Examining Parity among Black and Hispanic Resident Physicians.

BACKGROUND: The US physician workforce does not represent the racial or ethnic diversity of the population it serves. OBJECTIVES: To assess whether the proportion of US physician trainees of Black race and Hispanic ethnicity has changed over time and then provide a conceptual projection of future trends. DESIGN: Cross-sectional, retrospective, analysis based on 11 years of publicly available data paired with recent US census population estimates. PARTICIPANTS: A total of 86,303 (2007-2008) to 103,539 (2017-2018) resident physicians in the 20 largest US Accreditation Council for Graduate Medical Education resident specialties. MAIN MEASURES: Changes in proportion of physician trainees of Black race and Hispanic ethnicity per academic year. Projected number of years it will then take, for specialties with positive changes, to reach proportions of Black race and Hispanic ethnicity comparable to that of the US population. KEY RESULTS: Among the 20 largest specialty training programs, Radiology was the only specialty with a statistically significant increase in the proportion of Black trainees, but it could take Radiology 77 years to reach levels of Black representation comparable to that of the US population. Obstetrics/Gynecology, Emergency Medicine, Internal Medicine/Pediatrics, and Orthopedic Surgery demonstrated a statistically significant increase in the proportion of Hispanic trainees, but it could take these specialties 35, 54, 61, and 93 years respectively to achieve Hispanic representation comparable to that of the US population. CONCLUSIONS: Among US residents in the 20 largest specialties, no specialty represented either the Black or Hispanic populations in proportions comparable to the overall US population. Only a small number of specialties demonstrated statistically significant increases. This conceptual projection suggests that current efforts to promote diversity are insufficient.

Transplant administration-A survey of the roles and responsibilities of kidney and pancreas medical directors of US transplant centers.

The current American Society of Transplantation (AST) accredited transplant fellowship programs in the United States provide no structured formal training in leadership and administration which is essential for successfully running a transplant program. We conducted a survey of medical directors of active adult kidney and kidney-pancreas transplant programs in the United States about their demographics, training pathways, and roles and responsibilities. The survey was emailed to 183 medical directors, and 123 (67.2%) completed the survey. A majority of respondents were older than 50 years (61%), males (80%), and holding that position for more than 10 years (47%). Only 51% of current medical directors had taken that position after completing a one-year transplant fellowship, and 58% took on the role with no prior administrative or leadership experience. The medical directors reported spending a median 50%-75% of time in clinical responsibilities, 25%-50% of time in administration, and 0%-25% time in research. The survey also captured various administrative roles of medical directors vis-à-vis other transplant leaders. The study, designed to be the starting point of an improvement initiative of the AST, provided important insight into the demographics, training pathways, roles and responsibilities, job satisfaction, education needs, and training gaps of current medical directors.

Grand rounds education in neurology, with a focus on headache medicine.

OBJECTIVE: To quantify the proportion of headache-related grand rounds in academic neurology programs and to compare this with adult neurology residency director views on the need for an increase in headache-related grand rounds. BACKGROUND: Although headache are among the most prevalent and most burdensome neurologic conditions, headache medicine is often considered underrepresented in neurology departments. Additionally, prior studies have shown that many neurology residency directors feel that training programs do not include an adequate amount of exposure to headache clinics or headache-related didactics. One important aspect of didactic education in neurology departments is adult neurology grand rounds. Previous publications have evaluated neither the proportion of headache-related grand rounds in academic neurology departments nor the residency program directors' views on appropriate amount of headache-related grand rounds. Our study has attempted to quantify this information to elucidate opportunities to improve practice educational gaps. METHODS: In this cross-sectional study, we surveyed adult neurology residency directors (from the Accreditation Council for Graduate Medical Education [ACGME] listing of academic adult neurology residency programs) between October 2018 and September 2019. In addition, we used two methods to obtain the proportion of headache-related grand rounds in neurology: (1) emailing residency directors a questionnaire asking for a list of prior grand rounds topics and (2) an online search for each academic neurology program. RESULTS: First, for our grand rounds analysis, headache medicine consisted of 3.7% of the lectures in 2017-2018 and 6.3% of the lectures in 2018-2019 (average of each institution; 17 institutions and 411 total lectures in 2017-2018, 21 institutions and 463 total lectures in 2018-2019). The most common number of lectures on headache medicine for each grand rounds series was zero (for 7 of 17 grand rounds series in 2017-2018 and 7 of 21 in 2018-2019), followed closely by one lecture (for 6 of 17 grand rounds series in 2017-2018 and 6 of 21 in 2018-2019). Second, for our survey, the response rate was 19.3% (29/150). No residency director thought their institution had too many grand rounds dedicated to headache medicine, and 62.1% (18/29) thought they had an adequate amount of headache grand rounds. Within the survey responders, 75.9% (22/29) of adult neurology residency programs have a board-certified headache specialist at their institution. CONCLUSIONS: Although most adult neurology residency directors believe that headache is adequately represented in adult neurology grand rounds, headache medicine makes up 4%-6% of all neurology grand rounds. Compared with other neurology subspecialties and the other core ACGME milestones, headache makes up the fewest grand rounds lectures that were assessed in this study.

Variability in gynecologic case volume of obstetrician-gynecologist residents graduating from 2009 to 2017.

BACKGROUND: Residency training in obstetrics-gynecology has changed significantly over time, with residents expected to master an increasing number of surgical procedures. Residency operative case logs are tracked by the Accreditation Council for Graduate Medical Education, which sets case minimums for all procedures. In 2018, the Accreditation Council for Graduate Medical Education created a combined minimally invasive hysterectomy category and now requires graduating residents to complete a minimum of 70 minimally invasive hysterectomies. OBJECTIVES: The objectiges of the study were to evaluate the range of operative gynecological experience across graduating obstetrician-gynecologist residents in the United States and to estimate the number of residents able to meet new Accreditation Council for Graduate Medical Education minimum hysterectomy cases. STUDY DESIGN: Accreditation Council for Graduate Medical Education surgical case logs of graduating obstetrician-gynecologist residents from 2009 to 2017 were analyzed for case volume trends. RESULTS: The average total number of gynecological cases per resident decreased from 438.2 to 431.5 (P < .0001). Minimally invasive hysterectomy averages increased from 43.6 to 69.3 (P < .0001), a trend driven principally by an increase in total laparoscopic hysterectomies. Mean case log decreases were noted in invasive cancer (70.7 to 54.3), incontinence and pelvic floor (85.6 to 56.7), and total abdominal hysterectomies (74.4 to 42.9); (P < .0001 for all). Mean increases were seen in total laparoscopic (118.8 to 146.3) and operative hysteroscopy (68.6 to 77.1) cases (P < .0001 for all). The ratio of the 90th percentile to the 10th percentile of resident case logs showed substantial variation in surgical volume for all procedures, although this ratio decreased over time. Graduates who logged 70 minimally invasive hysterectomy cases were estimated to fall at the 51st percentile in 2017; this was down from the 91st percentile in 2009. CONCLUSION: Nationwide, graduates of obstetrician-gynecologist residency experience significant variability in their surgical training. Based on our extrapolation of Accreditation Council for Graduate Medical Education data, approximately half of residency graduates fell below the 70 case minimally invasive hysterectomy minimum in 2017. Meeting the new Accreditation Council for Graduate Medical Education hysterectomy minimums may be challenging for a significant proportion of residency programs. Understanding the scope and variability of gynecology training is needed to continue to improve and address gaps in resident education.

Maintaining High-Quality Multidisciplinary Pain Medicine Fellowship Programs: Part I: Innovations in Pain Fellows' Education, Research, Applicant Selection Process, Wellness, and ACGME Implementation During the COVID-19 Pandemic.

BACKGROUND: Pain fellowship programs are facing unique challenges during the COVID-19 pandemic. Restrictions from state governments and the Centers for Disease Control and Prevention have resulted in a rapidly changing and evolving learning environment for todays' fellows. Innovative solutions must be sought to guarantee that proper education is maintained and to ensure the well-being of our trainees. METHODS: We assembled a panel of pain program directors who serve as officers/board members of the Association of Pain Program Directors to provide guidance and formulate recommendations to pain fellowship directors nationally. This guidance is based on reviewing current changes to the Accreditation Council for Graduate Medical Education (ACGME) and American Board of Anesthesiology policies and best available evidence and expert opinion on the use of remote educational activities, research endeavors, and trainee wellness. CONCLUSIONS: The country is in the midst of an unprecedented pandemic. The impact on pain management fellowships has been severe and will likely last for months, resulting in extraordinary challenges to the administration of pain fellowship programs and the education of our fellows. Understanding revisions to ACGME policies, using technology to promote remote learning opportunities, and providing trainees with opportunities to alleviate their anxiety and encourage mental health are beneficial strategies to implement. Together, we can implement innovative solutions to help overcome these challenges.

Current US neurosurgical resident involvement, interest, and barriers in global neurosurgery.

OBJECTIVE: It is estimated that nearly 47 million preventable deaths occur annually due the current worldwide deficit in surgical care; subsequently, the World Health Organization resolved unanimously to endorse a decree to address this deficit. Neurosurgeons from industrialized nations can help address the needs of underserved regions. Exposure during training is critical for young neurosurgeons to gain experience in international work and to cultivate career-long interest. Here, the authors explore the opinions of current residents and interest in global neurosurgery as well as the current state of international involvement, opportunities, and barriers in North American residency training. METHODS: An internet-based questionnaire was developed using the authors' university's REDCap database and distributed to neurosurgical residents from US ACGME (Accreditation Council for Graduate Medical Education)-approved programs. Questions focused on the resident's program's involvement and logistics regarding international rotations and the resident's interest level in pursuing these opportunities. RESULTS: A 15% response rate was obtained from a broad range of training locations. Twenty-nine percent of respondents reported that their residency program offered elective training opportunities in developing countries, and 7.6% reported having participated in these programs. This cohort unanimously felt that the international rotation was a beneficial experience and agreed that they would do it again. Of those who had not participated, 81.3% reported interest or strong interest in international rotations. CONCLUSIONS: The authors' results indicate that, despite a high level of desire for involvement in international rotations, there is limited opportunity for residents to become involved. Barriers such as funding and rotation approval were recognized. It is the authors' hope that governing organizations and residency programs will work to break down these barriers and help establish rotations for trainees to learn abroad and begin to join the cause of meeting global surgical needs. To meet overarching international neurosurgical needs, neurosurgeons of the future must be trained in global neurosurgery.

Trends in United States neurosurgery residency education and training over the last decade (2009-2019).

OBJECTIVE: Postgraduate training in medicine has been under scrutiny in the last 10 years, with a focus on improving residents' education. The aim of this study was to quantify trends in neurosurgery residency (NSR) training and education over the last 10 years. METHODS: The authors assessed Accreditation Council for Graduate Medical Education (ACGME), National Resident Matching Program, and American Board of Neurological Surgeons records and searched PubMed to collate 2009-2019 data. Analyzed trends included residents' demographic data, programs' characteristics, graduation and attrition rates, match data, resident case logs, and qualitative educational curriculum changes. RESULTS: Significant increases in residents' demographic data (p < 0.05) included the number of female residents (from 12.7% to 17.6%) and the absolute number of residents (from 1112 to 1462). Age (mean 28.8 years), ethnicity, and number of residents per program (mean 13 residents per program) were unchanged. There were 16 new ACGME NSR programs, with currently 115 programs nationwide. The number of applicants per year (324 applicants per year) and the matching rate (mean 64%) remained stable. The mean attrition rate of 2.6% (range 2%-4%) was higher than the mean 2.1% ACGME attrition rate, a rate that decreased from 3% in 2009 to 1.6% in 2019. Education curriculum changes aimed at the standardization of training across the US included residents' boot camp (2009), the Milestones project (2012), and mandatory 7-year training initiated in 2013. An increase in endovascular, functional, trauma, and spine resident caseload was noted. The number of yearly publications about US NSR education has significantly increased (p < 0.05). CONCLUSIONS: NSR education has received greater attention over the last decade in the US. Standardization of training has been implemented. A steady number of students remain interested in neurosurgery, with an increased number of women entering the field. Attention to wellness, in addition to high-quality education, should be further assessed as a factor to improve the overall NSR training and retention rate.

Advice on How to Choose a Geriatric Psychiatry Fellowship.

The population of older adults with mental health and substance use disorders in the United States is increasing at a significant rate. This growth creates a critical need for trained geriatric psychiatrists. Unfortunately, the number of psychiatrists choosing to receive subspecialty training in geriatric psychiatry has not kept pace with the growing needs of society. Many different methods for enhancing the recruitment of physicians interested in subspecialty training are being discussed nationally. One way to improve recruitment is to provide prospective residents a clear understanding of the process by which one may apply to and select a fellowship program. In this article, we discuss the process by which physicians interested in pursuing fellowship training in geriatric psychiatry can make an informed decision to apply to and choose programs that best fit their needs.

The Clinical Competency Committee in Adult Cardiothoracic Anesthesiology-Perspectives From Program Directors Around the United States.

The clinical competency committee offers a fellowship program a structured approach to assess the clinical performance of each trainee in a comprehensive fashion This special article examines the structure and function of this important committee in detail. Furthermore, the strategies for the optimal functioning of this committee are also discussed as a way to enhance the overall quality of the fellowship program.

Preparing for a Fellowship in Adult Cardiothoracic Anesthesiology: Resources and Approaches for the Anesthesiology Trainee.

Adult cardiothoracic anesthesiology (ACTA) is a competitive fellowship. Despite increases in both the number of programs offering cardiothoracic fellowships and the number of residents applying each year, there is little direction or advice for prospective candidates. This review aims to educate anesthesiology residents who are hoping to pursue cardiothoracic anesthesiology, by examining a brief history of the advanced perioperative echocardiography qualification, the credentialing goals of ACTA fellowships, and the current status of ACTA fellowships. The second part of the review covers the ACTA fellowship application and aims to assist the candidate in navigating this process. The review examines the qualifications that fellowship programs look for in a candidate, including a discussion on professional behavior, and what an applicant can look for in a program. Finally, there is a brief discussion on post-match preparation.

Direct enhancement of readiness for wartime critical specialties by civilian-military partnerships for neurosurgical care: residency training and beyond.

Military neurosurgery has played an integral role in the development and innovation of neurosurgery and neurocritical care in treating battlefield injuries. It is of paramount importance to continue to train and prepare the next generation of military neurosurgeons. For the Army, this is currently primarily achieved through the military neurosurgery residency at the National Capital Consortium and through full-time out-service positions at the Veterans Affairs-Department of Defense partnerships with the University of Florida, the University of Texas-San Antonio, and Baylor University. The authors describe the application process for military neurosurgery residency and highlight the training imparted to residents in a busy academic and level I trauma center at the University of Florida, with a focus on how case variety and volume at this particular civilian-partnered institution produces neurosurgeons who are prepared for the complexities of the battlefield. Further emphasis is also placed on collaboration for research as well as continuing education to maintain the skills of nondeployed neurosurgeons. With ongoing uncertainty regarding future conflict, it is critical to preserve and expand these civilian-military partnerships to maintain a standard level of readiness in order to face the unknown with the confidence befitting a military neurosurgeon.

Burnout: Prevalence and Associated Factors Among Radiology Residents in New England With Comparison Against United States Resident Physicians in Other Specialties.

OBJECTIVE: The objective of our study was to establish burnout prevalence, associated demographic and program-related factors, and degree of burnout in New England radiology residents relative to residents in other specialties. MATERIALS AND METHODS: A 31-item survey, including nine demographic and program-related questions and the 22-item Maslach Burnout Inventory-Health Services Survey, was sent to all resident members of the New England Roentgen Ray Society (20 programs, 472 residents). Emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA) scores were calculated and stratified using published normative data. Multiple linear regression analysis was performed to identify burnout predictors. Chi-square testing with Bonferroni correction was performed to confirm predictors associated with high burnout. The EE, DP, and PA scores were compared with the results of residents from other specialties. RESULTS: There were 94 responses. High EE, high DP, and low PA scores were reported by 37%, 48%, and 50% of respondents, respectively. EE, DP, and PA scores and rates were low relative to those reported across specialties. Increasing residency year correlated with high EE (p = 0.002) and high DP (p < 0.001). No other factor significantly correlated with burnout. CONCLUSION: A high degree of burnout, increasing over the postgraduate years, was present in more than one-third of responding radiology residents but was present in a smaller percentage relative to residents across other specialties. Radiology residents score relatively poorly in PA and therefore addressing PA may be central to improving burnout symptoms overall.

Number of Weeks Rotating in the Emergency Department Has a Greater Effect on Ultrasound Milestone Competency Than a Dedicated Ultrasound Rotation.

OBJECTIVES: Ultrasound (US) is vital to modern emergency medicine (EM). Across residencies, there is marked variability in US training. The "goal-directed focused US" part of the Milestones Project states that trainees must correctly acquire and interpret images to achieve a level 3 milestone. Standardized methods by which programs teach these skills have not been established. Our goal was to determine whether residents could achieve level 3 with or without a dedicated US rotation. METHODS: Thirty-three first- and second-year residents were assigned to control (no rotation) and intervention (US rotation) groups. The intervention group underwent a 2-week curriculum in vascular access, the aorta, echocardiography, focused assessment with sonography for trauma, and pregnancy. To test acquisition, US-trained emergency medicine physicians administered an objective structured clinical examination. To test interpretation, residents had to identify normal versus abnormal findings. Mixed-model logistic regression tested the association of a US rotation while controlling for confounders: weeks in the emergency department (ED) as a resident, medical school US rotation, and postgraduate years. RESULTS: For image acquisition, medical school US rotation and weeks in the ED as a resident were significant (P = .03; P = .04) whereas completion of a US rotation and postgraduate years were not significant. For image interpretation, weeks in the ED as a resident was the only significant predictor of performance (P = .002) whereas completion of a US rotation and medical school US rotation were not significant. CONCLUSIONS: To achieve a level 3 milestone, weeks in the ED as a resident were significant for mastering image acquisition and interpretation. A dedicated US rotation did not have a significant effect. A medical school US rotation had a significant effect on image acquisition but not interpretation. Further studies are needed to best assess methods to meet US milestones.

Applied clinical anatomy: the successful integration of anatomy into specialty-specific senior electives.

PURPOSE: A strong foundation in anatomical knowledge is essential for physicians in all fields. Despite this established importance, anatomy continues to be primarily taught only during the pre-clinical years of medical school. Senior medical students have more mature clinical reasoning and analytical skills; therefore, advanced anatomy courses have great potential to integrate basic and clinical sciences to better prepare senior medical students for residency. METHODS: At our institution, five electives have been implemented that integrate anatomical education in clinical contexts in the fields of emergency medicine, musculoskeletal medicine, radiology, surgery, and obstetrics and gynecology. These 4-week courses are all offered in the spring of the final year of medical school. The course curricula, content, and evaluation data are described for each of the courses. RESULTS: The five electives have been extremely popular at our institution, and all have been consistently filled each year by students entering diverse disciplines. Course evaluations have been positive and students specifically note how these courses allow them the opportunity to integrate basic anatomical knowledge into clinical contexts. Students have marked improvement in anatomical knowledge after completion of these electives. CONCLUSIONS: Advanced anatomy courses that integrate anatomical education with clinical reasoning are important curricular innovations that are popular with students and lead to important improvements in anatomical knowledge. Anatomists can lead the charge for better integration of basic sciences into senior medical school curricula.

Training Residents in the Use of Telepsychiatry: Review of the Literature and a Proposed Elective.

Many regions in the United States are deficient in mental health services, especially those in rural areas. As a result of these deficiencies, many patients in need of psychiatric services are often left untreated. Although it is clear that telepsychiatry has great potential in improving patient access to mental health care in areas where psychiatric services are deficient, the lack of familiarity with the technology and inadequate training are current barriers to expanding the use of telepsychiatry. A review of telepsychiatry, its clinical applications, and evidence-based literature regarding competencies in graduate medical education related to telepsychiatry are provided. An approach to implementing telepsychiatry into a curriculum is suggested. We also propose an elective clinical experience with resources for didactics or independent study that will enable residents to develop a knowledge base and competence in the practice of telepsychiatry.

Guided outcomes in learned efficiency model in clinical medical education: a randomized controlled trial of self-regulated learning.

OBJECTIVE: The guided outcomes in learned efficiency (GOLE) model emphasizes the use of evidence-based resources to understand the diagnosis, treatment, follow-up, and prevention of disease. We seek to determine whether presentations created using the GOLE model are superior to an unstructured approach in achieving Accreditation Council for Graduate Medical Education (ACGME) Core Competencies. STUDY DESIGN: Consenting medical students were randomized to GOLE or control groups to individually research a self-selected clinical topic. A validated survey instrument was used prepresentation and postpresentation to assess perceived improvement in knowledge. Subjects completed self-evaluations at enrollment and after presentation of their chosen clinical topic. Other students, residents, and a faculty member also completed evaluations after each student presentation. Standard statistical methods (analysis of variance, 2-tailed t test) were used to determine if a statistically significant difference existed between intervention and control groups. RESULTS: Self-assessments were similar in the GOLE and control groups. Externally perceived presentation scores were greater in the GOLE group (ACGME global P < .0001, presentation global P = .07), which demonstrated a significant improvement in 5 core competencies. Time spent preparing the presentation and resources utilized did not differ between groups. CONCLUSION: The presentations prepared using the GOLE model were rated higher by observers than those prepared using traditional techniques.

Practice Readiness? Trends in Chief Resident Year Training Experience Across 13 Residency Programs.

INTRODUCTION: Urology residency prepares trainees for independent practice. The optimal operative chief resident year experience to prepare for practice is undefined. We analyzed the temporal arc of cases residents complete during their residency compared to their chief year in a multi-institutional cohort. METHODS: Accreditation Council for Graduate Medical Education case logs of graduating residents from 2010 to 2022 from participating urology residency programs were aggregated. Resident data for 5 categorized index procedures were recorded: (1) general urology, (2) endourology, (3) reconstructive urology, (4) urologic oncology, and (5) pediatric urology. Interactions were tested between the trends for total case exposure in residency training relative to the chief resident year. RESULTS: From a sample of 479 resident graduates, a total of 1,287,433 total cases were logged, including 375,703 during the chief year (29%). Urologic oncology cases had the highest median percentage completed during chief year (56%) followed by reconstructive urology (27%), general urology (24%), endourology (17%), and pediatric urology (2%). Across the study period, all categories of cases had a downward trend in median percentage completed during chief year except for urologic oncology. However, only trends in general urology (slope of -0.68, P = .013) and endourology (slope of -1.71, P ≤ .001) were significant. CONCLUSIONS: Over 50% of cases completed by chief residents are urologic oncology procedures. Current declining trends indicate that residents are being exposed to proportionally fewer general urology and endourology cases during their chief year prior to entering independent practice.

Navigating the challenges of establishing a new residency program in anatomic pathology based on the Accreditation Council for Graduate Medical Education International standards in the post-Soviet era Kazakhstan: strategies and successes.

In 1991, after the dissolution of the Soviet Union, newly independent Kazakhstan faced challenges of a healthcare system in transition. Anatomic pathology practice remains one of the least developed medical specialties in Kazakhstan. Acute shortage of pathologists is a universal phenomenon. There is no subspecialty pathology practice as yet. Residency programs in anatomic pathology are found only in a few tertiary health institutions in the big cities. Nazarbayev University School of Medicine was established in 2015 to reform medical education in Kazakhstan. Prior to this time, in 2010, Nazarbayev University was established to lead higher education reforms in the country. Each school in Nazarbayev University was paired with an international partner to jump-start its trajectory to excellence. Establishing a new residency program in anatomic pathology based on a western pedagogy was a new innovation that needed multi-level stakeholder consultation and support. In partnership with the University of Pittsburgh School of Medicine and its hospital system, the University of Pittsburgh Medical Center, we established the first residency program in anatomic pathology based on the Accreditation Council for Graduate Medical Education International standards in Central Asia. We have identified 5 strategic approaches that led to our rapid success, including targeted strategic partnership; robust engagement with the local stakeholders; adoption and contextualizing of an existing pedagogy; ensuring adequate and fit-for-purpose infrastructure; and organizational restructuring and optimization. We hope that these suggestions will be translatable to help those facing the arduous but exciting task of establishing a new residency program from scratch.