Evidence for validity of the epidemic-pandemic impacts inventory (brief healthcare module): Internal structure and association with other variables.

The COVID-19 pandemic has subjected healthcare workers to enormous stress. Measuring the impact of this public health emergency is essential to developing strategies that can effectively promote resilience and wellness. The Epidemic-Pandemic Impacts Inventory Supplemental Healthcare Module-Brief Version (EPII-SHMb) was developed to measure impacts among occupational cohorts serving on the front lines of healthcare. While this instrument has been utilized in COVID-19 related studies, little is known about its psychometric properties. This study collects evidence for validity of the EPII-SHMb by evaluating its internal structure and how its scores associate with other variables. Physicians and nursing staff across a large New York health system were cross-sectionally surveyed using an online questionnaire between June and November 2020. Exploratory factor analysis resulted in a 3-factor solution, identifying factors Lack of Workplace Safety (7 items), Death/Dying of Patients (3 items), and Lack of Outside Support (2 items). Internal consistency was high overall and within physician/nursing and gender subgroups (Cronbach's alpha: 0.70 - 0.81). Median scores on Death/Dying of Patients were higher among those who directly cared for COVID-19 patients or worked in COVID-19 hospital units. These results are promising. Additional studies evaluating other dimensions of validity are necessary.

Evaluating burnout during the COVID-19 pandemic among physicians in a large health system in New York.

PURPOSE: The COVID-19 pandemic has generated significant psychological distress among health care workers worldwide. New York State, particularly New York City and surrounding counties, were especially affected, and experienced over 430,000 COVID-19 cases and 25,000 deaths by mid-August 2020. We hypothesized that physicians and trainees (residents/fellows) who were redeployed outside of their specialty to treat COVID-19 inpatients would have higher burnout. METHODS: We conducted a cross-sectional survey to assess burnout among attending and trainee physicians who provided patient care during the COVID-19 pandemic between March-May 2020 across a diverse health care system in New York. Separate multivariable logistic regressions were performed to determine the association between redeployment and measures of burnout: Emotional Exhaustion (EE) and Depersonalization. Burnout measures were also compared by physician vs trainee status. The differential association between redeployment and outcomes with respect to trainee status was also evaluated. RESULTS: Redeployment was significantly associated with increased odds of EE {OR =1.53, 95% CI: 1.01-2.31} after adjusting for gender and Epidemic-Pandemic Impacts Inventory (EPII) score. Similarly, being a trainee, especially a junior level trainee, was associated with increased odds of EE {OR = 1.59, 95% CI: 1.01-2.51} after adjusting for gender and EPII scores. However, neither redeployment nor trainee status were significantly associated with Depersonalization. Interactions between redeployment and trainee status were not significant for any of the outcomes (p>.05). CONCLUSION: Physicians who were redeployed to treat COVID-19 patients had higher reported measures of EE. Trainees, irrespective of redeployment status, had higher EE as compared with attendings. Additional research is needed to understand the long-term impact of redeployment on burnout among redeployed physicians. Programs to identify and address potential burnout among physicians, particularly trainees, during pandemics may be beneficial.

Supervision and Care Quality as Perceived by Redeployed Attendings, Fellows, and Residents During a COVID-19 Surge: Lessons for the Future.

PURPOSE: To better prepare for potential future large-scale redeployments, this study examines quality of supervision and care as perceived by redeployed residents, fellows, and attendings during a COVID-19 surge. METHOD: During April and May 2020, attendings, fellows, and residents redeployed at 2 teaching hospitals were invited to participate in a survey, which included questions on respondents' prior experience; redeployed role; amount of supervision needed and received; and perceptions of quality of supervision, patient care, and interprofessional collaboration. Frequencies, means, and P values were calculated to compare perceptions by experience and trainee status. Narrative responses to 2 open-ended questions were independently coded; themes were constructed. RESULTS: Overall, 152 of 297 (51.2%) individuals responded, including 64 of 142 attendings (45.1%), 40 of 79 fellows (50.6%), and 48 of 76 residents (63.2%). Fellows and attendings, regardless of prior experience, perceived supervision as adequate. In contrast, experienced residents reported receiving more supervision than needed, while inexperienced residents reported receiving less supervision than needed and rated overall supervision as poor. Attendings, fellows, and experienced residents rated the overall quality of care as acceptable to good, whereas inexperienced residents perceived overall quality of care as worse to much worse, particularly when compared with baseline. CONCLUSIONS: Narrative themes indicated that the quality of supervision and care was buffered by strong camaraderie, a culture of informal consultation, team composition (mixing experienced with inexperienced), and clinical decision aids. The markedly negative view of inexperienced residents suggests a higher risk for disillusionment, perhaps even moral injury, during future redeployments. Implications for planning are explored.

Supervision, Interprofessional Collaboration, and Patient Safety in Intensive Care Units during the COVID-19 Pandemic.

Background: To meet coronavirus disease (COVID-19) demands in the spring of 2020, many intensive care (IC) units (ICUs) required help of redeployed personnel working outside their regular scope of practice, causing an expansion and change of staffing ratios. Objective: How did this composite alternative ICU workforce experience supervision, interprofessional collaboration, and quality and safety of care under the unprecedented clinical circumstances at the height of the first pandemic wave as lived experiences uniquely captured during the first peak of the pandemic? Methods: An international, cross-sectional survey was conducted among physicians, nurses, and allied personnel deployed or redeployed to ICUs in Utrecht, New York, and Dublin from April to May of 2020. Data were analyzed separately for the three sites. Quantitative data were treated for descriptive statistics; qualitative data were analyzed thematically and combined for general interpretations. Results: On the basis of 234, 83, and 34 responses (response rates of 68%, 48%, and 41% in Utrecht, New York, and Dublin, respectively), we found that the amount of supervision and the quality and safety of care were perceived as being lower than usual but still acceptable. The working atmosphere was overwhelmingly felt to be collaborative and supportive. Where IC-certified nurse-to-patient ratios had decreased most (Utrecht), nurses voiced criticism about supervision and quality of care. Continuity within the work environment, team composition, and informal ("curbside") consultations were critical mediators of success. Conclusion: In the exceptional circumstances encountered during the COVID-19 pandemic, many ICUs were managed by a composite workforce of IC-certified and redeployed personnel. Although supervision is critical for safe care, supervisory roles were not clearly related to the amount of prior ICU experience. Vital for satisfaction with the quality of care was the span of control for those who assumed supervisory roles (i.e., the ratio of certified to noncertified personnel). Stable teams that matched less experienced personnel with more experienced personnel; a strong, interprofessional, collaborative atmosphere; a robust culture of informal consultation; and judicious, more flexible use of rules and regulations proved to be essential.

Current State of the Medical Student Performance Evaluation: A Tool for Reflection for Residency Programs.

BACKGROUND: The Medical Student Performance Evaluation (MSPE) provides important information to residency programs. Despite recent recommendations for standardization, it is not clear how much variation exists in MSPE content among schools. OBJECTIVES: We describe the current section content of the MSPE in US allopathic medical schools, with a particular focus on variations in the presentation of student performance. METHODS: A representative MSPE was obtained from 95.3% (143 of 150) of allopathic US medical schools through residency applications to the Zucker School of Medicine at Hofstra/Northwell in select programs for the 2019-2020 academic year. A manual data abstraction tool was piloted in 2018-2019. After training, it was used to code all portions of the MSPE in this study. The results were analyzed, and descriptive statistics were reported. RESULTS: In preclinical years, 30.8% of MSPEs reported data regarding performance of students beyond achieving "passes" in a pass/fail curriculum. Only half referenced performance in the fourth year including electives, acting internships, or both. About two-thirds of schools included an overall descriptor of comparative performance in the final paragraph. Among these schools, a majority provided adjectives such as "outstanding/excellent/very good/good," while one-quarter reported numerical data categories. Regarding clerkship grades, there were numerous nomenclature systems used. CONCLUSIONS: This analysis demonstrates the existence of extreme variability in the content of MSPEs submitted by US allopathic medical schools in the 2019-2020 cycle, including the components and nomenclature of grades and descriptors of comparative performance, display of data, and inclusion of data across all years of the medical education program.

Student Perception of Case-based Teaching by Near-Peers and Faculty during the Internal Medicine Clerkship: A Noninferiority Study.

INTRODUCTION: Third-year medical students traditionally receive their didactic or small group teaching sessions from clinical faculty during clerkship rotations. Near-peer teaching is increasingly recognized as an acceptable method for teaching, however most near-peer teaching takes place during the pre-clinical curriculum. We sought to determine if fourth year medical students were noninferior to faculty in facilitating small group discussions during clerkship rotations. METHODS: Seventy-five third-year medical students participated in a small group session focused on rheumatologic diseases during their internal medicine clerkship rotation. Students were taught by fourth-year medical students who self-selected to participate as near-peer teachers at 1 clinical site (near-peers, N = 36) and by clinical faculty at another site (N = 39). At the end of the session, third-year medical students completed a survey evaluating teacher performance and effectiveness. RESULTS: There was no significant difference between the 2 groups on each of the 17 survey items assessing teacher performance, the total teaching performance score, and the teaching effectiveness rating (all P-values >.05). A mean between-group difference of 2% in favor of the near-peers indicated noninferiority of the near-peer teachers compared with faculty teachers on the total teaching performance score. An absolute difference of 14% in favor of the near-peers indicated noninferiority of the near-peer teachers compared with faculty teachers on the teaching effectiveness score. Near-peer teachers reported several benefits, including improving their own medical knowledge and skills as a future educator. DISCUSSION: Our data supports the noninferiority of the perceived performance and effectiveness of near-peer teachers compared to faculty teachers in the clerkship setting. Adding near-peer teachers to the clerkship setting is feasible and can be beneficial to all stakeholders.

Exploring the relationship between emotion and cognitive load types during patient handovers.

Cognitive Load Theory has emerged as an important approach to improving instruction in the health professions workplace, including patient handovers. At the same time, there is growing recognition that emotion influences learning through numerous cognitive processes including motivation, attention, working memory, and long-term memory. This study explores how emotion influences the cognitive load experienced by trainees performing patient handovers. From January to March 2019, 693 (38.7%) of 1807 residents and fellows from a 24-hospital health system in New York city completed a survey after performing a handover. Participants rated their emotional state and cognitive load. The survey included questions about features of the learner, task, and instructional environment. The authors used factor analysis to identify the core dimensions of emotion. Regression analyses explored the relationship between the emotion factors and cognitive load types. Two emotion dimensions were identified representing invigoration and tranquility. In regression analyses, higher levels of invigoration, tranquility, and their interaction were independently associated with lower intrinsic load and extraneous load. The interaction of invigoration and tranquility predicted lower germane load. The addition of the emotion variables to multivariate models including other predictors of cognitive load types significantly increased the amount of variance explained. The study provides a model for measuring emotions in workplace learning. Because emotion appears to have a significant influence on cognitive load types, instructional designers should consider strategies that help trainees regulate emotion in order to reduce cognitive load and improve learning and performance.

Review of the Medical Student Performance Evaluation: analysis of the end-users' perspective across the specialties.

The Medical Student Performance Evaluation (MSPE) is an important tool of communication used by program directors to make decisions in the residency application process. To understand the perspective and usage of the MSPE across multiple medical specialties now and in anticipation of the planned changes in USMLE Step 1 score-reporting. A survey instrument including quantitative and qualitative measures was developed and piloted. The final survey was distributed to residency programs across 28 specialties in 2020 via the main contact on the ACGME listserv. Of the 28 specialties surveyed, at least one response was received from 26 (93%). Eight percent of all programs (364/4675) responded to the survey, with most respondents being program directors. Usage of the MSPE varied among specialties. Approximately 1/3 of end-users stated that the MSPE is very or extremely influential in their initial screening process. Slightly less than half agreed or strongly agreed that they trust the information to be an accurate representation of applicants, though slightly more than half agree that the MSPE will become more influential once USMLE Step 1 becomes pass/fail. Professionalism was rated as the most important component and noteworthy characteristics among the least important in the decision-making process. Performance in the internal medicine clerkship was rated as the most influential while neurology and psychiatry performances were rated as less influential. Overwhelmingly, respondents suggested that including comparative performance and/or class rank would make the MSPE more useful once USMLE Step 1 becomes pass/fail. MSPE end-users across a variety of specialties utilize this complex document in different ways and value it differentially in their decision-making processes. Despite this, continued mistrust of the MSPE persists. A better understanding of end-users' perceptions of the MSPE offers the UME community an opportunity to transform the MSPE into a highly valued, trusted document of communication.

Evidence for validity for the Cognitive Load Inventory for Handoffs.

CONTEXT: Patient handovers remain a significant patient safety challenge. Cognitive load theory (CLT) can be used to identify the cognitive mechanisms for handover errors. The ability to measure cognitive load types during handovers could drive the development of more effective curricula and protocols. No such measure currently exists. METHODS: The authors developed the Cognitive Load Inventory for Handoffs (CLIH) using a multi-step process, including expert interviews to enhance content validity and talk-alouds to optimise response process validity. The final version contained 28 items. From January to March 2019, we administered a cross-sectional survey to 1807 residents and fellows from a large health care system in the USA. Participants completed the CLIH following a handover. Exploratory factor analysis of data from one-third of respondents identified high-performing items; confirmatory factor analysis of data from the remaining sample assessed model fit. Model fit was evaluated using the comparative fit index (CFI) (>0.90), Tucker-Lewis index (TFI) (>0.80), standardised root mean square residual (SRMR) (<0.08) and root mean square of error of approximation (RMSEA) (<0.08). RESULTS: Participants included 693 trainees (38.4%) (231 in the exploratory study and 462 in the confirmatory study). Eleven items were removed during exploratory factor analysis. Confirmatory factor analysis of the 16 remaining items (five for intrinsic load, seven for extraneous load and four for germane load) supported a three-factor model and met criteria for good model fit: the CFI was 0.95, TFI was 0.93, RMSEA was 0.074 and SRMR was 0.07. The factor structure was comparable for gender and role. Intrinsic, extraneous and germane load scales had high internal consistency. With one exception, scale scores were associated, as hypothesised, with postgraduate level and clinical setting. CONCLUSIONS: The CLIH measures three types of cognitive load during patient handovers. Evidencefor validity is provided for the CLIH's content, response process, internal structure and association with other variables. This instrument can be used to determine the relative drivers of cognitive load during handovers in order to optimize handover instruction and protocols.

The Revised Medical School Performance Evaluation: Does It Meet the Needs of Its Readers?

BACKGROUND: The Medical School Performance Evaluation (MSPE) is an important factor for application to residency programs. Many medical schools are incorporating recent recommendations from the Association of American Medical Colleges MSPE Task Force into their letters. To date, there has been no feedback from the graduate medical education community on the impact of this effort. OBJECTIVE: We surveyed individuals involved in residency candidate selection for internal medicine programs to understand their perceptions on the new MSPE format. METHODS: A survey was distributed in March and April 2018 using the Association of Program Directors in Internal Medicine listserv, which comprises 4220 individuals from 439 residency programs. Responses were analyzed, and themes were extracted from open-ended questions. RESULTS: A total of 140 individuals, predominantly program directors and associate program directors, from across the United States completed the survey. Most were aware of the existence of the MSPE Task Force. Respondents read a median of 200 to 299 letters each recruitment season. The majority reported observing evidence of adoption of the new format in more than one quarter of all medical schools. Among respondents, nearly half reported the new format made the MSPE more important in decision-making about a candidate. Within the MSPE, respondents recognized the following areas as most influential: academic progress, summary paragraph, graphic representation of class performance, academic history, and overall adjective of performance indicator (rank). CONCLUSIONS: The internal medicine graduate medical education community finds value in many components of the new MSPE format, while recognizing there are further opportunities for improvement.

A Novel Curriculum to Prepare Internal Medicine Residents for Fellowship Interviews.

BACKGROUND: Applications to the Fellowship Match through the National Resident Matching Program (NRMP) Specialties Matching Service (SMS) are at an all-time high. Data regarding the preparedness of medical residents who go through the interview process is limited. OBJECTIVE: To assess whether the implementation of an interview curriculum could improve medical resident preparedness for and performance during fellowship interviews. METHODS: All third-year internal medicine residents (N = 18) at the Zucker School of Medicine at Hofstra/Northwell (Northwell) applying to subspecialty fellowship participated in an interview curriculum that comprised a didactic session and an Objective Structured Teaching Exercise (OSTE). Participants were surveyed on preparedness before and after the curriculum and medical residents and faculty were surveyed on medical resident performance after their OSTE and after their Northwell fellowship interview. RESULTS: Out of the total possible number of participants, 16 (89%) were included in our analysis. Pre and post-test statistical differences in survey responses were evaluated using the Wilcoxon signed rank test. Medical resident preparedness and resident perceived performance increased in all measured categories, including overall preparedness (P = .001) and overall interview skills (P = .008). No significant change in faculty-rated resident performance was observed. CONCLUSION: The development and institution of a formal interview curriculum improved medical resident preparedness and perceived performance. However, this significant improvement seen between medical resident pre and post surveys did not translate to improvement between faculty pre and post surveys. Future studies should look at fellowship match rates to objectively assess the impact of the curriculum.

Clinician-Educator Tracks for Trainees in Graduate Medical Education: A Scoping Review.

PURPOSE: Clinician-educator tracks (CETs) appear to be increasing in prevalence in graduate medical education (GME) and may play an important role in medical education workforce development. The authors conducted a scoping review to characterize the current state of knowledge about CETs' structure, content, and outcomes. METHOD: Six databases were searched in January 2018 for English-language peer-reviewed articles published through 2017 to identify articles describing CETs in GME. To be included, the CET had to target GME learners (residents/fellows), be longitudinal, have the primary aim of developing trainees into clinician-educators (CEs), and address at least one CE core competency (direct teaching, curriculum development, mentorship/advising, leadership, assessment, educational scholarship). The authors extracted and analyzed data from included articles. RESULTS: Of 1,434 articles identified, 19 were included in the review, representing 18 separate CETs. All but 2 CETs (11%) were specialty-specific. Most included a core curriculum with classroom-based sessions (18; 100%), workplace-based opportunities to practice skills (17; 94%), and a required scholarly project (16; 89%). Seventeen (94%) focused on skills related to direct teaching. Four (22%) identified mentoring/advising as a core curriculum focus. Five (28%) required project dissemination. Time spent in CETs varied widely (median: 166 hours; range: 8 hours/4-month period to 1,288 hours/2-year period). The most common reported outcomes were learner reactions (7; 39%) and career tracking (11; 61%). CONCLUSIONS: This review yields a composite picture of the current state of CETs in GME. The results highlight the paucity of outcomes data and areas for potential standardization and future research.

Medical education using minimal technology: achieving professional development.

Background: Traditional journal clubs have been limited by the geography of participants. Web based modalities and social media platforms are now being used to bridge this barrier. Medical education journal club, given the diversity of its community would lend well to these platforms. To date there is very little published regarding online medical education journal clubs. Objective: To bridge geographical barriers; enhance interdisciplinary and interprofessional discussion and collaboration; and to provide opportunities for continuing medical education and faculty development; a monthly synchronous medical education journal club was created for faculty. Design/Methods: From April 2015 to November 2016, 11 online journal clubs were held for the faculty at Northwell Health and the Barbara and Donald Zucker School of Medicine at Hofstra/Northwell (Zucker SOM). All articles picked were relevant to medical education and participants were from multiple disciplines. Results: 74% of respondent participants agreed that the content covered during the sessions would positively impact personal and/or professional life and 58% of respondents reported that their overall knowledge/skill level changed positively. Conclusions: On-line medical education journal club can provide a valuable opportunity for continuing education and faculty development for both the participant and the presenter.

Psychometric Properties of Two Developmental Screening Instruments for Hispanic Children in the Philadelphia Region.

OBJECTIVE: To assess the validity of Spanish versions of the Survey of Well-being of Young Children (SWYC) Milestones and the Ages & Stages Questionnaire, Third Edition (ASQ-3), and to document the rates of developmental delays in an urban cohort of children with Hispanic parents. METHODS: Spanish-speaking families with a child 9 to 60 months of age (N = 991) were initially screened using Spanish translations of the SWYC Milestones and the ASQ-3. A stratified random sample of 494 of these children subsequently received standardized clinical assessment to confirm the presence of developmental delays. Reverse weighting corrected for the selection bias inherent in the stratification scheme. RESULTS: Fifty-five percent of toddlers (9 to 41 months of age) and 34.8% of preschoolers (42 to 60 months of age) scored in the moderately to severely delayed range, most frequently in language. Sensitivity and specificity for toddlers with severe delays associated with the SWYC were 0.69 and 0.64, respectively, and 0.55 and 0.75 for the ASQ-3. Sensitivity and specificity for preschoolers with severe delays associated with the SWYC were 0.87 and 0.58, respectively, and 0.71 and 0.86 for the ASQ-3. CONCLUSIONS: Although psychometric properties of the Spanish translated versions are not as strong as the English versions, the findings suggest that both the SWYC Milestones and ASQ-3 represent promising tools for identifying Hispanic children with developmental delays. The rate of delays were consistent with other studies showing a high percentage of Hispanic children with developmental delays, most frequently in language skills.

The Correlation of Stress in Residency With Future Stress and Burnout: A 10-Year Prospective Cohort Study.

BACKGROUND: Residents and practicing physicians displaying signs of stress is common. It is unclear whether stress during residency persists into professional practice or is associated with future burnout. OBJECTIVE: We assessed the persistence of stress after residency and its correlation with burnout in professional practice. We hypothesized that stress would linger and be correlated with future burnout. METHODS: A prospective cohort study was conducted over 10 years using survey instruments with existing validity evidence. Residents over 3 academic years (2003-2005) were surveyed to measure stress in residency. Ten years later, these residents were sought out for a second survey measuring current stress and burnout in professional practice. RESULTS: From 2003 to 2005, 143 of 155 residents participated in the initial assessment (92% response rate). Of those, 21 were excluded in 2015 due to lack of contact information; follow-up surveys were distributed to 122 participants, and 81 responses were received (66% response rate and 57% of original participants). Emotional distress in residency correlated with emotional distress in professional practice (correlation coefficient = 0.45, P < .0001), emotional exhaustion (correlation coefficient = 0.30, P = .007), and depersonalization (correlation coefficient = 0.25, P = .029). Multivariate linear regression showed that emotional distress in residency was associated with future emotional distress (ß estimate = 0.57, P = .005) and depersonalization (ß estimate = 2.29, P = .028). CONCLUSIONS: We showed emotional distress as a resident persists into individuals' professional practice 10 years later and has an association with burnout in practice.

Resident dashboards: helping your clinical competency committee visualize trainees' key performance indicators.

INTRODUCTION: Under the Next Accreditation System, programs need to find ways to collect and assess meaningful reportable information on its residents to assist the program director regarding resident milestone progression. This paper discusses the process that one large Internal Medicine Residency Program used to provide both quantitative and qualitative data to its clinical competency committee (CCC) through the creation of a resident dashboard. METHODS: Program leadership at a large university-based program developed four new end of rotation evaluations based on the American Board of Internal Medicine (ABIM) and Accreditation Council of Graduated Medical Education's (ACGME) 22 reportable milestones. A resident dashboard was then created to pull together both milestone- and non-milestone-based quantitative data and qualitative data compiled from faculty, nurses, peers, staff, and patients. RESULTS: Dashboards were distributed to the members of the CCC in preparation for the semiannual CCC meeting. CCC members adjudicated quantitative and qualitative data to present their cohort of residents at the CCC meeting. Based on the committee's response, evaluation scores remained the same or were adjusted. Final milestone scores were then entered into the accreditation data system (ADS) on the ACGME website. CONCLUSIONS: The process of resident assessment is complex and should comprise both quantitative and qualitative data. The dashboard is a valuable tool for program leadership to use both when evaluating house staff on a semiannual basis at the CCC and to the resident in person.

Long-term neurofunctional outcome, executive functioning, and behavioral adaptive skills following fetal myelomeningocele surgery.

BACKGROUND: Myelomeningocele (MMC) represents the first nonlethal anomaly to be treated by prenatal intervention. Case series and a prospective, randomized study show that fetal surgery for MMC before 26 weeks' gestation may preserve neurological function. Long-term follow-up is a fundamental component to evaluate the overall efficacy of any new medical or surgical procedure. To further delineate the long-term impact of fMMC surgery, we continued to follow children treated in our institution before the Management of Myelomeningocele Study trial by the means of parental questionnaires to assess changes in functional, developmental, and cognitive status as these unique patients grow older. OBJECTIVE: The objective of the study was to evaluate the long-term neurological outcome, executive functioning (EF), and behavioral adaptive skills (BAS) following fetal myelomeningocele (fMMC) surgery. STUDY DESIGN: Prior to the Management of Myelomeningocele Study trial, 54 patients underwent fMMC surgery at our institution. Parents of 42 children (78%) participated in structured questionnaires focusing on neurofunctional outcome. EF and BAS were measured by the Behavior Rating Inventory of Executive Function (BRIEF) and the Adaptive Behavioral Assessment System II. The BRIEF is organized into 3 primary indices including the following: Global Executive Composite, Metacognition Index, and Behavioral Regulation Index. The Adaptive Behavioral Assessment System II results in a general adaptive composite score. Based on SD intervals, EF and BAS were categorized as being average, borderline, or impaired. RESULTS: At a median follow-up age of 10 years (range, 8-14 years), 33 (79%) are community ambulators, 3 (9%) are household ambulators, and 6 (14%) are wheelchair dependent. Preschool ambulation was predictive of long-term ambulation (P < .01), whereas the need for tethered cord surgery was associated with persistent deterioration of ambulatory status (P = .007). Normal bladder function was found in 26%. Although the majority scored within the average range for the Behavioral Regulation Index, Metacognition Index, and Global Executive Composite indices, significantly more children who had fMMC surgery had deficits in EF in all 3 BRIEF indices compared with the population norms. The general adaptive composite scores were also more likely to fall below average following fMMC surgery. Normal early neurodevelopmental outcomes were predictive of normal EF and BAS (P < .01). Need for shunting was associated with a significant impairment of BAS (P = .02). CONCLUSION: The present study suggests that fMMC surgery improves long-term functional outcome. The majority of fMMC children can successfully complete everyday tasks at home and at school. Abnormalities of BAS appear to be more common than impairments in EF and therefore offer an area for early screening and interventional therapy for these at-risk children. Non-shunted fMMC children with normal early neurodevelopmental outcome are less likely to experience problems with EF and BAS. fMMC surgery improves long-term ambulatory status. Symptomatic spinal cord tethering with or without intradural inclusion cyst is associated with functional loss. More than expected fMMC children are continent, but bowel and bladder control continue to be an ongoing challenge for the fMMC children.

Reforming Your Health Care Reform Curriculum.

INTRODUCTION: The landscape of health care is changing drastically, and the future within which our residents practice medicine will look very different than today's current health care system. Our residency program created a weeklong introduction to health care reform in the United States for residents. METHODS: The materials for faculty facilitators associated with this publication include PowerPoint presentations, a debate script on bundled payments, and an evaluation survey. The weeklong curriculum requires 7 hours of scheduled time from all learners, with an additional 5 hours for the residents and faculty running the debate. The survey completed at the end of the week showed that on a query of interest in health care reform (1 = no interest, 5 = very interested), interest level increased from an average score of 2.35 presession to an average score of 3.61 postsession. RESULTS: Self-reported basic understanding of all areas queried increased from pre- to postsession. DISCUSSION: This endeavor works best as a collaboration between residency program directors, associate program directors, residents, and other willing parties at one's home institution as the didactics were designed to include all PGY levels. Overall, this method of introducing a very complicated topic was well received by the residents, who voted to continue the weeklong curriculum going forward.