Comparing Faculty and Trainee Evaluators of First-Year Resident Skills.

OBJECTIVE: To determine if senior residents are comparable to faculty in assessing first-year resident skills on their overall assessment. BACKGROUND: As resident training moves towards a competency-based model, innovative approaches to evaluation and feedback through simulation need to be developed for both procedural as well as interpersonal and communication skills. In most areas of simulation, the faculty assess resident performance however; in clinical practice, first-year residents are often overseen and taught by senior residents. We aim to explore the agreement between faculty and senior resident assessors to determine if senior residents can be incorporated into a competency-based curriculum as appropriate evaluators of first-year resident skills. DESIGN: Annual surgical first year resident training for central line placement, obtaining informed consent and breaking bad news at a single institution is assessed through an overall assessment (OA). In previous years, only faculty have been the evaluators for the OA. In this study, select senior residents were asked to participate as evaluators and agreement between groups of evaluators was assessed across the 3 tasks taught during surgical first-year resident training. SETTING: Vanderbilt University Medical Center, tertiary hospital, Simulation Center. PARTICIPANTS: Anesthesia and surgery interns, chief residents, anesthesia and surgical faculty. RESULTS: Agreement between faculty and senior resident assessors was strongest for the central line placement simulation with a faculty average competency score of 10.71 and 9.59 from senior residents (κ = 0.43; 95% CI: -0.2, 0.34). Agreement was less substantial for simulated informed consent (κ = 0.08; 95% CI: -0.19, 0.36) and the breaking bad news simulation (κ = 0.07; 95% CI: -0.2, 0.34). CONCLUSION: Select senior residents are comparable to faculty evaluators for procedural competency; however, there was less agreement between evaluator groups for interpersonal and communication-based competencies.

The Kidney Transplant: Maintaining Excellent Outcomes While Increasing Skills Acquisition.

OBJECTIVE/BACKGROUND: Kidney transplantation is a complex operation that incorporates multiple fundamental surgical techniques and is an excellent opportunity for surgical skill development during residency training. We hypothesized that increasing resident competency, measured as anastomosis time, could be demonstrated while maintaining high-quality surgical outcomes during the learning process. METHODS: We performed a retrospective cohort study of surgical resident involvement in kidney transplantation and recorded the anastomosis time. The study population comprised adult, single organ kidney transplants (n = 2052) at a large academic transplant center between 2006 and 2019. Descriptive statistics included frequencies, medians, and means. A mixed model of anastomosis time on number of procedures was fitted. Poisson models were fitted with outcomes of the number of patients with delayed graft function and number of patients that underwent reoperation postoperatively, with the exposure being number of kidney transplants performed by resident. RESULTS: Results from the mixed model suggest that as the number of times a resident performs the surgery increases, the time to conduct the operation decreases with statistical significance. The Poisson regression demonstrated no significant relationship between the operative volume of a resident and postoperative complications. CONCLUSION: This study demonstrated statistical evidence that with an increase in the number of renal transplantations performed by a surgical resident, anastomosis time decreased. It also demonstrated no significant relationship between number of kidney transplants performed by a resident and postoperative complications, suggesting that patient outcomes for this operation are not adversely affected by resident involvement.

Forming the Hematology-Oncology Collaborative Videoconferencing (CO-VID) Learning Initiative: Experiential Lessons Learned From a Novel Trainee-Led Multidisciplinary Virtual Learning Platform.

PURPOSE: COVID-19 challenged medical practice and graduate medical education. Building on previous initiatives, we describe and reflect on the formative process and goals of the Hematology-Oncology Collaborative Videoconferencing Learning Initiative, a trainee-led multi-institutional virtual COVID-19 learning model. METHODS: Clinical fellows and faculty from 13 US training institutions developed consensus needs, goals, and objectives, recruited presenters, and generated a multidisciplinary COVID-19 curriculum. Weekly Zoom conferences consisted of two trainee-led instructional segments and a trainee-moderated faculty Q&A panel. Hematology-oncology training program faculty and trainees were the targeted audience. Leadership evaluations consisted of anonymized baseline and concluding mixed methods surveys. Presenter evaluations consisted of session debriefs and two structured focus groups. Conference evaluations consisted of attendance, demographics, and pre- or postmultiple-choice questions on topic learning objectives. RESULTS: In 6 weeks, the initiative produced five conferences: antivirals, anticoagulation, pulmonology, provider resilience, and resource scarcity ethics. The average attendance was 100 (range 57-185). Among attendees providing both pre- and postconference data, group-level knowledge appeared to increase: antiviral (n = 46) pre-/postcorrect 82.6%/97.8% and incorrect 10.9%/2.2%, anticoagulation (n = 60) pre-/postcorrect 75%/93.3% and incorrect 15%/6.7%, and pulmonary (n = 21) pre-/postcorrect 66.7%/95.2% and incorrect 33.3%/4.8%. Although pulmonary management comfort appeared to increase, comfort managing of antivirals and anticoagulation was unchanged. At the conclusion of the pilot, leadership trainees reported improved self-confidence organizing multi-institutional collaborations, median (interquartile range) 58.5 (50-64) compared with baseline 34 (26-39), but did not report improved confidence in other educational or leadership skills. CONCLUSION: During crisis, trainees built a multi-institutional virtual education platform for the purposes of sharing pandemic experiences and knowledge. Accomplishment of initiative goals was mixed. Lessons learned from the process and goals may improve future disaster educational initiatives.

Long-term mortality associated with acute kidney injury in children following congenital cardiac surgery.

OBJECTIVE: Children undergoing congenital cardiac surgery (CCS) are at increased risk for acute kidney injury (AKI) due to a number of factors. Recent evidence suggests AKI may influence mortality beyond the immediate postoperative period and hospitalization. We sought to determine the association between renal failure and longer-term mortality in children following CCS. METHODS: Our Study population included all patients that underwent cardiac surgery at our institution during a period of 3 years from 2004 through 2006. The primary definition of acute renal injury was based on pRIFLE using estimated creatinine clearance (pRIFLE eCCL). RESULTS: Predictors of mortality. Age, single ventricle status, and renal failure as defined by pRIFLE stage F were associated with mortality. The hazard ratio for a patient with renal failure as defined by pRIFLE stage F was 3.82 (CI 1.89-7.75). Predictors of AKI as defined by pRIFLE. Duration of cardiopulmonary bypass (CPB) and age were the only variables associated with pRIFLE by univariate analysis. However, in the ordinal or survival model, age was the only variable associated with renal failure as defined by pRIFLE. As patient age increases from 0.30 to 3.5 years, the risks of having renal injury (pRIFLE stage I) or failure (pRIFLE stage F) decreases (OR 0.44, CI 0.21-0.94). CONCLUSION: Mortality risk following CCS is increased in younger patients and those experiencing postoperative renal failure as defined by pRIFLE for a period of time that extends well beyond the immediate postoperative period and the time of hospitalization.

Achievement in surgical residency: are objective measures of performance associated with awards received in final years of training?

OBJECTIVE: For the past 15 years at our institution's general surgery residency program, 3 of the senior residents have been chosen to be awarded either (1) Best Resident in Research, (2) Best Resident in Teaching, or (3) Best Resident Overall. Considering that these awards serve as data representing outstanding performance as surgical residents, the objective of this study was to determine the association between receiving one of these awards and objective measures of performance. METHODS: Individual files were reviewed for the 103 residents who graduated from our institution's general surgery program from 1994 to 2010. These data were studied as a whole, and then divided into an award-winning group and a non-award winning group and subsequently compared across several objective parameters, including The United States Medical Licensing Examination (USMLE) scores, American Board of Surgery In-Training Examination (ABSITE) scores, first-time American Board of Surgery Certifying and Qualifying Examination pass rates, Alpha Omega Alpha membership status, and number of research years, using a logistic regression model. RESULTS: Overall, 103 residents completed their general surgery residency training at our institution from 1994 to 2010, and of these residents, 16 (16%) received the Best Resident in Research award, 15 (16%) received the Best Resident in Teaching award, and 17 (17%) received the Best Resident Overall award in their final years of training. Compared with those who did not receive an award, a hypothesis-based one-tailed test revealed that award winners had a significantly lower median USMLE Step 1 scores (p = 0.04) and marginally lower median USMLE Step 2 scores (p = 0.05). Alpha Omega Alpha membership status, median ABSITE percent correct overall, first-time American Board of Surgery examination pass rates, and number of research years during residency were not significantly different between the 2 groups. CONCLUSION: Many factors contribute to success during general surgery residency. Our study showed that higher USMLE and ABSITE scores were not associated with receiving top awards in final years of training at one institution over 15 years.

The role of the nonphysician educator in general surgery residency training: from outcome project and duty-hours restrictions to the next accreditation system and milestones.

OBJECTIVE: In 2002 and 2003 the ACGME Outcome Project (assessing residents based on competencies) and duty-hours restrictions were implemented. One strategy for assisting PDs in the increased workload was to hire nonphysician educators with training and experience in curriculum design, teaching techniques, adult learning theories, and research methods. This study sought to document prevalence and responsibilities of nonphysician educators. METHODS: IRB approval was received for a two-part study. All 247 general surgery PDs were e-mailed the question, "Do you have a nonphysician educator as a member of your surgery education office?" Those who replied "yes" or volunteered "not currently but in the past" were e-mailed a link to an electronic survey concerning the role of the nonphysician educator. SETTING: Residency training programs in general surgery. PARTICIPANTS: General surgery program directors. RESULTS: Of the 126 PDs who responded to the initial query, 37 said "yes" and 4 replied "not currently but in the past". Thirty-two PDs of the initial 41 respondents completed the survey. Significant findings included: 65% were hired in the last 6 years; faculty rank is held by 69%; and curriculum development was the most common responsibility but teaching, research, and administrative duties were often listed. PDs perceived that faculty, residents, and medical students had mostly positive attitudes towards nonphysician educators. CONCLUSIONS: The overall results seem to support the notion that nonphysician educators serve as vital members of the team.

Patient enrollment onto clinical trials: the role of physician knowledge.

Sixty-six attending physicians at academic medical centers completed a 43-question self-assessment evaluating communication skills, comfort with clinical trial enrollment, and knowledge of patient-related barriers to enrollment on clinical trials. Responses and demographic information were analyzed for trends and for association with estimated trial enrollment. Physician-described enrollment of patients onto trials varied widely, with estimated enrollment varying from less than 5 patients to well over 125 enrolled during the previous year. Participants perceived themselves to have excellent communication skills and were comfortable with the trial enrollment process, though did not consistently identify patient-related barriers to enrollment. Physician knowledge of clinical trials currently enrolling within their field was associated with increased patient enrollment on study (p = 0.03). Academic physicians expressed confidence in their skills related to clinical trial enrollment despite less than ideal reported enrollment. Knowledge of clinical trials currently enrolling within a physician's specialty was associated with estimated patient enrollment, and may represent a correctable barrier to trial enrollment.

Resultados perinatales en recién nacidos de madres adolescentes atendidos en el Hospital Nacional Dos de Mayo, julio 2013 - junio 2014 / Perinatal outcomes in newborn infants of adolescent mothers attended at the National Hospital Dos de Mayo, July 2013 - June 2014

Contribuir al conocimiento de las características perinatales de los recién nacidos de madres adolescentes en el Hospital Nacional Dos de Mayo. Metodología: El presente trabajo es un estudio observacional, transversal, retrospectivo y descriptivo. La muestra está constituida por el total de recién nacidos de madres adolescentes atendidos en el HNDM durante el periodo julio 2013 a junio 2014, que consta de 480 neonatos que cumplen con los criterios de inclusión y exclusión del estudio, para lo cual se revisaron todas las historias clínicas de los recién nacidos. Los datos obtenidos han sido revisados exhaustivamente con asesoría del tutor, información que fue vaciada en una ficha de recolección de datos elaborada para este fin. Análisis estadístico: Se creó una base datos en Microsoft Office Excel XP. Para la estadística descriptiva se empleó el programa estadístico SPSS versión actualizada. Las variables, determinación de proporciones y frecuencias, además tablas y gráficos de contingencia 2x2. Resultados: La frecuencia de presentación de recién nacidos de madres adolescentes fue de 16.43 por ciento que corresponden a 480 nacimientos de un total de 2921, de las cuales 394 (82.08 por ciento) corresponden a adolescentes de 17 a 19 años, 85 (17.71 por ciento) de 14 a 16 años y un recién nacido (0.21 por ciento) de 10 a 13 años a edad, además de ello 256 neonatos (53.33 por ciento) son de sexo masculino y 224 de sexo femenino (42.67 por ciento), los nacidos por cesárea fueron 267 nacimientos (55.63 por ciento) y 213 (44.38 por ciento) son de parto vaginal, en relación al puntaje APGAR al minuto, 454 recién nacidos (94.58 por ciento) presentaron un puntaje de 7 a 10, seguido de 18 neonatos (3.75 por ciento) con puntaje de 4 a 6, y 8 (1.67 por ciento) con puntaje menos o igual a 3, a los cinco minutos el APGAR, fue de 474 (98.75 por ciento) para recién nacidos fueron vigorosos, 4 (0.83 por ciento) con depresión moderada con puntaje de 4 a 6, y 2...

Effectiveness of a clinical intervention for MD/PhD students re-entering medical school.

BACKGROUND AND PURPOSE: For MD/PhD students, the transition to medical school following graduate research can be difficult. We developed a clinical intervention, the Clinical Preceptorship Program (CPP), for MD/PhD students at Vanderbilt to ease the transition to the core clinical clerkship year (the 3rd medical year) following graduate training. In this study, we determined whether the CPP prepared MD/PhD students adequately for medical school reentry. METHODS: Clerkship grades were obtained for 680 medical students and 50 MD/PhD students for academic years 2004-2010. A student's unpaired t test was used to analyze differences between group grades. RESULTS: We did not detect significant differences in the grades of the MD versus MD/PhD students. No differences in individual clerkships were detected with the exception of the Surgery clerkship. CONCLUSIONS: These data suggest that the CPP intervention was successful in preparing MD/PhD students for the core clerkship year. Such a clinical intervention can be an effective preparation for MD/PhD students returning to medical school.

Teaching in the operating room: results of a national survey.

BACKGROUND: With the institution of the work-hour restrictions in 2003, less time may be available for surgical residents to learn operative technique and judgment. While numerous studies have evaluated the use of surgical simulation training to enhance operative skills, little is known about the quality of teaching that takes place in the operating room (OR). The purpose of this study was to assess residents' perception of faculty teaching in the OR in order to target ways to improve operative education. METHODS: A request for resident participation in an online survey was sent to the Program Coordinator at all 255 ACGME-accredited general surgery residency programs. RESULTS: A total of 148 programs (59%) participated in the survey, and anonymous responses were submitted by 998 of 4926 residents (20%). Most residents reported that attending surgeons verbalize their operative approach (55%), include residents in intraoperative decisions (61%), and offer technical advice (84%). However, few residents reported that faculty help to identify the resident's personal educational operative goals preoperatively (18%) or discuss areas of improvement with residents (37%). Of all cases scrubbed in the past year, most residents feel as though they only actually performed the procedure between 26% and 50% (29%) or between 51% and 75% (32%) of the time. However, more than half of all residents (51%) log these procedures for ACGME as primary surgeon 76%-100% of the time. CONCLUSIONS: This study demonstrates that from the residents' perspective, a number of opportunities exist to improve teaching in the OR, such as guiding residents with preoperative preparation and providing them with constructive feedback. These findings also suggest that residents may be logging cases without feeling as though they actually perform the operations.

Intraoperative blood loss predicts hemorrhage-related reoperation after orthotopic liver transplantation.

Postoperative hemorrhage after orthotopic liver transplantation (OLT) may require early reoperative intervention. Previous studies have shown intraoperative transfusion requirement as a main determinant of reoperative intervention after OLT. The goal of this study was to develop an intraoperative hemorrhage model predicting need for reoperation after OLT. A single institution, retrospective review of adult primary OLT patients from January 2002 to 2008 was conducted. Multivariate logistical regression analysis was performed to identify predictors of reoperation due to postoperative hemorrhage. Secondary analysis was conducted on patients in the reoperation group managed with temporary open abdomen techniques. Four hundred and ten primary transplantations were performed with 59 patients (14.4%) requiring reoperation. The adjusted odds of reoperation when intraoperative blood loss (IBL) increases from 1.5 L to 10.0 L is 2.48 [95% confidence interval: (1.18, 5.31)]. IBL of 10.0 L predicts a 19.4 per cent probability of reoperation. Patients managed with open abdomen (n = 8) exhibited a significant IBL difference (16.0 L vs. 6.0 L, P < 0.001) when compared with the closed abdomen cohort. Our results indicate that intraoperative blood loss is the primary predictor of reoperation after OLT and provide a hemorrhage threshold to guide postoperative management of complicated OLT patients.

Exostoses of the external auditory canal in white-water kayakers.

OBJECTIVES/HYPOTHESIS: Exostoses of the external auditory canal are benign bony tumors associated with frequent cold-water exposure. Obstruction may lead to conductive hearing loss and recurrent otitis externa, requiring surgical correction when symptoms become intolerable. This study aimed to characterize the prevalence of exostoses in white-water kayakers and identify associated risk factors and protective measures. STUDY DESIGN: Cross-sectional. METHODS: Six hundred eleven white-water kayakers from across the United States were included in the study. Percent occlusion was graded as minimal (<25%), moderate (25%-75%) or severe (>75%). Subjects completed a survey of risk factors and protective measures. Kruskal-Wallis and chi(2) tests were performed to determine significant associations with percent occlusion. A multivariate proportional odds regression model was fit to adjust for confounding between the variables. RESULTS: The prevalence of exostoses in kayakers was 79% (482/611); 13% (78/611) had >or=75% occlusion. Percent occlusion was associated with total years kayaked (P < .001), frequency >or=1 day/week (P < .001), male gender (P < .001), and increasing age (P = .005), although frequency, gender, and age were confounded by total years. Styles that involve repeated submersion were also associated with greater occlusion (freestyle, P = .036; squirt, P = .016). Subjects who used earplugs for a greater proportion of their kayaking career were less likely to have exostoses (P < .001). When adjusted for confounding, only total years (P = .0003) and age (P = .0027) remained significant. CONCLUSIONS: Kayakers are the first inland population to experience exostoses at the rates seen in coastal populations (e.g., surfers). When used long-term, earplugs may be protective.

Breast cancer survivors' health-related quality of life : racial differences and comparisons with noncancer controls.

BACKGROUND: Small samples with few minority women and/or the absence of comparisons to peers without cancer histories have limited previous research suggesting racial differences in breast cancer survivors' health-related quality of life (HRQoL). This study not only compared HRQoL of African American and white breast cancer survivors, but also compared the HRQoL of these women to that of same-race women with no cancer history. METHODS: Data from the Women's Health Initiative-Observational Study were used, including 5021 cancer survivors and 88,532 women without a history of cancer. Multivariate regression analyses estimated differences in breast cancer survivors' baseline HRQoL (RAND36), depressive symptoms (CES-D short-form), and sleep quality (WHIIRS). RESULTS: African American breast cancer survivors reported worse physical functioning and general health compared with white survivors. Among African Americans, survivors reported worse role limitations due to physical health, pain, general health, and vitality than women without a history of cancer. This was most evident in those with more recent diagnoses. Most significant differences between groups were small in magnitude (Cohen d = .21-.36). CONCLUSIONS: These results add to the increasing knowledge of cancer disparities by showing that African American women have small, but clinically meaningful, decrements in physical HRQoL compared with white survivors and with African American women without cancer. Because African American women also face diagnosis with higher grade tumors and higher breast cancer mortality, more research is needed to examine the physical and psychosocial experiences of African American breast cancer survivors to elucidate the mechanisms leading to poorer outcomes.