Trainee advocacy for medical education on the care of people with intellectual and/or developmental disabilities: a sequential mixed methods analysis.

BACKGROUND: Medical trainees (medical students, residents, and fellows) are playing an active role in the development of new curricular initiatives; however, examinations of their advocacy efforts are rarely reported. The purpose of this study was to understand the experiences of trainees advocating for improved medical education on the care of people with intellectual and/or developmental disabilities. METHODS: In 2022-23, the authors conducted an explanatory, sequential, mixed methods study using a constructivist paradigm to analyze the experiences of trainee advocates. They used descriptive statistics to analyze quantitative data collected through surveys. Participant interviews then yielded qualitative data that they examined using team-based deductive and inductive thematic analysis. The authors applied Kern's six-step approach to curriculum development as a framework for analyzing and reporting results. RESULTS: A total of 24 participants completed the surveys, of whom 12 volunteered to be interviewed. Most survey participants were medical students who reported successful advocacy efforts despite administrative challenges. Several themes were identified that mapped to Steps 2, 4, and 5 of the Kern framework: "Utilizing Trainee Feedback" related to Needs Assessment of Targeted Learners (Kern Step 2); "Inclusion" related to Educational Strategies (Kern Step 4); and "Obstacles", "Catalysts", and "Sustainability" related to Curriculum Implementation (Kern Step 5). CONCLUSIONS: Trainee advocates are influencing the development and implementation of medical education related to the care of people with intellectual and/or developmental disabilities. Their successes are influenced by engaged mentors, patient partners, and receptive institutions and their experiences provide a novel insight into the process of trainee-driven curriculum advocacy.

Pulse oximeter provision and training of non-physician anesthetists in Zambia: a qualitative study exploring perioperative care after training.

BACKGROUND: Pulse oximetry monitoring is included in the WHO Safe Surgery Checklist and recognized as an essential perioperative safety monitoring device. However, many low resource countries do not have adequate numbers of pulse oximeters available or healthcare workers trained in their use. Lifebox, a nonprofit organization focused on improving anesthetic and surgical safety, has procured and distributed pulse oximeters and relevant educational training in over 100 countries. We aimed to understand qualitatively how pulse oximetry provision and training affected a group of Zambian non-physician anesthetists' perioperative care and what, if any, capacity gaps remain. METHODS: We identified and approached non-physician anesthetists (NPAPs) in Zambia who attended a 2019 Lifebox pulse oximetry training course to participate in a semi-structured interview. Interviews were audio recorded and transcribed. Codes were iteratively derived; the codebook was tested for inter-rater reliability (pooled kappa > 0.70). Team-based thematic analysis identified emergent themes on pulse oximetry training and perioperative patient care. RESULTS: Ten of the 35 attendees were interviewed. Two themes emerged concerning pulse oximetry provision and training in discussion with non-physician anesthetists about their experience after training: (1) Impact on Non-Physician Anesthetists and the Healthcare Team and (2) Impact on Perioperative Patient Monitoring. These broad themes were further explored through subthemes. Increased knowledge brought confidence in monitoring and facilitated quick interventions. NPAPs reported improved preoperative assessments and reaffirmed the necessity of having pulse oximetry intraoperatively. However, lack of device availability led to case delays or cancellations. A portable device travelling with the patient to the recovery ward was noted as a major improvement in postoperative care. Pulse oximeters also improved communication between nurses and NPAPs, giving NPAPs confidence in the recovery process. However, this was not always possible, as lack of pulse oximeters and ward staff unfamiliarity with oximetry was commonly reported. NPAPs expressed that wider pulse oximetry availability and training would be beneficial. CONCLUSION: Among a cohort of non-physician anesthetists in Zambia, the provision of pulse oximeters and training was perceived to improve patient care throughout the perioperative timeline. However, capacity and resource gaps remain in their practice settings, especially during transfers of care. NPAPs identified a number of areas where patient care and safety could be improved, including expanding access to pulse oximetry training and provision to ward and nursing staff to ensure the entire healthcare team is aware of the benefits and importance of its use.

Examination of an Intergenerational Summer Meal Program for Children and Older Adults.

Unreliable access to a sufficient quantity of affordable, nutritious food in the U.S. is a persistent public health threat significantly impacting households with children (15%) and older adults (20%). Well-established nutrition assistance programs serve children and seniors independently, yet few programs utilize an intergenerational meal program model. The aim of this mixed methods study is to examine the impact of an intergenerational meal program administered through a partnership between a local school district and a county Senior Nutrition Program. Participating older adults completed surveys to assess food security and program attendance, and examine their understanding and utilization of community-based food resources. Interviews with a subsample of participants explored perceptions of the intergenerational meal program and community-level food security. Older adults (n = 83) completed surveys in English (59%), Spanish (25%), and Mandarin (16%). They identified primarily as Asian (44%), Latinx (30%), White (21%), and multi-racial (5%). Forty-eight percent of participants indicated low or very low food security at some time in the last 12 months. The subsample of interview participants (n = 24; Spanish 46% and English 54%) revealed key insights: 1) perceived benefits of an intergenerational meal program; 2) community-level food insecurity and struggles of older adults to make ends meet; and 3) importance and challenge of obtaining nutritious foods for those with limited budgets and medical comorbidities. Implementation of this intergenerational meal program highlights the opportunity to support the nutritional needs of children and older adults while leveraging a new interdisciplinary partnership and existing organizational capacity.

Local and Visiting Physician Perspectives on Short Term Surgical Missions in Guatemala: A Qualitative Study.

OBJECTIVE: To explore the impact of short-term surgical missions (STMs) on medical practice in Guatemala as perceived by Guatemalan and foreign physicians. SUMMARY BACKGROUND DATA: STMs send physicians from high-income countries to low and middle-income countries to address unmet surgical needs. Although participation among foreign surgeons has grown, little is known of the impact on the practice of foreign or local physicians. METHODS: Using snowball sampling, we interviewed 22 local Guatemalan and 13 visiting foreign physicians regarding their perceptions of the impact of Guatemalan STMs. Interviews were transcribed verbatim, iteratively coded, and analyzed to identify emergent themes. Findings were validated through triangulation and searching for disconfirming evidence. RESULTS: We identified 2 overarching domains. First, the delivery of surgical care by both Guatemalan and foreign physicians was affected by practice in the STM setting. Differences from usual practice manifested as occasionally inappropriate utilization of skills, management of postoperative complications, the practice of perioperative care versus "pure surgery," and the effect on patient-physician communication and trust. Second, both groups noted professional and financial implications of participation in the STM. CONCLUSIONS: While Guatemalan physicians reported a net benefit of STMs on their careers, they perceived STMs as an imperfect solution to unmet surgical needs. They described missed opportunities for developing local capacity, for example through education and optimal resource planning. Foreign physicians described costs that were manageable and high personal satisfaction with STM work. STMs could enhance their impact by strengthening working relationships with local physicians and prioritizing sustainable educational efforts.

Feasibility and acceptability of virtually coaching residents on communication skills: a pilot study.

BACKGROUND: Developing communication skills is a key competency for residents. Coaching, broadly accepted as a training modality in medical education, has been proven a successful tool for teaching communication skills. Little research is available thus far to investigate virtual coaching on communication skills for telemedicine encounters. The purpose of the study was to test the hypothesis that virtually coaching residents on communication skills is feasible and acceptable. We surveyed 21 resident-faculty pairs participating in a "fully virtual" coaching session (patient, coach, and resident were virtual). METHODS: We asked 50 neurology resident-faculty coach pairs to complete one "fully virtual" coaching session between May 20 and August 31, 2020. After each session, the resident and coach completed a 15-item survey, including Likert-style scale and open-ended questions, assessing feasibility and acceptability. Descriptive statistics and qualitative content and thematic analyses were performed. RESULTS: Forty-two percent (21/50) of all eligible residents completed "fully virtual" coaching sessions. The overall survey response rate was 91 % (38/42). The majority of respondents agreed that the direct observation and debriefing conversation were easy to schedule and occurred without technical difficulties and that debriefing elements (self-reflection, feedback, takeaways) were useful for residents. Ninety-five percent of respondents rated the coach's virtual presence to be not at all disruptive to the resident-patient interaction. Virtual coaching alleviated resident stress associated with observation and was perceived as an opportunity for immediate feedback and a unique approach for resident education that will persist into the future. CONCLUSIONS: In this pilot study, residents and faculty coaches found virtual coaching on communication skills feasible and acceptable for telemedicine encounters. Many elements of our intervention may be adoptable by other residency programs. For example, residents may share their communication goals with clinic faculty supervisors and then invite them to directly observe virtual encounters what could facilitate targeted feedback related to the resident's goals. Moreover, virtual coaching on communication skills in both the in-person and telemedicine settings may particularly benefit residents in challenging encounters such as those with cognitively impaired patients or with surrogate decision-makers.

Implementation of a Synoptic Operative Report for Rectal Cancer: A Mixed-Methods Study.

BACKGROUND: The National Accreditation Program for Rectal Cancer is a collaborative effort to improve the quality of rectal cancer care, including multidisciplinary assessment, treatment planning, and documentation using synoptic radiology, pathology, and operative reports. OBJECTIVE: The purpose of this study was to examine the implementation and use of a synoptic operative report for rectal cancer. DESIGN: This was a convergent mixed-methods implementation study of electronic medical record data, surveys, and qualitative interviews. SETTINGS: The study was conducted at US medical centers. PARTICIPANTS: Colorectal surgeons were included. INTERVENTION: After development, the synoptic operative report was iteratively revised and ultimately approved by the American Society of Colon and Rectal Surgeons Executive Council and the National Accreditation Program for Rectal Cancer and then implemented into participants' institutional electronic medical record systems. MAIN OUTCOME MEASURES: Change in fidelity to documentation of 19 critical items after implementation of synoptic reports and in-depth details and perspectives about the synoptic operative report were measured. RESULTS: Thirty-seven surgeons from 14 institutions submitted preimplementation operative reports (n = 180); 32 of 37 surgeons submitted postimplementation reports (n = 118). The operation type, approach, and formation of a stoma were present in >70% of preimplementation reports; however, the location of the tumor, the type of reconstruction, and the distal margin were reported in <50%. Each item was present in ≥89% of postimplementation reports. Twenty eight of 37 participants completed the survey, and 21 of 37 participants completed qualitative interviews. Emergent themes included concerns for additional burden and time constraints using the synoptic report themselves, as well as errors or absent information in traditional narrative operative reports of other surgeons. LIMITATIONS: The study was limited by its sample size, cross-sectional nature, specialized centers, and inclusion of colorectal surgeons only. CONCLUSIONS: Although fidelity to the 19 items substantially increased after implementation of the synoptic report, reactions to the synoptic report varied among surgeons. Many indicated concerns that it would hinder workflow or add extra time burden. Others felt the synoptic report could indirectly improve rectal cancer quality of care and provide useful data for quality improvement and research. More work is needed to update and improve the synoptic operative report and streamline the workflow. See Video Abstract at http://links.lww.com/DCR/B100. IMPLEMENTACIÓN DE UN INFORME OPERATIVO SINÓPTICO PARA EL CÁNCER DE RECTO: UN ESTUDIO UTILIZANDO MÉTODOS MIXTOS: El Programa Nacional de Acreditación para el Cáncer Rectal es una iniciativa de colaboración para mejorar la calidad de la atención del cáncer rectal, utilizando evaluación multidisciplinaria, planificación del tratamiento y documentación mediante radiología sinóptica, patología e informes quirúrgicos.Examinar la implementación y el uso de un informe operativo sinóptico para el cáncer de recto.Estudio de implementación de métodos mixtos convergentes de datos de registros médicos electrónicos, encuestas y entrevistas cualitativas.Centros médicos de los Estados Unidos.Cirujanos colorrectales.Después de su formulación, el informe operativo sinóptico fue revisado de forma iterativa y finalmente aprobado por el Consejo Ejecutivo de la Sociedad Americana de Cirujanos de Colon y Rectal y el Programa Nacional de Acreditación para el Cáncer Rectal. Posteriormente, se implementó en los sistemas de registros médicos electrónicos institucionales de los participantes.Cambios en la precisión de documentación de 19 ítems críticos después de la implementación de informes sinópticos; Revisión de detalles y perspectivas en a profundidad sobre el informe operativo sinóptico.Treinta y siete cirujanos de 14 instituciones presentaron informes operativos previos a la implementación (n = 180); 32/37 cirujanos presentaron informes posteriores a la implementación (n = 118). El tipo de operación, el enfoque y la formación de un estoma estuvieron presentes en > 70% de los informes previos a la implementación; sin embargo, la ubicación del tumor, el tipo de reconstrucción y el margen distal se informaron en <50%. Cada ítem estuvo presente en > 89% de los informes posteriores a la implementación. 28/37 participantes completaron la encuesta y 21/37 participantes completaron entrevistas cualitativas. Los temas emergentes incluyeron preocupaciones por la carga adicional y las limitaciones de tiempo usando el informe sinóptico en sí, y errores o información ausente en los informes operativos narrativos tradicionales de otros cirujanos.Tamaño de la muestra, estudio transversal, centros especializados, cirujanos colorrectales solamente.Aunque la fidelidad a los 19 ítems aumentó sustancialmente después de la implementación del informe sinóptico, las reacciones al informe sinóptico variaron entre los cirujanos. Muchos indicaron preocupaciones de que obstaculizaría el flujo de trabajo o agregaría una carga de tiempo adicional. Otros consideraron que el informe sinóptico podría mejorar indirectamente la calidad de la atención del cáncer de recto y proporcionar datos útiles para la mejora de la calidad y la investigación. Se necesita más trabajo para actualizar y mejorar el informe operativo sinóptico y agilizar el flujo de trabajo. Consulte Video Resumen en http://links.lww.com/DCR/B100. (Traducción-Dr. Adrian E. Ortega).

Drivers, Beliefs, and Barriers Surrounding Surgical Opioid Prescribing: A Qualitative Study of Surgeons' Opioid Prescribing Habits.

BACKGROUND: Recent data demonstrate that surgeons overprescribe opioids and vary considerably in the amount of opioids prescribed for common procedures. Limited data exist about why and how surgeons develop certain opioid prescribing habits. We sought to identify surgeons' knowledge, attitudes, and beliefs about opioid prescribing and elicit barriers to guideline-based prescribing. METHODS: We conducted qualitative semistructured interviews accompanied by demographic surveys at an academic medical center. Surgical residents and faculty members were selected by maximum variation purposive sampling. We used thematic analysis to identify themes associated with opioid prescribing. RESULTS: Twenty surgical residents and twenty-one surgical faculty members were interviewed. Characteristics of individual surgeons, patients, health care teams, practice environments, and the complex interplay between these domains drove prescribing habits. Attending-resident communication about opioid prescribing was extremely limited. Surgeons received little training and feedback about opioid prescribing and were rarely aware of negative long-term consequences, limiting motivation to change prescribing habits. Although surgeons frequently interacted with pain management physicians to comanage patients postoperatively, few involved pain management physicians in preoperative planning. Perceived barriers to guideline-based prescribing included the following: limitations to electronic prescribing, cross-coverage problems, inadequate time for patient education, and impediments to use of nonopioid alternatives. CONCLUSIONS: Interventions to improve compliance with opioid prescribing guidelines should include surgeon education and personal feedback. Future interventions should aim to improve attending-resident communication about opioid prescribing, reduce hurdles to electronic prescribing, provide clear pain management plans for cross-covering physicians, assess alternative methods for efficient patient education, and maximize use of nonnarcotic pain medications.

Combating Child Summer Food Insecurity: Examination of a Community-Based Mobile Meal Program.

Low-income children's access to meals decreases during the summer months due to losing the benefit of the free and reduced-price lunches they normally receive during the school year. Few studies critically examine community-based approaches to providing summer meals. This mixed methods study examined a mobile meal program implemented in a community with large economic disparities. Parents and caregivers who attended the mobile meal program with a child at one of three sites completed surveys that screened for risk of food insecurity and examined access and utilization of community food resources. Interviews with a representative subsample of English- and Spanish-speaking participants elicited an in-depth understanding of food insecurity in the community and perspectives on the mobile meal program. Surveys (n = 284) were completed in English (78%) and Spanish (22%). Participants identified primarily as Asian (32%), Latino/Hispanic (29%), and White (27%), with 26% screening positive for risk of food insecurity within the past 12 months. Qualitative interviews (n = 36) revealed widespread support for meals served in public settings as they were perceived to be welcoming, fostered social interactions, and helped the community at large. Participants described the high cost of living as a key motivation for participating and cited immigration fears as a barrier to accessing public resources. Findings from this study suggest the importance of innovative community-based approaches to serving hard-to-reach children during the summer.

Preclinical curriculum of prospective case-based teaching with faculty- and student-blinded approach.

BACKGROUND: Case-based teaching with real patient cases provides benefit of simulating real-world cognition. However, while clinical practice involves a prospective approach to cases, preclinical instruction typically involves full disclosure of case content to faculty, introducing hindsight bias into faculty teaching in medical curricula. METHODS: During 2015-2018, we piloted an optional medical school curriculum involving 6-7 one-hour sessions over a 3-month period each year. New groups enrolled each year from first- and second-year classes. A facilitator provided a blinded physician discussant and blinded students with case information during and not in advance of each session, allowing prospective case-based discussions. Cases were based on real patients treated in the Department of Medicine. Clinical material was presented in the chronologic sequence encountered by treating physicians. Content covered a median of 5 patient visits/case (range: 2-10) spanning over months. A 14-item survey addressing components of the reporter-interpreter-manager-educator (RIME) scheme was developed and used to compare self-reported clinical skills between course participants and non-participant controls during the 2016 course iteration. RESULTS: This elective curriculum at Stanford School of Medicine involved 170 preclinical students (22.7% of 750 eligible). During the 2016 course iteration, a quasi-experimental study compared self-reported clinical skills between 29 course participants (response rate: 29/49 [59.2%]) and 35 non-participant controls (response rate: 35/132 [26.5%]); students self-assessed clinical skills via the RIME-based survey developed for the course. Two-sample t-tests compared the change in pre- and post-course skills between course participants and non-participants. Of 15 Department of Medicine faculty members invited as discussants, 12 (80%) consented to participate. Compared with controls, first-year participants self-assessed significantly greater improvement in understanding how clinicians reason through cases step-by-step to arrive at diagnoses (P = 0.049), work through cases in longitudinal settings (P = 0.049), and share information with patients (P = 0.047). Compared with controls, second-year participants self-assessed significantly greater improvement (P = 0.040) in understanding how clinicians reason through cases step-by-step to arrive at diagnoses. CONCLUSIONS: Prospective case-based discussions with blinding of faculty and students to clinical content circumvents hindsight bias and may impart real-world cognitive skills as determined by student self-report.

Determining the educational value of a technical and nontechnical skills medical student curriculum.

BACKGROUND: Residency application rates to general surgery remain low. The purpose of this study is to describe the educational value of a curriculum designed to increase preclinical medical student interest in surgical careers to better understand the process by which medical students decide to pursue a career in surgery. MATERIALS AND METHODS: We used qualitative methodology to describe the educational value of a technical and nontechnical skills curriculum offered to preclinical medical students at our institution. We conducted semistructured interviews of students and instructors who completed the curriculum in 2016. The interviews were recorded, transcribed, and inductively coded. The data were analyzed for emergent themes. RESULTS: A total of eight students and five instructors were interviewed. After analysis of 13 transcripts, four themes emerged: (1) The course provides a safe environment for learning, (2) acquisition and synthesis of basic technical skills increases preclinical student comfort in the operating room, (3) developing relationships with surgeons creates opportunities for extracurricular learning and scholarship, and (4) operative experiences can inspire students to explore a future career in surgery. CONCLUSIONS: These factors can help inform the design of future interventions to increase student interest, with the ultimate goal of increasing the number of students who apply to surgical residency programs.

The long-term impact of a comprehensive scholarly concentration program in biomedical ethics and medical humanities.

BACKGROUND: There is a strong and growing interest in biomedical ethics and medical humanities (BEMH) within medical education for facilitating key components of medical professionalism and ethics, clinical communication and observational skills, and self-care and reflective practices. Consequently, United States (US) medical institutions have begun to incorporate BEMH through formal Scholarly Concentrations (SCs). This is the first study to examine the impact of a US BEMH SC, from student experience in medical school to post-graduate development, as perceived by graduate physicians. METHODS: Graduated students who participated in the BEMH SC or did extensive BEMH research prior to the BEMH SC's establishment (n = 57) were sampled for maximum variation across graduating years. In telephone surveys and interviews, participants discussed the perceived impact of the BEMH SC on (a.) student experience during medical school and (b.) post-graduate development. Interviews were audiotaped, transcribed, and de-identified. The authors iteratively generated a codebook; two raters coded independently, adjudicated codes, and completed inter-rater reliability (IRR) tests. The authors subsequently conducted a team-based thematic analysis, identifying emergent themes. RESULTS: Nineteen BEMH graduates were interviewed. Results were analyzed according to (a.) student experience and (b.) post-graduate development. Overall, respondents perceived impacts in reinforcing knowledge and skills in clinical ethics; solidifying self-care and reflective practices; refining a sense of professional identity and integrity for ethically challenging situations; and promoting student skills, productivity, and later careers involving BEMH. CONCLUSION: A comprehensive US BEMH SC achieved the purported aims of BEMH in medical education, with graduate physicians perceiving persisting effects into clinical practice. Furthermore, the structure and format of a SC may offer additional advantages in promoting student scholarly skill and productivity, career development, and professional identity formation-core competencies identified across clinical training and ethics programs. Our findings indicate that a BEMH SC is effective in achieving a range of desired immediate and post-graduate effects and represent a particularly promising venue for BEMH in medical education. We believe these findings to be of critical significance to medical educators and administrators when considering how best to incorporate BEMH into SCs and medical curricula.

Pilot evaluation of the Computer-Based Assessment for Sampling Personal Characteristics test.

BACKGROUND: High attrition rates hint at deficiencies in the resident selection process. The evaluation of personal characteristics representative of success is difficult. Here, we evaluate a novel tool for assessing personal characteristics. MATERIALS AND METHODS: To evaluate feasibility, we used an anonymous voluntary survey questionnaire offered to study participants before and after contact with the CASPer test. To evaluate the CASPer test as a predictor of success, we compared CASPer test assessments of personal characteristics versus traditional faculty assessment of personal characteristics with applicant rank list position. RESULTS: All applicants (n = 77) attending an in-person interview for general surgery residency, and all faculty interviewers (n = 34) who reviewed these applications were invited to participate. Among applicants, 84.4% of respondents (65 of 77) reported that a requirement to complete the CASPer test would have no bearing or would make them more likely to apply to the program (mean = 3.30, standard deviation = 0.96). Among the faculty, 62.5% respondents (10 of 16) reported that the same condition would have no bearing or would make applicants more likely to apply to the program (mean = 3.19, standard deviation = 1.33). The Spearman's rank-order correlation coefficients for the relationships between traditional faculty assessment of personal characteristics and applicant rank list position, and novel CASPer assessment of personal characteristics and applicant rank list position, were -0.45 (P = 0.033) and -0.41 (P = 0.055), respectively. CONCLUSIONS: The CASPer test may be feasibly implemented as component of the resident selection process, with the potential to predict applicant rank list position and improve the general surgery resident selection process.

Evaluation of a technical and nontechnical skills curriculum for students entering surgery.

BACKGROUND: Prior interventions to address declining interest in surgical careers have focused on creating early exposure and fostering mentorship at the preclinical medical student level. Navigating the surgical environment can be challenging, however, and preclinical students may be more likely to pursue a surgical career if they are given the tools to function optimally. MATERIALS AND METHODS: We designed a 10-wk technical and nontechnical skills curriculum to provide preclinical students with knowledge and skills necessary to successfully navigate the surgical learning environment, followed by placement in high-fidelity surgical simulations and scrubbing in on operative cases with attending surgeons. We administered pre-post surveys to assess student confidence levels in operative skills, self-perceptions of having a mentor, overall course efficacy, and interest in a career in surgery. RESULTS: The overall response rates presurvey and postsurvey were 100% (30 of 30) and 93.3% (28 of 30), respectively. Confidence levels across all operative skills increased significantly after completing the course. Faculty mentorship increased significantly from 30.0% before to 61.5% after the course. Overall effectiveness of the course was 4.00 of 5 (4 = "very effective"), and although insignificant, overall interest in a career in surgery increased at the completion of the course from 3.77 (standard deviation = 1.01) to 4.17 (standard deviation = 0.94). CONCLUSIONS: Our curriculum was effective in teaching the skills necessary to enjoy positive experiences in planned early exposure and mentorship activities. Further study is warranted to determine if this intervention leads to an increase in students who formally commit to a career in surgery.

Perceptions of US-Based Muslim Patients of Their Dermatology Care.

Importance: Cultural humility training is of growing interest, yet the religious and cultural accommodations of Muslim patients in dermatology have not been studied. Objective: To explore the perceptions of Muslim patients of their dermatology care. Design, Setting, and Participants: This qualitative mixed-methods study, consisting of surveys and semistructured interviews, recruited participants from 2 clinical sites within a large academic health care system in California. Participants were adult, English-speaking, Muslim patients who were evaluated at least once by a medical or surgical dermatologist between January 2022 and January 2023. Main Outcomes and Measures: A survey obtained the following data: demographics, religious practices pertinent to dermatology care, and experiences of bias outside and inside the dermatology clinic. Semistructured interviews covered topics related to positive and negative experiences in the dermatology clinic, accommodation of cultural and religious needs in dermatology, and future interventions. Results: A total of 21 patients (mean [SD] age, 36.4 [11.6] years; range, 26-71 years) participated in the study: 5 male individuals (24%) and 16 female individuals (76%), including 10 female individuals who wore hijab. Eleven participants identified as Middle Eastern (52%), 8 as South Asian (38%), 1 as North African (5%), and 1 as Pacific Islander (5%). Survey results showed variations in the impact of Islamic practices on dermatology care. Interviews showed that Muslim participants did not perceive dermatology care as a priority and expressed interest in community events focused on general dermatology education. They also experienced stigmatization of their skin disease and cosmetic care. Prior experiences with Islamophobia and colorism hindered the Muslim patient-dermatologist relationship and disclosure of the need for accommodations. There were instances when participants experienced bias and poor cultural humility from dermatologists. Finally, Muslim participants had unique religious and cultural needs pertinent to their care, including clinician gender concordance, medication timing adjustment while fasting, and halal medication ingredients. Conclusions and Relevance: This qualitative mixed-methods study explored the experiences of Muslim patients in dermatology in the US. Recommendations supported by this study include incorporating religion into cultural humility training, increasing diversity in the dermatology workforce, implementing policies for clearer medication labeling, supporting dermatology research in subpopulations of Muslim individuals in the US, and partnering with community organizations for dermatology education.

Usability of ENTRUST as an Assessment Tool for Entrustable Professional Activities (EPAs): A Mixed Methods Analysis.

OBJECTIVE: As the American Board of Surgery transitions to a competency-based model of surgical education centered upon entrustable professional activities (EPAs), there is a growing need for objective tools to determine readiness for entrustment. This study evaluates the usability of ENTRUST, an innovative virtual patient simulation platform to assess surgical trainees' decision-making skills in preoperative, intra-operative, and post-operative settings. DESIGN: This is a mixed-methods analysis of the usability of the ENTRUST platform. Quantitative data was collected using the system usability scale (SUS) and Likert responses. Analysis was performed with descriptive statistics, bivariate analysis, and multivariable linear regression. Qualitative analysis of open-ended responses was performed using the Nielsen-Shneiderman Heuristics framework. SETTING: This study was conducted at an academic institution in a proctored exam setting. PARTICIPANTS: The analysis includes n = 47 (PGY 1-5) surgical residents who completed an online usability survey following the ENTRUST Inguinal Hernia EPA Assessment. RESULTS: The ENTRUST platform had a median SUS score of 82.5. On bivariate and multivariate analyses, there were no significant differences between usability based on demographic characteristics (all p > 0.05), and SUS score was independent of ENTRUST performance (r = 0.198, p = 0.18). Most participants agreed that the clinical workup of the patient was engaging (91.5%) and felt realistic (85.1%). The most frequent heuristics represented in the qualitative analysis included feedback, visibility, match, and control. Additional themes of educational value, enjoyment, and ease-of-use highlighted participants' perspectives on the usability of ENTRUST. CONCLUSIONS: ENTRUST demonstrates high usability in this population. Usability was independent of ENTRUST score performance and there were no differences in usability identified in this analysis based on demographic subgroups. Qualitative analysis highlighted the acceptability of ENTRUST and will inform ongoing development of the platform. The ENTRUST platform holds potential as a tool for the assessment of EPAs in surgical residency programs.

ENTRUST: A Serious Game-Based Virtual Patient Platform to Assess Entrustable Professional Activities in Graduate Medical Education.

Background: As entrustable professional activities (EPAs) are implemented in graduate medical education, there is a great need for tools to efficiently and objectively evaluate clinical competence. Readiness for entrustment in surgery requires not only assessment of technical ability, but also the critical skill of clinical decision-making. Objective: We report the development of ENTRUST, a serious game-based, virtual patient case creation and simulation platform to assess trainees' decision-making competence. A case scenario and corresponding scoring algorithm for the Inguinal Hernia EPA was iteratively developed and aligned with the description and essential functions outlined by the American Board of Surgery. In this study we report preliminary feasibility data and validity evidence. Methods: In January 2021, the case scenario was deployed and piloted on ENTRUST with 19 participants of varying surgical expertise levels to demonstrate proof of concept and initial validity evidence. Total score, preoperative sub-score, and intraoperative sub-score were analyzed by training level and years of medical experience using Spearman rank correlations. Participants completed a Likert scale user acceptance survey (1=strongly agree to 7=strongly disagree). Results: Median total score and intraoperative mode sub-score were higher with each progressive level of training (rho=0.79, P<.001 and rho=0.69, P=.001, respectively). There were significant correlations between performance and years of medical experience for total score (rho=0.82, P<.001) and intraoperative sub-scores (rho=0.70, P<.001). Participants reported high levels of platform engagement (mean 2.06) and ease of use (mean 1.88). Conclusions: Our study demonstrates feasibility and early validity evidence for ENTRUST as an assessment platform for clinical decision-making.

Validity Evidence for ENTRUST as an Assessment of Surgical Decision-Making for the Inguinal Hernia Entrustable Professional Activity (EPA).

OBJECTIVE: As the American Board of Surgery (ABS) moves toward implementation of Entrustable Professional Activities (EPAs), there is a growing need for objective evaluation of readiness for entrustment of residents. This requires not only assessment of technical skills and knowledge, but also surgical decision-making in preoperative, intraoperative, and postoperative settings. We developed and piloted an Inguinal Hernia EPA Assessment on ENTRUST, a serious game-based online virtual patient simulation platform to assess trainees' decision-making competence. DESIGN: This is a prospective analysis of resident performance on the ENTRUST Inguinal Hernia EPA Assessment using bivariate analyses. SETTING: This study was conducted at an academic institution in a proctored exam setting. PARTICIPANTS: Forty-three surgical residents completed the ENTRUST Inguinal Hernia EPA Assessment. RESULTS: Four case scenarios for the Inguinal Hernia EPA and corresponding scoring algorithms were iteratively developed by expert consensus aligned with ABS EPA descriptions and functions. ENTRUST Inguinal Hernia Grand Total Score was positively correlated with PGY-level (p < 0.0001). Preoperative, Intraoperative, and Postoperative Total Scores were also positively correlated with PGY-level (p = 0.001, p = 0.006, and p = 0.038, respectively). Total Case Scores were positively correlated with PGY-level for cases representing elective unilateral inguinal hernia (p = 0.0004), strangulated inguinal hernia (p < 0.0001), and elective bilateral inguinal hernia (p = 0.0003). Preoperative Sub-Scores were positively correlated with PGY-level for all cases (p < 0.01). Intraoperative Sub-Scores were positively correlated with PGY-level for strangulated inguinal hernia and bilateral inguinal hernia (p = 0.0007 and p = 0.0002, respectively). Grand Total Score and Intraoperative Sub-Score were correlated with prior operative experience (p < 0.0001). Prior video game experience did not correlate with performance on ENTRUST (p = 0.56). CONCLUSIONS: Performance on the ENTRUST Inguinal Hernia EPA Assessment was positively correlated to PGY-level and prior inguinal hernia operative performance, providing initial validity evidence for its use as an objective assessment for surgical decision-making. The ENTRUST platform holds potential as tool for assessment of ABS EPAs in surgical residency programs.

"It's Like Learning by the Seat of Your Pants": Surgeons Lack Formal Training in Opioid Prescribing.

OBJECTIVE: To determine the training surgical residents and faculty receive on opioid prescribing, and to identify opportunities for curricula development to fill training gaps. DESIGN: We conducted qualitative semi-structured interviews and surveys. After applying an overarching organizational framework, we used an iterative, team-based process to develop relevant inductive codes. We then performed thematic analyses to identify and catalogue critical domains related to surgeons' education about opioid prescribing. SETTING: Tertiary care academic medical center. PARTICIPANTS: Maximum variation purposive sampling was used to recruit general surgery residents and surgical faculty members. RESULTS: We interviewed 21 attending surgeons and 20 surgical residents. Surgeons reported minimal formal training on pain management and prescribing opioids. A minority of individuals described receiving opioid training in the form of continuing medical education, intern boot camp sessions, and medical school classes. Participants compensated for the lack of formal training during residency by informally learning from senior residents, consulting pain specialists, and seeking external learning resources. Increased surgical experience was correlated with increased comfort with pain management. A majority of surgeons desired formal training. The most commonly requested educational resources were opioid prescribing guidelines for common operations and recommendations for treating chronic pain patients. Residents requested that training occur early in residency to maximize the benefits received. Based on these findings, we developed a conceptual framework to explain how surgeons learn to prescribe opioids and to highlight opportunities for improvement. CONCLUSIONS: Although surgeons routinely prescribe opioids and desire education on opioids, a majority of them do not receive any training. Instituting formal educational programs is critical for improving opioid prescribing practices among surgeons.These programs should include standard prescribing guidelines and address management of acute postoperative pain in patients with chronic pain.

In situ interprofessional operating room simulations: Empowering learners in crisis resource management principles.

BACKGROUND: Given the multifaceted nature of operating room teams, miscommunication at various perioperative stages leads to lapses in teamwork and communication, which potentiates adverse events. In situ interprofessional operating room simulations are a valuable tool in identifying the possible threats to patient safety in the operating room. Participant confidence may also increase; however, perceived confidence in specific areas of team communication in the clinical environment remains unclear. This research aims to study how in situ interprofessional operating room simulations increase participants' individual confidence in 4 team principles derived from crisis resource management: using effective communication, utilizing resources, establishing role clarity, and using effective situational awareness. METHODS: Over a 2-year period, interdisciplinary operating room team members were assigned to participate in 13 simulated surgical case scenarios, which were chosen based on the volunteer surgeon's specialty. These cases were designed to engage all team members and included a crisis scenario (ie, hemorrhage, airway emergency, arrhythmia, or cardiac arrest). All statistical analyses were performed using RStudio version 1.2.1335 software. We analyzed matched pre- and postsimulation self-assessment of individual confidence using the Wilcoxon signed-rank test for each of the 4 aforementioned constructs of interest derived from crisis resource management training principles. Significance was set at P < .0038, using Bonferroni correction, for all comparisons to account for the multiple comparisons problem. RESULTS: There was a statistically significant shift in the 4-point scale toward greater self-reported confidence from presimulation to postsimulation for each of the 4 team principles: using effective communication (P = .0019, r = 0.18), utilizing resources well (P = .0014, r = 0.18), establishing role clarity (P < .0010, r = 0.22), and using effective situational awareness (P < .0010, r = 0.27). CONCLUSION: In this pilot study, we describe how teaching crisis resource management principles in an in situ operative simulation is an effective way to increase the confidence of communication skills among the members of an interdisciplinary procedure/operative team during crisis scenarios. In situ simulation can be used to evaluate system competence and interdisciplinary dynamics, and to identify latent conditions that predispose to medical error. As we continue to conduct these sessions, we aim to evaluate their impact on individual confidence and the advancement of interdisciplinary efforts to improve patient care.

Self-efficacy Toward a Healthcare Career Among Minority High School Students in a Surgical Pipeline Program: A Mixed Methods Study.

OBJECTIVE: While many barriers to healthcare careers exist for URM students, a strong sense of self-efficacy may help mitigate these obstacles. This study explores how URM high school students describe their academic challenges and compares their descriptions across self-efficacy scores. DESIGN: We conducted a convergent mixed methods study of URM high school students. Students completed a validated self-efficacy questionnaire and participated in semi-structured focus group interviews to discuss their approach to academic challenges, goal setting, and achievement. The primary outcome was academic, social, and emotional self-efficacy, measured using the Self-Efficacy Questionnaire for Children. We separated participants into high and low self-efficacy groups based on scores in each domain. Using thematic analysis, we identified and compared common themes associated with academic challenges and goal setting. SETTING: Surgical exposure pipeline program sponsored by Stanford University Department of Surgery PARTICIPANTS: Low-income, high academic achieving URM high school students interested in science, technology, engineering and mathematics, and/or healthcare careers. RESULTS: Thirty-one high school students completed the focus groups and self-efficacy questionnaire. Most students scored in the high self-efficacy group for at least one domain: 65% for academic self-efficacy, 56% for social self-efficacy, and 19% for emotional self-efficacy. Four emergent themes highlighted participants' perspectives toward educational success: fulfillment in academic challenges, focus on future goals, failing forward, and asking for help. Compared to students with low self-efficacy scores, students in the high-scoring self-efficacy groups more often discussed strategies and concrete behaviors such as the importance of seeking support from teachers and peers and learning from failure. CONCLUSIONS: Students in high self-efficacy groups were more comfortable utilizing approaches that helped them succeed academically. Additional efforts are needed to bolster student self-efficacy, particularly in students from URM backgrounds, to increase diversity in medical schools.