Does Masked Interviewing Encourage Holistic Review in Residency Selection? A Mixed-Methods Study.

Problem: Medical educators increasingly champion holistic review. However, in U.S. residency selection, holistic review has been difficult to implement, hindered by a reliance on standardized academic criteria such as board scores. Masking faculty interviewers to applicants' academic files is a potential means of promoting holistic residency selection by increasing the interview's ability to make a discrete contribution to evaluation. However, little research has directly analyzed the effects of masking on how residency selection committees evaluate applicants. This mixed-methods study examined how masking interviews altered residency selection in an anesthesiology program at a large U.S. academic medical center. Intervention: During the 2019-2020 residency selection season in the University of Pennsylvania's Department of Anesthesiology & Critical Care, we masked interviewers to the major academic components of candidates' application files (board scores, transcripts, letters) on approximately half of interview days. The intent of the masking intervention was to mitigate the tendency of interviewers to form predispositions about candidates based on standardized academic criteria and thereby allow the interview to make a more independent contribution to candidate evaluation. Context: Our examination of the masking intervention used a concurrent, partially mixed, equal-status mixed-methods design guided by a pragmatist approach. We audio-recorded selection committee meetings and qualitatively analyzed them to explore how masking affected the process of candidate evaluation. We also collected independent candidate ratings from interviewers and consensus committee ratings and statistically compared ratings of candidates interviewed on masked days to ratings from conventional days. Impact: In conventional committee meetings, interviewers focused on how to reconcile academic metrics and interviews, and their evaluations of interviews were framed according to predispositions about candidates formed through perusal of application files. In masked meetings, members instead spent considerable effort evaluating candidates' "fit" and whether they came off as tactful. Masked interviewers gave halting opinions of candidates and sometimes pushed for committee leaders to reveal academic information, leading to masking breaches. Higher USMLE Step 1 score and higher medical school ranking were statistically associated with more favorable consensus rating. We found no significant differences in rating outcomes between masked and conventional interview days. Lessons learned: Elimination of academic metrics during the residency interview phase does not straightforwardly promote holistic review. While critical reflection among medical educators about the fairness and utility of such metrics has been productive, research and intervention should focus on the more proximate topic of how programs apply academic and other criteria to evaluate applicants.

Failure to Debrief after Critical Events in Anesthesia Is Associated with Failures in Communication during the Event.

WHAT WE ALREADY KNOW ABOUT THIS TOPIC: Debriefing after an actual critical event is an established good practice in medicine, but a gap exists between principle and implementation. WHAT THIS ARTICLE TELLS US THAT IS NEW: Failure to debrief after critical events is common among anesthesia trainees and likely anesthesia teams. Communication breakdowns are associated with a high rate of the failure to debrief. BACKGROUND: Debriefing after an actual critical event is an established good practice in medicine, but a gap exists between principle and implementation. The authors' objective was to understand barriers to debriefing, characterize quantifiable patterns and qualitative themes, and learn potential solutions through a mixed-methods study of actual critical events experienced by anesthesia personnel. METHODS: At a large academic medical center, anesthesiology residents and a small number of attending anesthesiologists were audited and/or interviewed for the occurrence and patterns of debriefing after critical events during their recent shift, including operating room crises and disruptive behavior. Patterns of the events, including event locations and event types, were quantified. A comparison was done of the proportion of cases debriefed based on whether the event contained a critical communication breakdown. Qualitative analysis, using an abductive approach, was performed on the interviews to add insight to quantitative findings. RESULTS: During a 1-yr period, 89 critical events were identified. The overall debriefing rate was 49% (44 of 89). Nearly half of events occurred outside the operating room. Events included crisis events (e.g., cardiac arrest, difficult airway requiring an urgent surgical airway), disruptive behavior, and critical communication breakdowns. Events containing critical communication breakdowns were strongly associated with not being debriefed (64.4% [29 of 45] not debriefed in events with a communication breakdown vs. 36.4% [16 of 44] not debriefed in cases without a communication breakdown; P = 0.008). Interview responses qualitatively demonstrated that lapses in communication were associated with enduring confusion that could inhibit or shape the content of discussions between involved providers. CONCLUSIONS: Despite the value of proximal debriefing to reducing provider burnout and improving wellness and learning, failure to debrief after critical events can be common among anesthesia trainees and perhaps anesthesia teams. Modifiable interpersonal factors, such as communication breakdowns, were associated with the failure to debrief.

How does training in anesthesia residency shape residents' approaches to patient care handoffs? A single-center qualitative interview study.

BACKGROUND: Handoffs are a complex procedure whose success relies on mutual discussion rather than simple information transfer. Particularly among trainees, handoffs present major opportunities for medical error. Previous research has explored best practices and pitfalls in general handoff education but has not discussed barriers specific to anesthesiology residents. This study characterizes the experiences of residents in anesthesiology as they learn handoff technique in order to inform strategies for teaching this important component of perioperative care. METHODS: In 2016, we conducted a semi-structured interview study of 30 anesthesia residents across all three postgraduate years at a major academic hospital. Interviews were coded by two coders using a grounded theory approach and an iterative process designed to enhance reliability and validity. RESULTS: Residents cited lack of consistency as a major impediment to proper handoff education. They found the impact of lectures and written materials to be limited. The level of guidance and direction they received from one-to-one attendings was described as highly variable. Residents' comfort in executing handoffs was heavily dependent on location and situation. They felt that coordination among the parties involved in the handoff was difficult to achieve, causing confusion about the importance of handoffs as well as proper protocol. Finally, residents offered opinions on when handoff education should occur during the residency and had several recommendations for its improving, including standardization of key handoff topics. CONCLUSIONS: In a single center study of anesthesiology resident handoff education, residents exhibited confusion related to a perceived disconnect between the stated importance of effective handoffs and a lack of consensus on proper handoff technique. Standardization of curriculum and framing expectations has the potential to enhance resident handoff training in academic anesthesia departments.

The role of feedback in ameliorating burnout.

PURPOSE OF REVIEW: Assessment of the current literature surrounding interventions directed toward the prevention of burnout in the field of medicine and particularly in anesthesiology. RECENT FINDINGS: Recently, burnout has been noted to lead to medication errors and subsequently increased harm to our patients. On a personal level, burnout can lead to depression and even suicide amongst physicians. Strategies to prevent burnout amongst anesthesiologists that have been studied in the literature include multisource feedback, mentorship and early recognition. SUMMARY: There remains no clear or definitive intervention to prevent burnout for physicians. However, changing our environment to embrace mentorship, the continual exchange of feedback and the fostering self-care could startlingly improve our work environment.

Improving Formative Feedback in the Operating Room Setting: Developing and Implementing an Initiative to Improve Feedback Quality and Culture.

PROBLEM: Formative feedback, given in an ongoing fashion during the learning process, is fundamental to clinical education. However, dissatisfaction with formative feedback among residents is common. Difficulties with formative feedback are intensified in the operating room (OR) setting due to fast pace, space limitations, and frequent rotation of residents and attendings. APPROACH: In the anesthesiology and critical care department at the University of Pennsylvania Perelman School of Medicine, the authors launched the Feedback Moment initiative from January 2018 to May 2018 in which 24 first-year residents and attendings were given a short series of prompts designed to facilitate regular, high-quality formative feedback. The authors conducted semistructured interviews with residents before and after the initiative to evaluate its impact. OUTCOMES: In baseline interviews, 18 participating residents stressed the importance of formative feedback but described feeling unsure of their performance due to lack of ongoing constructive input from attendings. They felt hesitant to approach attendings for feedback due to a desire not to interrupt OR workflow or appear incompetent. In follow-up interviews, residents described the initiative as helping to normalize constructive formative feedback but difficult to execute regularly due to OR workflow issues and frequent rotation of attendings with varying approaches. NEXT STEPS: Challenges faced by participants in this initiative highlight several considerations for effective OR-based formative feedback. Alternative timings for initiating feedback must be considered in light of the hectic nature of the OR workflow. Residents should be equipped with the skills necessary to adapt to varying practice patterns and frequent rotation between attendings, while attendings should be trained to provide a clear rationale for constructive feedback that allows residents to quickly adapt to practice variation. Finally, establishing clear goals among resident-attending pairs is critical to ensuring that formative feedback given in necessarily brief sessions is focused and productive.

Understanding Debriefing: A Qualitative Study of Event Reconstruction at an Academic Medical Center.

PURPOSE: This qualitative study sought to characterize the role of debriefing after real critical events among anesthesia residents at the Hospital of the University of Pennsylvania. METHOD: From October 2016 to June 2017 and February to April 2018, the authors conducted 25 semistructured interviews with 24 anesthesia residents after they were involved in 25 unique critical events. Interviews focused on the experience of the event and the interactions that occurred thereafter. A codebook was generated through annotation, then used by 3 researchers in an iterative process to code interview transcripts. An explanatory model was developed using an abductive approach. RESULTS: In the aftermath of events, residents underwent a multistage process by which the nature of critical events and the role of residents in them were continuously reconstructed. Debriefing-if it occurred-was 1 stage in this process, which also included stages of internal dialogue, event documentation, and lessons learned. Negotiated in each stage were residents' culpability, reputation, and the appropriateness of their affective response to events. CONCLUSIONS: Debriefing is one of several stages of interaction that occur after a critical event; all stages play a role in shaping how the event is interpreted and remembered. Because of its dynamic role in constituting the nature of events and residents' role in them, debriefing can be a high-stakes interaction for residents, which can contribute to their reluctance to engage in it. The function and quality of debriefing can be assessed in more insightful fashion by understanding its relation to the other stages of event reconstruction.

Encouraging Reflexivity in a Residency Leadership Development Program: Expanding Outside the Competency Approach.

PROBLEM: While leadership development is increasingly a goal of academic medicine, it is typically framed as competency acquisition, which can limit its focus to a circumscribed set of social behaviors. This orientation may also reinforce the cultural characteristics of academic medicine that can make effective leadership difficult, rather than training leaders capable of examining and changing this culture. Expanding leadership development so it promotes social reflexivity presents a way to bolster some of the weaknesses of the competency paradigm. APPROACH: In 2013-2016, the University of Penn sylvania's Department of Anesthesiology and Critical Care (DACC) carried out a leadership development program for residents, which included seminars focused on developing particular leadership skills and annual capstone sessions facilitating discussion between residents and attending physicians about topics chosen by residents. The capstone sessions proved to be most impactful, serving as forums for open conversation about how these groups interact when engaged in social behaviors such as giving/receiving feedback, offering support after an adverse event, and teaching/learning in the clinic. OUTCOMES: The success of the capstone sessions led to a 2016 DACC-wide initiative to facilitate transparency among all professional roles (faculty, residents, nurse anesthetists, administrative staff) and encourage widespread reflexive examination about how the manner in which these groups interact encourages or impedes leadership and teamwork. NEXT STEPS: Further work is necessary to describe how leadership program formats can be diversified to better encourage reflexivity. There is also a need to develop mechanisms for assessing outcomes of leadership programs that expand outside the competency-based system.

In Situ Operating Room-Based Simulation: A Review.

OBJECTIVE: To systematically review the literature surrounding operating room-based in situ training in surgery. METHODS: A systematic review was conducted of MEDLINE. The review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology, and employed the Population, Intervention, Comparator, Outcome (PICO) structure to define inclusion/exclusion criteria. The Kirkpatrick model was used to further classify the outcome of in situ training when possible. RESULTS: The search returned 308 database hits, and ultimately 19 articles were identified that met the stated PICO inclusion criteria. Operating room-based in situ simulation is used for a variety of purposes and in a variety of settings, and it has the potential to offer unique advantages over other types of simulation. Only one randomized controlled trial was conducted comparing in situ simulation to off-site simulation, which found few significant differences. One large-scale outcome study showed improved perinatal outcomes in obstetrics. CONCLUSIONS: Although in situ simulation theoretically offers certain advantages over other types of simulation, especially in addressing system-wide or environmental threats, its efficacy has yet to be clearly demonstrated.

Perioperative management of a patient scheduled for bilateral hand transplant.

The perioperative management of a patient receiving a bilateral hand transplant is presented. The anesthetic management required careful fluid administration, homeothermic temperature maintenance, and postoperative analgesia. The role of different anesthesia subspecialties is highlighted.