment: a grounded theory study of verbal teaching interactions in the operating room.

BACKGROUND: Teaching in the operating room is one of the major cornerstones of surgical education. As time available for intraoperative resident teaching diminishes, such teaching time becomes increasingly precious. We studied how surgeons communicate with residents during an operation, with the goal of enhancing intraoperative teaching opportunities. METHODS: Grounded theory methodology was used to investigate intraoperative verbal communication during four videotaped surgical procedures. Utterance-by-utterance analysis was performed to generate codes for each surgeon-resident interaction. Interactions were then analyzed to determine the percentage time spent in verbal teaching, number of topics covered, times each topic was visited, and time per topic. RESULTS: Four main types of teaching surgeon-resident verbal interaction were identified from 1306 interactions. Instrumental interactions were intended solely to move the operation forward. Pure teaching interactions served to educate the trainee, shape judgment, or enhance performance. Instrumental and Teaching interactions were directive but also contained teaching. Banter was discussion unrelated to the operation. Analysis of a subset of the operations demonstrated 13-29 topics covered per procedure, with each topic addressed between 1 and 8 times, and 25-330 seconds spent per topic. Most teaching instances were prompted by errors in resident performance. CONCLUSION: Instances of verbal teaching were numerous, arose opportunistically in this study, and focused typically on multiple points. To maximize teaching opportunities, the authors propose a structured approach to intraoperative teaching that involves identification of a limited set of specific learning objectives, followed by intraoperative teaching and postoperative debriefing targeted to those objectives.

A surgical simulation curriculum for senior medical students based on TeamSTEPPS.

OBJECTIVE: To investigate whether the existing Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) curriculum can effectively teach senior medical students team skills. DESIGN Single-group preintervention and postintervention study. SETTING AND INTERVENTION: We integrated a TeamSTEPPS module into our existing resident readiness elective. The curriculum included interactive didactic sessions, discussion groups, role-plays, and videotaped immersive simulation scenarios. MAIN OUTCOME MEASURES: Improvement of self-assessment scores, multiple-choice examination scores, and performance ratings of videotaped simulation scenarios before and after intervention. The videos were rated by masked reviewers on the basis of a global rating instrument (TeamSTEPPS) and a more detailed nontechnical skills evaluation tool(NOTECHS). PARTICIPANTS: Seventeen students participated and completed the study. RESULTS: The self-evaluation scores improved from 12.76 to 16.06 (P < .001). The increase was significant for all of the TeamSTEPPS competencies and highest for leadership skills (from 2.2 to 3.2; P < .001). The multiple-choice score rose from 84.9% to 94.1% (P < .01). The postintervention video ratings were significantly higher for both instruments (TeamSTEPPS, from 2.99 to 3.56; P < .01; and NOTECHS, from 4.07 to 4.59; P < .001). CONCLUSIONS: The curriculum led to improved self-evaluation and multiple-choice scores as well as improved team skills during simulated immersive patient encounters. The TeamSTEPPS framework may be suitable for teaching medical students teamwork concepts and improving their competencies. Larger studies using this framework should be considered to further evaluate the generalizability of our results and the effectiveness of TeamSTEPPS for medical students.

Pursuing professional accountability: an evidence-based approach to addressing residents with behavioral problems.

OBJECTIVE: To develop an evidence-based approach to the identification, prevention, and management of surgical residents with behavioral problems. DESIGN: The American College of Surgeons and Southern Illinois University Department of Surgery hosted a 1-day think tank to develop strategies for early identification of problem residents and appropriate interventions. Participants read a selection of relevant literature before the meeting and reviewed case reports. SETTING: American College of Surgeons headquarters, Chicago, Illinois. PARTICIPANTS: Medical and nursing leaders in the field of resident education; individuals with expertise in dealing with academic law, mental health issues, learning deficiencies, and disruptive physicians; and surgical residents. MAIN OUTCOME MEASURES: Evidence-based strategies for the identification, prevention, and management of problem residents. RESULTS: Recommendations based on the literature and expert opinions have been made for the identification, remediation, and reassessment of problem residents. CONCLUSIONS: It is essential to set clear expectations for professional behavior with faculty and residents. A notice of deficiency should define the expected acceptable behavior, timeline for improvement, and consequences for noncompliance. Faculty should note and address systems problems that unintentionally reinforce and thus enable unprofessional behavior. Complaints, particularly by new residents, should be investigated and addressed promptly through a process that is transparent, fair, and reasonable. The importance of early intervention is emphasized.