Improved Confidence and Clinical Application: The Effects of a Longitudinal Suture Curriculum for Medical Students.

OBJECTIVE: The ability to competently suture is an expected skill for graduating medical students, but many graduates report feeling unprepared to perform this skill. This study aimed to improve student confidence and clinical readiness for third-year clerkships by implementing a novel, mandatory 7.5-hour longitudinal suturing skills curriculum across the first 3 years of medical school. METHODS: The required suturing skills curriculum was implemented for all medical students throughout the first 3 years of medical school at a large academic health center in the mid-South United States. Precurriculum (n = 167) and postcourse (n = 148) surveys were administered to first-year students in the first year of the curriculum (2017-2018), and a parallel follow-up survey was administered to this cohort in 2020 after students completed their clinical clerkship year (n = 82). Aggregate changes in students' survey responses were analyzed for proper instrument position, simple interrupted sutures, and instrument ties using independent groups Mann-Whitney U tests and Rosenthal correlation coefficients for effect sizes. RESULTS: Statistically significant improvement from pre to post was observed in student comfort in performing three basic skills: proper instrument position (P < 0.001), simple interrupted suture (P < 0.001), and instrument ties (P < 0.001). These pre-post gains were sustained at 2-year follow-up (P < 0.001). Also, the majority of students (66%) reported they were very or completely prepared to suture wounds during their clerkships. Most (83%) also reported they had successfully sutured patient wounds during third-year clerkships without needing significant direction or guidance. CONCLUSIONS: We found that a longitudinal suture curriculum with dedicated faculty involvement can improve student confidence in suturing and overall preparedness for third-year clerkships. Although the study is limited to ratings of student comfort and self-reported performance as well as some attrition of responses at postcourse survey and postclerkship survey, the findings highlight the importance of a focused curriculum dedicated to teaching basic suturing skills. Our findings also contribute to the limited body of work examining longitudinal surgical skills development for medical students.

Loss of Meaning at Work Associated with Burnout Risk in Academic Medicine.

OBJECTIVES: Meaning at work has been proposed as one of the key drivers of professional burnout in healthcare, but few studies have simultaneously measured this relation. METHODS: In this cross-sectional analysis of 1637 individuals at the University of Arkansas for Medical Sciences, burnout was measured using the Copenhagen Burnout Inventory work-related subscale. RESULTS: Meaningful work was measured using items adapted from the Work as Meaning Inventory. The prevalence of work-related burnout increased with each level of diminished meaning at work. From the highest ("always") to the lowest ("never") level of meaning at work, the prevalence of burnout was: 13, 26, 57, 84, and 94%, respectively. CONCLUSIONS: Work-related burnout was inversely proportional to reported meaning at work in an academic medical center.

A One-Year Institutional View of Resident Physician Burnout.

OBJECTIVES: This prospective study explores the prevalence, associated characteristics, and trajectory of burnout over one academic year in a multidisciplinary sample of resident physicians using a relatively new burnout survey instrument. METHODS: All residents from a U.S. academic health center (n = 633) were invited to complete the Copenhagen Burnout Inventory (CBI) three times, with 4-month time lags between invitations. A total of 281 (44%) provided complete CBI survey responses at least once, and 43 (7%) did at all three times. Descriptive statistics, cross-sectional analyses, correlations, and multivariable linear regression analyses were computed, as well as repeated measures ANOVAs and paired t tests, as appropriate, for each CBI domain (personal, work, patient-related burnout). RESULTS: About half had CBI scores indicating moderate-to-high levels of personal burnout (49-52%) and work-related burnout (45-49%), whereas patient-related burnout was less common (14-24%). However, patient-related burnout increased significantly from the beginning to the end of the year. Regression analyses indicated patient-related burnout was significantly higher for postgraduate year 1-2 residents compared to PGY 4+ residents, but was not significantly different by gender. Personal and work burnout scores were significantly higher for females. Persistently high burnout was observed in only 6% of respondents. CONCLUSIONS: In this study of resident physicians using the CBI, burnout was prevalent and higher levels of burnout were observed for females on the personal and work burnout domains, while junior residents had higher patient-related burnout. Persistently, high burnout was rare. The CBI demonstrated high reliability, was practical to administer, and produced similar results with existing burnout research.

Use of Mock Oral Examinations in Vascular Surgery Training Programs: A Nationwide Survey.

BACKGROUND: Mock oral examinations (MOEs) are valuable tools for knowledge assessment and preparation for the surgical certifying examinations. Use of MOE is not standardized. We sought to determine the current use in vascular residencies/fellowships. METHODS: Program directors (PD) of all U.S. vascular training programs were sent anonymous online surveys in July of 2015 evaluating importance of MOEs, current use, barriers to implementation, and preparedness of trainees to sit for the certifying board examination (CE). Comparisons were performed between programs that use MOEs and those that do not. RESULTS: Fifty-four percent (59/108) of program directors completed the survey. The majority believed MOEs are important for vascular residents and fellows (86% versus 81%); however, only 51% (30/59) use them. The most common reason for using MOE was to provide feedback about readiness for the CE (90%). Of programs not giving MOE, 69% expected their trainees to get oral examinations at national conferences. The most common barriers to implementation/continuation of MOEs were availability of faculty (48%) or time (31%). Irrespective of whether they used MOE or not, 29% believed vascular fellows were better prepared for the CE than vascular residents. CONCLUSIONS: MOEs are regarded as a valuable tool to prepare trainees for the CE. However, it is not a commonly adopted practice, due to variables such as institutional/faculty availability. A third of program directors believed that vascular fellows were more prepared to pass the CE than vascular residents which may warrant further investigation into how programs can more rigorously prepare vascular residents for the vascular CEs.

Integrating Collaborative Learning and Competition in a Hematology/Oncology Training Program.

New educational methods and structures to improve medical education are needed to face the challenge of an exponential increase and complexity of medical knowledge. Collaborative learning has been increasingly used in education, but its use in medical training programs is in its infancy, and its impact is still unknown; the role of competition in education is more controversial. We introduced these pedagogical methods to the hematology/oncology fellowship program at the University of Arkansas for Medical Sciences to improve attendance and performance at didactic activities and different educational outcomes. One year after the adoption of these methods, the fellowship program has reached many of the expected goals from this intervention without the negative consequences of competition observed in younger learners. The most important conclusion of this project is that collaboration and cross-generational team work provide a healthy and effective learning environment and competition may not add further benefit. Analysis, interpretation, and discussion of our experience are provided. This study was approved by the University of Arkansas for Medical Sciences IRB as a low risk educational intervention not requiring a consent form.

Relationships between study habits, burnout, and general surgery resident performance on the American Board of Surgery In-Training Examination.

BACKGROUND: The American Board of Surgery In-Training Examination (ABSITE) is used by programs to evaluate the knowledge and readiness of trainees to sit for the general surgery qualifying examination. It is often used as a tool for resident promotion and may be used by fellowship programs to evaluate candidates. Burnout has been associated with job performance and satisfaction; however, its presence and effects on surgical trainees' performance are not well studied. We sought to understand factors including burnout and study habits that may contribute to performance on the ABSITE examination. METHODS: Anonymous electronic surveys were distributed to all residents at 10 surgical residency programs (n = 326). Questions included demographics as well as study habits, career interests, residency characteristics, and burnout scores using the Oldenburg Burnout Inventory, which assesses burnout because of both exhaustion and disengagement. These surveys were then linked to the individual's 2016 ABSITE and United States Medical Licensing Examination (USMLE) step 1 and 2 scores provided by the programs to determine factors associated with successful ABSITE performance. RESULTS: In total, 48% (n = 157) of the residents completed the survey. Of those completing the survey, 48 (31%) scored in the highest ABSITE quartile (≥75th percentile) and 109 (69%) scored less than the 75th percentile. In univariate analyses, those in the highest ABSITE quartile had significantly higher USMLE step 1 and step 2 scores (P < 0.001), significantly lower burnout scores (disengagement, P < 0.01; exhaustion, P < 0.04), and held opinions that the ABSITE was important for improving their surgical knowledge (P < 0.01). They also read more frequently to prepare for the ABSITE (P < 0.001), had more disciplined study habits (P < 0.001), were more likely to study at the hospital or other public settings (e.g., library, coffee shop compared with at home; P < 0.04), and used active rather than passive study strategies (P < 0.04). Gender, marital status, having children, and debt burden had no correlation with examination success. Backward stepwise multiple regression analysis identified the following independent predictors of ABSITE scores: study location (P < 0.0001), frequency of reading (P = 0.0001), Oldenburg Burnout Inventory exhaustion (P = 0.02), and USMLE step 1 and 2 scores (P = 0.007 and 0.0001, respectively). CONCLUSIONS: Residents who perform higher on the ABSITE have a regular study schedule throughout the year, report less burnout because of exhaustion, study away from home, and have shown success in prior standardized tests. Further study is needed to determine the effects of burnout on clinical duties, career advancement, and satisfaction.

Effects of Mentorship on Graduating Vascular Surgery Trainees.

BACKGROUND: Mentorship within surgery, particularly vascular surgery, has not been extensively evaluated. This study sought to examine mentorship experiences in graduating vascular trainees (VTs). METHODS: An anonymous electronic survey examining current mentor relationships, ideal characteristics, academic productivity, and operative comfort level was emailed to all US graduating 2015 (n = 141) and 2016 (n = 144) VTs during their last year of training. A parallel survey was emailed to program/associate program directors (PDs) of all US vascular training programs (n = 169). RESULTS: Surveys were completed by 65 (38%) PDs and 62 (22%) VTs. Forty-three (69%) VTs identified a mentor with no difference in frequency of having a mentor noted among gender, type of training (fellowship/residency), or geographical region. The majority (41/43, 95%) recognized a vascular surgeon as their mentor; the mentor was assigned to 10 of 43 (23%) trainees and was their PD to 9 of 43 (21%). Ideal mentor characteristics, identified by VTs using 4-point Likert scales, were approachability, supportiveness, and accessibility (3.94, 3.76, and 3.74, respectively), while those of a good mentee were enthusiasm, ethical work, and commitment (3.79, 3.69, and 3.45, respectively). Trainees scored accessibility, approachability, compassion, and same gender significantly higher than PDs as characteristics of ideal mentors (P < 0.05). The majority of PDs thought mentorship increased access to research opportunities, professional networking, and job opportunities, but not operative skill (90%, 95%, 65%, and 18%, respectively). There was no difference between trainees with mentors and those without in terms of reported academic productivity or operative comfort level. Vascular fellows reported higher comfort than residents in open abdominal aortic aneurysm repair (3.32 vs. 2.73, P = 0.006), juxtarenal aneurysm repair (2.8 vs. 2.1, P = 0.02), and aorto-mesenteric bypass (2.57 vs. 1.93, P = 0.03), and neither group was comfortable performing carotid stenting or fenestrated endovascular aneurysm repairs. CONCLUSIONS: There is no difference in academic productivity or case comfort level between surgical trainees with mentors and those without. Possible benefits identified by PDs and trainees include professional networking and increased research and job opportunities. Mentors should be approachable, accessible, supportive, and ethical, while mentees should be enthusiastic, ethical, committed, and approachable. Vascular fellows feel more comfortable with open vascular operations than residents, and nether group feels comfortable with complex endovascular cases. More research is warranted.

Nicotine Dependence and Willingness to Quit Smoking in Vascular Surgery Patients.

BACKGROUND: Smoking rates have declined; however, it remains the primary modifiable risk factor for vascular disease. While vascular surgeons often advise patients to quit, few provide assistance. We sought to understand patients' interest in quitting and determine factors that influence this willingness to quit. METHODS: Anonymous surveys were given to vascular surgery clinic patients in a single institution over a 5-month period. Demographic information, smoking status, cessation attempts, and barriers to quitting were obtained. Nicotine dependence was determined using the Fagerstrom Test, and willingness to quit was assessed using a contemplation ladder. Patient's willingness to quit was evaluated in relation to symptomatic status, previous/planned operation, and nicotine dependence levels. RESULTS: A total of 490 patients (92%) completed the survey with 109 (22%) current smokers, 195 (40%) former smokers, and 186 (38%) never smokers. Never smokers were more likely to be female and employed while smokers were more likely to be disabled. Although 51% of smokers displayed moderate/high nicotine dependence, 54% demonstrated willingness to consider quitting within 6 months. The primary barrier to cessation identified was previous failed attempt(s) to quit in 44%. Most (90%) had previously attempted quitting, 63% attempted 3 or more times, and the most common technique used was "quitting cold turkey". Fifty-nine percent of patients reported physicians' had offered assistance in cessation, but only 2% had been in a cessation program. There was no correlation between willingness to consider quitting and symptomatic status, previous/planned operation, or nicotine dependence. Smokers of less than 10 cigarettes/day had a lower nicotine dependence level (P = 0.0001) and higher willingness to consider quitting (P = 0.0015), as did those who had fewer failed prior attempts to quit and who did not believe it was too late to quit. CONCLUSIONS: Most of our vascular patients self-report as nonsmokers. Over half of those who smoke demonstrate willingness to consider quitting within 6 months, which is not dependent on nicotine dependence, previous/planned operation, or symptomatic status. Those who smoke less than 10 cigarettes per day, have fewer past failed attempts to quit, and believe that it is not too late to quit are more likely to consider quitting. Vascular surgeons should be more aware of previous quit attempts and patterns of smoking and be proactive in assisting patients in cessation attempts.

Mobile spaced education for surgery rotation improves National Board of Medical Examiners scores.

BACKGROUND: Use of mobile devices for medical education is increasing. The aim of this study was to describe the implementation of a spaced education-based app study program in a third year medical school surgery rotation and examine its effects on National Board of Medical Examiners (NBME) examination performance. MATERIALS AND METHODS: Case-based questions were created and distributed to students on a voluntary basis via a mobile app. Questions were repeated in a spaced based manner until mastered. Students completed surveys regarding study habits and app use. NBME examination scores and prior academic measures were obtained. Users of the app were compared to non-users of the app and the previous years' class. RESULTS: One hundred fifty-two students were offered the app; 121 (80%) used it. App users had a final NBME score of 77.5% compared with 68.8% (P < 0.01) in non-users, although their prior academic achievement was better. Categorizing them by their academic achievement and intensity of app use demonstrated significantly higher scores in regular users of the app as compared with casual and non-users in mid (78 versus 75 versus 71.2%, P < 0.01) and low-achieving students (71.4 versus 70 versus 64.6, P < 0.01), but not high-achieving students (85.3 versus 81.1 versus 79.7, P = 0.09). Stepwise linear regression modeling revealed intensity of app use accounted for 6% of the variance in NBME scores. CONCLUSIONS: Use of the app-based program was an effective tool associated with higher scores on standardized tests in lower level achieving students.

What Do Medical Students Perceive as Meaningful in the Psychiatry Clerkship Learning Environment? A Content Analysis of Critical Incident Narratives.

OBJECTIVES: In order to better understand the professional development of medical students during their psychiatry clerkship, this study identifies common themes and characteristics of students' critical incident narratives which are designed to capture a recount of clerkship experiences they perceived as meaningful. METHODS: A total of 205 narratives submitted by psychiatry clerkship students in 2010-2011 were subjected to a thematic analysis using a methodological approach and adaptation of categories derived from prior similar research. Descriptive content analysis was also carried out to assess the valence of the narrative content, characters involved, and whether there was evidence that the experience changed students' perspectives in some way. RESULTS: Narratives contained a variety of positive (19%) and negative content (24%) and many contained a hybrid of both (57%). The most common theme (29%) concerned issues of respect and disrespect in patient, clinical, and coworker interactions. In general, the majority (68%) of students' meaningful experience narratives reflected a change in their perspective (e.g., I learned that...). Narratives containing positive and hybrid content were associated with a change in students' perspective (χ(2) = 10.61, df = 2, p < 0.005). CONCLUSIONS: Medical students are keenly aware of the learning environment. Positive and hybrid critical incident narratives were associated with a stated change in their beliefs, attitudes, or behaviors due to the experience. Understanding the events that are meaningful to students can also provide rich feedback to medical educators regarding the ways in which students perceive clinical learning environments and how to best foster their professional development.

Relationships between the Survey of Organizational Research Climate (SORC) and self-reported research practices.

The Survey of Organizational Research Climate (SORC) is a validated tool to facilitate promotion of research integrity and research best practices. This work uses the SORC to assess shared and individual perceptions of the research climate in universities and academic departments and relate these perceptions to desirable and undesirable research practices. An anonymous web- and mail-based survey was administered to randomly selected biomedical and social science faculty and postdoctoral fellows in the United States. Respondents reported their perceptions of the research climates at their universities and primary departments, and the frequency with which they engaged in desirable and undesirable research practices. More positive individual perceptions of the research climate in one's university or department were associated with higher likelihoods of desirable, and lower likelihoods of undesirable, research practices. Shared perceptions of the research climate tended to be similarly predictive of both desirable and undesirable research practices as individuals' deviations from these shared perceptions. Study results supported the central prediction that more positive SORC-measured perceptions of the research climate were associated with more positive reports of research practices. There were differences with respect to whether shared or individual climate perceptions were related to desirable or undesirable practices but the general pattern of results provide empirical evidence that the SORC is predictive of self-reported research behavior.

Development and validation of the Survey of Organizational Research Climate (SORC).

Development and targeting efforts by academic organizations to effectively promote research integrity can be enhanced if they are able to collect reliable data to benchmark baseline conditions, to assess areas needing improvement, and to subsequently assess the impact of specific initiatives. To date, no standardized and validated tool has existed to serve this need. A web- and mail-based survey was administered in the second half of 2009 to 2,837 randomly selected biomedical and social science faculty and postdoctoral fellows at 40 academic health centers in top-tier research universities in the United States. Measures included the Survey of Organizational Research Climate (SORC) as well as measures of perceptions of organizational justice. Exploratory and confirmatory factor analyses yielded seven subscales of organizational research climate, all of which demonstrated acceptable internal consistency (Cronbach's α ranging from 0.81 to 0.87) and adequate test-retest reliability (Pearson r ranging from 0.72 to 0.83). A broad range of correlations between the seven subscales and five measures of organizational justice (unadjusted regression coefficients ranging from 0.13 to 0.95) document both construct and discriminant validity of the instrument. The SORC demonstrates good internal (alpha) and external reliability (test-retest) as well as both construct and discriminant validity.

Do they stay or do they go? Residents who become faculty at their training institutions.

OBJECTIVE: Few data exist on the topic of internal hiring of trainees in academic medicine. This study examines nationally representative data to determine the frequency of faculty psychiatrists who are employed in the same department in which they completed their residency training. METHOD: Estimates of internal faculty hiring were obtained by reviewing a random sample of publically available psychiatry department websites in the United States. RESULTS: Among the 26 departments reviewed, there was wide variation in the rates of psychiatrists who received training in the same department in which they were currently employed as faculty members, with a median of 45.5%, ranging from 0% to 71%. CONCLUSION: Results suggest that departmental hiring of one's own graduates is common practice in academic psychiatry, and there is wide variation in this practice across psychiatry departments in the United States.

A multi-institutional study from the US ROPE Consortium examining factors associated with directly entering practice upon residency graduation.

BACKGROUND: There is concern regarding the competency of today's general surgery graduates as a large proportion defer independent practice in favor of additional fellowship training. Little is known about the graduates who directly enter general surgery practice and if their operative experiences during residency differ from graduates who pursue fellowship. METHODS: Nineteen Accreditation Council for Graduate Medical Education-accredited general surgery programs from the US Resident OPerative Experience Consortium were included. Demographics, career choice, and case logs from graduates between 2010 to 2020 were analyzed. RESULTS: There were 1,264 general surgery residents who graduated over the 11-year period. A total of 248 (19.6%) went directly into practice and 1,016 (80.4%) pursued fellowship. Graduates directly entering practice were more likely to be a high-volume resident (43.1% vs 30.5%, P < .01) and graduate from a high-volume program (49.2% vs 33.0%, P < .01). Direct-to-practice graduates performed 53 more cases compared with fellowship-bound graduates (1,203 vs 1,150, P < .01). On multivariable analysis, entering directly into practice was positively associated with total surgeon chief case volume (odds ratio = 1.47, 95% confidence interval 1.18-1.84, P < .01) and graduating from a US medical school (odds ratio = 2.54, 95% confidence interval 1.45-4.44, P < .01) while negatively associated with completing a dedicated research experience (odds ratio = 0.31, 95% confidence interval 0.22-0.45, P < .01). CONCLUSION: This is the first multi-institutional study exploring resident operative experience and career choice. These data suggest residents who desire immediate practice can tailor their experience with less research time and increased operative volume. These data may be helpful for programs when designing their experience for residents with different career goals.

Evidence for validity of a survey to measure the learning environment for professionalism.

BACKGROUND: With the emphasis on professionalism in academic health settings, including recently added accreditation requirements for US medical schools, there is a need for a valid and feasible method to assess the learning environment for professionalism. AIM: This article describes the development and investigation of the validity of a brief measure, the learning environment for professionalism (LEP) survey, designed to assess medical student perceptions of professionalism among residents and faculty during clinical rotations. METHOD: Two successive cohorts of third-year medical students completed the 22-item LEP survey at the conclusion of clerkship rotations, providing a total of 902 responses for scale reliability and principal components factor analysis, as well as assessment of changes in scores over time and correlations with a related clerkship evaluation item. RESULTS: The internal structure of the LEP survey was consistent with intended goals to assess both positive and negative professionalism behaviors. Acceptable internal consistency, sensitivity to change over time, and positive relationships between LEP scores and a concurrent measure of professionalism were observed. CONCLUSIONS: Use of the instrument could help identify clinical learning environments for professionalism that represent either best practices or areas in need of improvement, assess the impact of professionalism initiatives, and help satisfy accreditation requirements.

A Transitional Year Residency Program Provides Innovative Solutions for Unmatched Medical Students.

BACKGROUND: The transition to residency is competitive with more medical students applying for residency positions than slots available, and some will face challenges securing a position in their desired specialty. Our institution created a transitional year (TY) residency program in 2016 to help meet the needs of our medical students who did not initially secure a position in the main residency Match. OBJECTIVE: This report provides a brief overview of the TY program and analysis of the program's value from the inaugural 3 years (2017-2020). METHODS: The TY program is based at a midsized, urban, academic health center and features a tailorable curriculum emphasizing preparation for residents' specialty career plans. We used participatory action research and appreciative inquiry strategies as part of the annual program evaluation to examine TY residents' perceptions of the program's value. Stakeholder perceptions were also elicited from a purposive selection of 4 program directors and 2 key medical school education leaders. RESULTS: Internal evaluations revealed a high rate of resident satisfaction with the TY program and self-reported benefits such as increased confidence, clinical proficiency, and professional enculturation. Stakeholders valued the program as a potential pipeline for increasing physicians in the state and providing valuable direction to students' career trajectories. CONCLUSIONS: Creating a TY residency program to meet the needs of unmatched medical students was feasible to implement, acceptable to residents in meeting their academic and career needs, and provided a sustainable institutional solution with benefits to multiple stakeholders.

Psychometric Properties of the Copenhagen Burnout Inventory in an Academic Healthcare Institution Sample in the U.S.

The Copenhagen Burnout Inventory (CBI) has demonstrated good psychometric properties among respondents in many different countries, but minimal research exists using the CBI in a U.S.-based sample. The current study represents a secondary analysis of existing CBI data from 1,679 academic health center employees at one mid-size teaching hospital in the southeastern region of the U.S. Analyses assessed CBI scale reliability, confirmatory factorial validity, discriminant validity against a measure of meaningful work, and test invariance for professional role sub-groups (physicians, nurses/physician assistants, and other hospital staff), gender groups, and different age groups. Results provided evidence for good reliability and discriminant validity as well as construct validity supporting the CBI proposed three-factor structure. Configural and metric variance equivalence were demonstrated across the range of employee types, and across age and gender groups. Scalar invariance equivalence was not established, suggesting further research may be needed to support group mean comparisons using the CBI.

Anatomy Scholars Program for Medical Students Entering a Surgical Residency.

A near-peer teaching experience for upper-level medical students could help prepare them for surgical residency by providing specific education opportunities and exposure to the field of surgery. Five medical students were selected to be near-peer teachers (NPTs) in gross anatomy, and then they reflected on their experiences. The NPTs spent the majority of effort in a teaching role, and reported improved NTS, anatomy knowledge, and dissection skills. MS1s and faculty also reported on the value of the ASP. Further development and evaluation of the ASP may be an excellent opportunity for future surgeons.