National Profile of the ACGME Milestones 1.0 and 2.0 within General Surgery: A Seven-Year National Study from 2014 to 2021.

PURPOSE: The Accreditation Council for Graduate Medical Education (ACGME) introduced General Surgery Milestones 1.0 in 2014 and Milestones 2.0 in 2020 as steps toward competency-based training. Analysis will inform residency programs on curriculum development, assessment, feedback, and faculty development. This study describes the distributions and trends for Milestones 1.0 and 2.0 ratings and proportion of residents not achieving the level 4.0 graduation target. METHODS: A deidentified dataset of milestone ratings for all ACGME-accredited General Surgery residency programs in the United States was used. Medians and interquartile ranges (IQR) were reported for milestone ratings at each PGY level. Percentages of PGY-5s receiving final year ratings of less than 4.0 were calculated. Wilcoxon rank sum tests were used to compare 1.0 and 2.0 median ratings. Kruskal-Wallis and Bonferroni post-hoc tests were used to compare median ratings across time periods and PGY levels. Chi-squared tests were used to compare the proportion of level 4.0 nonachievement under both systems. RESULTS: Milestones 1.0 data consisted of 13,866 residents and Milestones 2.0 data consisted of 7,633 residents. For 1.0 and 2.0, all competency domain median ratings were higher for subsequent years of training. Milestones 2.0 had significantly higher median ratings at all PGY levels for all competency domains except Medical Knowledge. Percentages of PGY-5 residents not achieving the graduation target in Milestones 1.0 ranged from 27% to 42% and in 2.0 from 5% to 13%. For Milestones 1.0, all subcompetencies showed an increased number of residents achieving the graduation target from 2014 to 2019. CONCLUSIONS: This study of General Surgery Milestones 1.0 and 2.0 data uncovered significant increases in average ratings and significantly fewer residents not achieving the graduation target under the 2.0 system. We hypothesize that these findings may be related more to rating bias given the change in rating scales, rather than a true increase in resident ability.

Let's Chalk About It: Introducing the TinyTalks Curriculum, a Paradigm for Short, Virtual Chalk Talks.

ABSTRACT: In busy clinical environments, educational opportunities must be designed to accommodate learner-specific needs. Many adult learners prefer short, relevant, technology-enhanced learning. As such, electronic learning (e-learning) experiences have become a prominent part of medical education. Yet, there remain challenges to e-learning experiences in the current educational landscape. To address these challenges, the authors developed the TinyTalks paradigm, which serves as the educational foundation for the TinyTalks curriculum.The TinyTalks paradigm was developed using the existing e-learning literature and foundational principles of adult learning and related theories. The TinyTalks paradigm includes 3 ground rules: (1) all TinyTalks videos must identify a category (approach to, explanation of, or application of) to clarify the focus of the topic, (2) all TinyTalks videos must be less than 7 minutes with all material presented on one virtual chalkboard screen, and (3) all TinyTalks videos must use the hook, frame, and delivery model, which guides the creation of the video. The resulting TinyTalks curriculum is an online repository of short, chalk talk-style educational videos, developed by interdisciplinary health professionals and targeted to the level of trainees, that is available to be used flexibly by learners for just-in-time learning, flipped classroom sessions, and/or self-study.The authors used Kern's 6-step approach to curriculum development as the conceptual framework for the development and implementation of the TinyTalks curriculum at Mass General for Children (June 2021-January 2023). While developing and implementing the curriculum, the authors focused on topic selection, stakeholder recruitment, establishing a process flow, and creating a virtual home.The authors believe the TinyTalks paradigm outlines an effective educational strategy that accommodates the unique needs of both learners and teachers in the medical education setting. The next steps are to scale the TinyTalks curriculum up by expanding the content library and to evaluate its efficacy.

Virtual training for small group facilitators.

BACKGROUND: In addition to providing patient care, interprofessional health care teams work collaboratively on a variety of projects. These projects often benefit from using facilitated small group project discussion sessions, such as the Harvard Macy Institute's (HMI) Step Back Process (SBP). Although having a trained facilitator is an important component of the SBP, only a limited number of health care professionals can attend HMI courses in person or virtually, limiting its impact. APPROACH: We developed three video-based education (VBE) modules to deliver facilitator training on the SBP, informed by principles of Mayer's cognitive theory of multimedia learning. For module development, we used a five-step approach. We evaluated effectiveness of the modules as a self-directed method to enhance SBP facilitator training. An initial survey collected demographic data and module feedback, a follow-up survey collected feedback on the modules' impact on facilitation and interviews focused on the participants' overall experience. EVALUATION: Survey results indicated that the modules were positively received and helped to improve participant confidence in facilitating. We identified four themes from the interviews: challenges of facilitating, value of group feedback, value of modules for experienced facilitators and the modules as part of a multi-modal approach to train new facilitators. IMPLICATIONS: This innovation provides insight on delivering facilitator training on the SBP using VBE. Health professions educators developing online facilitator training could adapt our development process and modify implementation guided by our results. Future work should evaluate the best methods to integrate VBE modules into a longitudinal virtual community and assess facilitation techniques.

Giving Literal Thanks: An ACGME-Sponsored Initiative to Bring Residents Back to the Bedside.

Background Resident burnout is at an all-time high. In response, the Accreditation Council for Graduate Medical Education (ACGME) developed the Back to Bedside grant for resident-led burnout interventions that increase the time residents spend with patients. Objective We designed a resident-patient reading intervention, Giving Literal Thanks (GLT), intended to increase meaningful time residents spend with patients and thereby decrease burnout. Methods All 65 pediatric residents rotating through our academic hospital's inpatient units from Fall 2019 through Fall 2021 were invited to read and gift books to their patients. We studied our intervention's relationship to resident burnout using a convergent mixed-methods design, including anonymous, unlinked pre-, peri-, and post-intervention surveys and focus groups. Qualitative and quantitative data were analyzed separately, then integrated to describe burnout pre- and post-intervention. Results Forty-one of 65 residents (63.1%) completed pre-intervention surveys, and 8 of 65 (12.3%) completed post-intervention surveys. Twenty-seven resident-patient reading interactions were recorded, and 2 focus groups were held (1 pre- and 1 post-intervention). Five themes were identified: (1) limited opportunities exist to spend time at the bedside; (2) spending time at the bedside is valuable; (3) other responsibilities may preclude time at the bedside; (4) GLT could promote positive outcomes; and (5) GLT might not be the right tool to reduce burnout. Further quantitative data analysis was prevented by low survey response rates. While GLT was positively received and feasible, we were unable to show an improvement in burnout. Conclusions GLT was well-regarded but may not improve resident burnout.

Effect of Increased Interprofessional Familiarity on Team Performance, Communication, and Psychological Safety on Inpatient Medical Teams: A Randomized Clinical Trial.

Importance: In large academic centers, medical residents work on multiple clinical floors with transient interactions with nursing colleagues. Although teamwork is critical in delivering high-quality medical care, little research has evaluated the effect of interprofessional familiarity on inpatient team performance. Objective: To determine the effectiveness of increased familiarity between medical residents and nurses on team performance, psychological safety, and communication. Design, Setting, and Participants: A 12-month randomized clinical trial in an inpatient general medical service at a large academic medical center was completed from June 25, 2019, to June 24, 2020. Participants included 33 postgraduate year (PGY)-1 residents in an internal medicine residency program and 91 general medicine nurses. Interventions: Fifteen PGY-1 residents were randomized to complete all 16 weeks of their general medicine inpatient time on 1 medical nursing floor (intervention group with 43 nurses). Eighteen PGY-1 residents completed 16 weeks on 4 different general medical floors as per usual care (control group with 48 nurses). Main Outcomes and Measures: The primary outcome was an assessment of team performance in physician-nurse simulation scenarios completed at 6 and 12 months. Interprofessional communication was assessed via a time-motion study of both work rounds and individual resident clinical work. Psychological safety and teamwork culture were assessed via surveys of both residents and nurses at multiple time points. Results: Of the intervention and control PGY-1 residents, 8 of 15 (54%) and 8 of 18 (44%) were women, respectively. Of the nurses in the intervention and control groups with information available, 37 of 40 (93%) and 34 of 38 (90%) were women, respectively, and more than 70% had less than 10 years of clinical experience. There was no difference in overall team performance during the first simulation. At the 12-month simulation, the intervention teams received a higher mean overall score in leadership and management (mean [SD], 2.47 [0.53] vs 2.17 [0.39]; P = .045, Cohen d = 0.65) and on individually rated items were more likely to work as 1 unit (100% vs 62%; P = .003), negotiate with the patient (61% vs 10%; P = .001), support other team members (61% vs 24%; P = .02), and communicate as a team (56% vs 19%; P = .02). The intervention teams were more successful in achieving the correct simulation case outcome of negotiating a specific insulin dose with the patient (67% vs 14%; P = .001). Time-motion analysis noted intervention teams were more likely to have a nurse present on work rounds (47% vs 28%; P = .03). At 6 months, nurses in the intervention group were more likely to report their relationship with PGY-1 residents to be excellent to outstanding (74% vs 40%; P = .003), feel that the input of all clinical practitioners was valued (95% vs 53%; P < .001), and say that feedback between practitioners was delivered in a way to promote positive interactions (90% vs 60%; P = .003). These differences diminished at the 12-month survey. Conclusions and Relevance: In this randomized clinical trial, increased familiarity between nurses and residents promoted more rapid improvement of nursing perception of team relationships and, over time, led to higher team performance on complex cognitive tasks in medical simulations. Medical centers should consider team familiarity as a potential metric to improve physician-nursing teamwork and patient care. Trial Registration: ClinicalTrials.gov Identifier: NCT05213117.

Finding my people: Effects of student identity and vulnerability to Stereotype Threat on sense of belonging in surgery.

BACKGROUND: Diversity in surgery lags behind the medical student population. We documented first-year medical students' vulnerability to stereotype threat (VST) and its impact on a sense of belonging in surgery. METHODS: All first-year medical students at a single academic institution were surveyed. Demographics, VST, anticipated clerkship experience, and sense of belonging were assessed. RESULTS: 44% of students were vulnerable to ST in upcoming clerkships, with the majority worried about surgical clerkships. More student from races/ethnicities underrepresented in medicine (URM; 74%) and sexual minorities (62%) were vulnerable than white (30%) and heterosexual (38%) students respectively (p = 0.001 and p = 0.017). Knowing a surgeon with a shared identity would enhance belonging for most students (84%). VST was higher for those who do not anticipate working with (p < 0.001) or do not know a surgeon (p = 0.0001) who shares their identity. CONCLUSION: VST significantly influences a student's sense of belonging in surgery. More research is needed to promote inclusivity in surgery.

Passing the Scalpel: Lessons on retirement planning from retired academic surgeons.

BACKGROUND: Almost half of practicing surgeons in the United States are currently older than 55, but guidelines on how to prepare for retirement are limited. We sought to identify possible facilitators for, and obstacles to, surgeons' preparations for retirement. METHODS: A qualitative study was conducted using semi-structured interviews with clinically inactive academic surgeons. Emergent themes were identified via a grounded theory approach. RESULTS: We interviewed 12 surgeons (83% male; median age 75 years). Major barriers to retirement from surgery included uncertainty about when to retire, limited identity outside of surgery, and perception of retirement as strictly individual/private. Facilitators of a successful retirement identified by the participants included early career financial planning, awareness of career trajectory, development of post-surgery goals, and utilization of collective knowledge. CONCLUSION: There are numerous barriers encountered by surgeons seeking to transition from clinical practice to retirement that could be overcome by dedicated departmental and institutional efforts.

Eyes of the Beholders: First-year medical students' perceptions of surgeons and the field of surgery.

BACKGROUND: Medical students have negative perceptions of surgery prior to their clerkships. To explore possible explanations, we examined the association between these perceptions, individual identity and vulnerability to stereotype threat (ST). METHODS: All first-year medical students at a single school received an electronic survey which assessed identity groups, vulnerability to ST and perceptions of surgeons/surgery. Multi-method analyses examined these associations. RESULTS: Women held more negative than positive views about the field of surgery (p = 0.007) but not surgeons. Students vulnerable to ST had negative views about both surgeons (p < 0.0001) and surgery (p = 0.007). They were also less interested in pursuing a surgical career compared to non-vulnerable students (56% vs. 80% p = 0.03). CONCLUSION: For some students, negative views of surgeons and surgery appear to be associated with individual identity and ST. Future research should aim to confirm these findings and identify strategies to develop positive perceptions for these populations.

Association of Use of the NEJM Knowledge+ Product and Performance on the ABIM IM-MOC Exam.

Phenomenon: Internal medicine physicians in the United States must pass the American Board of Internal Medicine Internal Medicine Maintenance of Certification (ABIM IM-MOC) examination as part of their ABIM IM-MOC requirements. Many of these physicians use an examination product to help them prepare, such as e-Learning products, including the ACP's MKSAP, UpToDate, and NEJM Knowledge+, yet their effectiveness remains largely unstudied. Approach: We compared ABIM IM-MOC examination performance among 177 physicians who attempted an ABIM IM-MOC examination between 2014-2017 and completed at least 75% of the NEJM Knowledge+ product prior to the ABIM IM-MOC examination and 177 very similar matched control physicians who did not use NEJM Knowledge+. Our measures of ABIM IM-MOC exam performance for NEJM Knowledge+ users were based on the results of the first attempt immediately following the NEJM Knowledge+ use and for non-users were based on the applicable matched examination performance. The three dichotomous examination performance outcomes measured on the first attempt at the ABIM IM-MOC examination included pass rate, scoring in the upper quartile, and scoring in the lower quartile. Findings: Use of NEJM Knowledge+ was associated with a regression adjusted 10.6% (5.37% to 15.8%) greater likelihood of passing the MOC examination (p < .001), 10.7% (2.61% to 18.7%) greater likelihood of having an examination score in the top quartile (p = .009), and -10.8% (-16.8% to -4.86%) lower likelihood of being in the bottom quartile of the MOC examination (p < .001) as compared to similar physicians who did not use NEJM Knowledge+. Insight: Physicians who used NEJM Knowledge+ had better ABIM IM-MOC exam performance. Further research is needed to determine what aspects of e-Learning products best prepare physicians for MOC examinations.

Applying a novel cost-evaluation framework to assess video-based neurosurgery education.

BACKGROUND: Analysis of comparative effectiveness uses different metrics to ensure that a new treatment is both effective and economical. However, there is a lack of financial frameworks to estimate the costs of introducing new technologies in medical and surgical education. METHODS: After conducting a literature review, we created and applied a framework ('REC') for the evaluation of three recent neurosurgery video modules aimed at medical students at Harvard Medical School. RESULTS: The most expensive component of these video-based education (VBE) modules was time cost. This cost was highly variable depending on the level of clinical seniority of the individuals involved in the video production process. CONCLUSION: Application of the REC framework to the three modules showed highly variable time and monetary cost differences between the modules. Usage of the REC framework will enable educators to institute effective planning, efficiently use resources, and clearly define a minimal viable education product to achieve desired learning outcomes.

NEJM Knowledge+ Question of the Week: A Novel Virtual Learning Community Effectively Utilizing an Online Discussion Forum.

Objectives: Asynchronous virtual learning communities provide learners with the ability to enhance their learning and contribute to their peers' learning in a safe environment. However, the tone and content of learner comments, the level of engagement among learners, and the role of moderators have not been well studied within non-course-related virtual learning communities. Therefore, we sought to explore these characteristics using the NEJM Knowledge+ Question of the Week (NEJM Knowledge+ QoW) forum, a web-based asynchronous virtual learning community. Methods: We reviewed 73 NEJM Knowledge+ questions posted on the QoW forum between 2015 and 2016. We then selected three QoWs to analyze through a multistep coding process based on three broad criteria that aligned with our study aims. Results: Learner comments reflected both positive and critical tones, with learners sharing their own clinical practice and local experiences to contextualize their perspectives and reactions to both the QoW answer and the responses of other learners. Learners also commonly requested moderators to act as expert referees. Conclusion: Asynchronous virtual learning communities can engage learners by providing the opportunity to enhance their knowledge through responding to proposed medical scenarios and sharing their experiences in a discussion forum. Future work should examine the impact that geographic region has on asynchronous virtual learning communities and the role of moderators in shaping the learning experience.

YouTube is the Most Frequently Used Educational Video Source for Surgical Preparation.

OBJECTIVE: The purpose of this study was to evaluate surgical preparation methods of medical students, residents, and faculty with special attention to video usage. DESIGN: Following Institutional Review Board approval, anonymous surveys were distributed to participants. Information collected included demographics and surgical preparation methods, focusing on video usage. Participants were questioned regarding frequency and helpfulness of videos, video sources used, and preferred methods between videos, reading, and peer consultation. Statistical analysis was performed using SAS. SETTING: Surveys were distributed to participants in the Department of Surgery at the University of Iowa Hospitals and Clinics, a tertiary care center in Iowa City, Iowa. PARTICIPANTS: Survey participants included fourth-year medical students pursuing general surgery, general surgery residents, and faculty surgeons in the Department of Surgery. A total of 86 surveys were distributed, and 78 surveys were completed. This included 42 learners (33 residents, 9 fourth-year medical students) and 36 faculty. RESULTS: The overall response rate was 91%; 90% of respondents reported using videos for surgical preparation (learners = 95%, faculty = 83%, p = NS). Regarding surgical preparation methods overall, most learners and faculty selected reading (90% versus 78%, p = NS), and fewer respondents reported preferring videos (64% versus 44%, p = NS). Faculty more often use peer consultation (31% versus 50%, p < 0.02). Among respondents who use videos (N = 70), the most used source was YouTube (86%). Learners and faculty use different video sources. Learners use YouTube and Surgical Council on Resident Education (SCORE) Portal more than faculty (YouTube: 95% versus 73%, p < 0.02; SCORE: 25% versus 7%, p < 0.05). Faculty more often use society web pages and commercial videos (society: 67% versus 38%, p < 0.03; commercial: 27% versus 5%, p < 0.02). CONCLUSIONS: Most respondents reported using videos to prepare for surgery. YouTube was the preferred source. Posting surgical videos to YouTube may allow for maximal access to learners who are preparing for surgical cases.