Measuring deliberate reflection in residents: validation and psychometric properties of a measurement tool.

PURPOSE: Reflective capacity is "the ability to understand critical analysis of knowledge and experience to achieve deeper meaning." In medicine, there is little provision for post-graduate medical education to teach deliberate reflection. The feasibility, scoring characteristics, reliability, validation, and adaptability of a modified previously validated instrument was examined for its usefulness assessing reflective capacity in residents as a step toward developing interventions for improvement. METHODS: Third-year residents and fellows from four anesthesia training programs were administered a slightly modified version of the Reflection Evaluation for Learners' Enhanced Competencies Tool (REFLECT) in a prospective, observational study at the end of the 2019 academic year. Six written vignettes of imperfect anesthesia situations were created. Subjects recorded their perspectives on two randomly assigned vignettes. Responses were scored using a 5-element rubric; average scores were analyzed for psychometric properties. An independent self-report assessment method, the Cognitive Behavior Survey: Residency Level (rCBS) was used to examine construct validity. Internal consistency (ICR, Cronbach's alpha) and interrater reliability (weighted kappa) were examined. Pearson correlations were used between the two measures of reflective capacity. RESULTS: 46/136 invited subjects completed 2/6 randomly assigned vignettes. Interrater agreement was high (k = 0.85). The overall average REFLECT score was 1.8 (1-4 scale) with good distribution across the range of scores. ICR for both the REFLECT score (mean 1.8, sd 0.5; α = 0.92) and the reflection scale of the rCBS (mean 4.5, sd 1.1; α = 0.94) were excellent. There was a significant correlation between REFLECT score and the rCBS reflection scale (r = .44, p < 0.01). CONCLUSIONS: This study demonstrates feasibility, reliability, and sufficiently robust psychometric properties of a modified REFLECT rubric to assess graduate medical trainees' reflective capacity and established construct/convergent validity to an independent measure. The instrument has the potential to assess the effectiveness of interventions intended to improve reflective capacity.

Mental Health in Obstetric Patients and Providers During the COVID-19 Pandemic.

Psychiatric morbidity is the most common childbirth complication with 1 in 5 women experiencing a perinatal mood or anxiety disorder. The cost of this psychiatric morbidity is pervasive, contributing to devastating maternal health, child developmental, and economic consequences. The coronavirus disease 2019 (COVID-19) pandemic, and associated changes to perinatal experiences, resulted in profound psychological reactions including increased anxiety, depression, stress disorders, and sleep disturbance, further impacting obstetric patients. Providers' mental health has been challenged by moral injury and shared trauma. This article reviews mental health outcomes in regard to the COVID-19 pandemic for obstetric patients and their providers.

The effect of marrow secretome and culture environment on the rate of metastatic breast cancer cell migration in two and three dimensions.

Metastasis is responsible for over 90% of cancer-related deaths, and bone is the most common site for breast cancer metastasis. Metastatic breast cancer cells home to trabecular bone, which contains hematopoietic and stromal lineage cells in the marrow. As such, it is crucial to understand whether bone or marrow cells enhance breast cancer cell migration toward the tissue. To this end, we quantified the migration of MDA-MB-231 cells toward human bone in two- and three-dimensional (3D) environments. First, we found that the cancer cells cultured on tissue culture plastic migrated toward intact trabecular bone explants at a higher rate than toward marrow-deficient bone or devitalized bone. Leptin was more abundant in conditioned media from the cocultures with intact explants, while higher levels of IL-1ß, IL-6, and TNFα were detected in cultures with both intact bone and cancer cells. We further verified that the cancer cells migrated into bone marrow using a bioreactor culture system. Finally, we studied migration toward bone in 3D gelatin. Migration speed did not depend on stiffness of this homogeneous gel, but many more dendritic-shaped cancer cells oriented and migrated toward bone in stiffer gels than softer gels, suggesting a coupling between matrix mechanics and chemotactic signals.

Real-world treatment patterns and outcomes using terlipressin in 203 patients with the hepatorenal syndrome.

BACKGROUND: Hepatorenal syndrome and acute kidney injury are common complications of decompensated cirrhosis, and terlipressin is recommended as first-line vasoconstrictor therapy. However, data on its use outside of clinical trials are lacking. AIMS: To assess practice patterns and outcomes around vasoconstrictor use for hepatorenal syndrome in UK hospitals. METHODS: This was a multicentre chart review study. Data were extracted from medical records of patients diagnosed with hepatorenal syndrome and treated by vasoconstrictor drugs between January 2013 and December 2017 at 26 hospitals in the United Kingdom. The primary outcome was improvement of kidney function, defined as complete response (serum creatinine improved to ≤1.5 mg/dL), partial response (serum creatinine reduction of ≥20% but >1.5 mg/dL) and overall response (complete or partial response). Other outcomes included need for dialysis, mortality, liver transplantation and adverse events. RESULTS: Of the 225 patients included in the analysis, 203 (90%) were treated with terlipressin (median duration, 6 days; range: 2-24 days). Mean (±standard deviation) serum creatinine at vasopressor initiation was 3.25 ± 1.64 mg/dL. Terlipressin overall response rate was 73%. Overall response was higher in patients with mild acute kidney injury (baseline serum creatinine <2.25 mg/dL), compared to those with moderate (serum creatinine ≥2.25 mg/dL and <3.5 mg/dL) or severe (serum creatinine ≥3.5 mg/dL). Ninety-day survival was 86% for all patients (93% for overall responders vs 66% for treatment nonresponders, P < 0.0001). CONCLUSION: Terlipressin is the most commonly prescribed vasoconstrictor for patients with hepatorenal syndrome in the United Kingdom. Treatment with terlipressin in patients with less severe acute kidney injury (serum creatinine <2.25 mg/dL) was associated with higher treatment responses, and 90-day survival.

Prevention and Management of Operating Room Fire: An Interprofessional Operating Room Team Simulation Case.

Introduction: Operating room (OR) fire can be a devastating and costly event to patients and health care providers. Prevention and effective management of such fires may present difficulties even for experienced OR staff. Methods: This simulation involved a 52-year-old man presenting for excisional biopsy of a cervical lymph node to be performed under sedation. Participants were expected to identify and manage both contained and uncontained fires resulting from ignition by electrosurgical cautery. We conducted weekly multidisciplinary simulations in the mock OR at Massachusetts General Hospital. Participants included surgery and anesthesiology residents, certified registered nurse anesthetists, registered nurses, and surgical technicians. Participants were unaware of the scenario content. Each 90-minute session was divided into three parts: an orientation (10 minutes), the case with rapid cycle debriefing (65 minutes), and a final debriefing with course evaluations (15 minutes). Equipment consisted of a simulation OR with general surgery supplies, general anesthesia equipment, a high-fidelity Laerdal SimMan 3G simulator, a code cart, a defibrillator, dry ice for smoke effects, and a projector with a fire image. Results: From April to June 2015, 86 participants completed this simulation. Participants reported that the simulation scenario was realistic (80%), was relevant to their clinical practice (93%), changed their practice (82%), and promoted teamwork (80%). Discussion: Prevention and management of OR fire require collaboration and prompt coordination between anesthesiologists, surgeons, and nurses. This simulation case scenario was implemented to train multidisciplinary learners in the identification and crisis management of such an event.

The evolution of pediatric sedation and anesthesia patient safety: An interview with Dr Charles J. "Charlie" Coté.

The career of Dr Charles J. Coté covered a period of major advances in pediatric anesthesia patient safety. Dr Coté (1946 --), Professor Emeritus in Anaesthesia at Harvard Medical School, helped develop pediatric sedation guidelines, conducted influential clinical research, edited a major textbook, and promoted pediatric anesthesia training fellowships in low- and middle-income countries. Based on a series of interviews with Dr Coté, this article reviews the career of this Robert M. Smith Award winner through the lens of improvements in pediatric sedation and anesthesia patient safety.

Simulation-Based Education and Team Training.

Simulation-based education (SBE) has become pervasive in health care training and medical education, and is even more important in subspecialty training whereby providers such as otolaryngologists and anesthesiologists share overlapping patient concerns because of the proximity of the surgical airway. Both these subspecialties work in a fast-paced environment involving high-stakes situations and life-changing events that necessitate critical thinking and timely action, and have an exceedingly small bandwidth for error. Team training in the form of interprofessional education and learning involving surgeons, anesthesiologists, and nursing is critical for patient safety in the operating room in general, but more so in otolaryngology surgery.

Drug Calculation Errors in Anesthesiology Residents and Faculty: An Analysis of Contributing Factors.

BACKGROUND: Limited data exist regarding computational drug error rates in anesthesia residents and faculty. We investigated the frequency and magnitude of computational errors in a sample of anesthesia residents and faculty. METHODS: With institutional review board approval from 7 academic institutions in the United States, a 15-question computational test was distributed during rounds. Error rates and the magnitude of the errors were analyzed according to resident versus faculty, years of practice (or residency training), duration of sleep, type of question, and institution. RESULTS: A total of 371 completed the test: 209 residents and 162 faculty. Both groups committed 2 errors (median value) per test, for a mean error rate of 17.0%. Twenty percent of residents and 25% of faculty scored 100% correct answers. The error rate for postgraduate year 2 residents was less than for postgraduate year 1 (P = .012). The error rate for faculty increased with years of experience, with a weak correlation (R = 0.22; P = .007). The error rates were independent of the number of hours of sleep. The error rate for percentage-type questions was greater than for rate, dose, and ratio questions (P = .001). The error rates varied with the number of operations needed to calculate the answer (P < .001). The frequency of large errors (100-fold greater or less than the correct answer) by residents was twice that of faculty. Error rates varied among institutions ranged from 12% to 22% (P = .021). CONCLUSIONS: Anesthesiology residents and faculty erred frequently on a computational test, with junior residents and faculty with more experience committing errors more frequently. Residents committed more serious errors twice as frequently as faculty.

The advancement of pediatric anesthesia pharmacology: David Ryan Cook (scions, serendipity, and six degrees of separation).

Dr David Ryan Cook, Professor Emeritus of Anesthesiology and Pharmacology at the University of Pittsburgh and Chief of Anesthesiology at Children's Hospital of Pittsburgh (1977-1999), is a pioneer in the field of pediatric anesthesiology and pharmacology. Dr Cook contributed significantly to the understanding of pharmacologic differences among infants, children, and adults. His work as a clinician-scientist, educator, and mentor defined the pharmacology of many of the anesthetic agents we continue to use today. He brought science to the art of anesthesia and enhanced the safety of pediatric perioperative care. Based on a 2017 interview with Dr Cook, this article outlines the development of his career and his contributions to the field of anesthesiology and pharmacology.

At the birth of pediatric anesthesia in Mexico: An interview with Dr. Estela Melman, a pioneering woman in medicine.

Dr. Estela Melman (1939-present), Professor in the Department of Anesthesiology, the American British Cowdray Medical Center, Mexico, is an influential pioneer who has shaped the scope and practice of pediatric anesthesia in Mexico and throughout the world. Her early work to reintroduce neural blockade into routine pediatric anesthetic care, particularly the caudal approach to the epidural space, helped to transform current anesthesia practice. Based on a series of interviews held with Dr. Melman between 2016 and 2017, this article reviews the remarkable career of a pioneering pediatric anesthesiologist.

Half a century of anesthesia for children: An interview with Dr. Nishan G. 'Nick' Goudsouzian.

The career of Dr Nishan Goudsouzian spanned half a century of pediatric anesthesia. His 50 years saw seminal contributions to the use of neuromuscular blocking agents in children, the development of proton beam therapy and magnetic resonance imaging for pediatric cancer, the introduction of the laryngeal mask airway, an explosion in the volume and depth of knowledge about pediatric anesthesia, the expansion of formal training in pediatric anesthesia, and the widening of academic efforts to improve anesthetic care for children worldwide. Based on interviews with Dr Goudsouzian, this article reviews the contributions of this Robert M. Smith Award winner to the development of pediatric anesthesia.

Identifying and Managing Intraoperative Arrhythmia: A Multidisciplinary Operating Room Team Simulation Case.

Introduction: Resuscitation of a critically ill patient is challenging for both novice learners and experienced health care providers. During a critical event, not only is it important to identify the correct underlying diagnosis, it is equally crucial that the appropriate Advance Cardiac Life Support algorithm, medications, and defibrillator modality are implemented. This scenario features a 56-year-old female who presents for excisional biopsy of an inguinal lymph node to evaluate lymphadenopathy concerning for lymphoma. Intraoperatively, she goes into cardiopulmonary arrest. Participants must identify and manage three different scenarios: (1) ventricular fibrillation, (2) unstable ventricular tachycardia, and (3) bradycardia, including the use of the defibrillator. Method: Weekly simulation sessions were conducted in the in situ simulation operating room at Massachusetts General Hospital. Surgical residents, anesthesiology residents, nurses, and surgical technicians participated in a multidisciplinary operating room team. Each approximately 60-minute session included an orientation, the case, and the debriefing. Equipment included a simulation operating room with general surgery supplies, general anesthesia equipment, a high-fidelity SimMan patient simulator, a code cart, and a defibrillator. Results: Ninety-one multidisciplinary participants completed this scenario from September to December 2015. Participants reported that the scenario was applicable to their clinical practice (96%), promoted teamwork skills (88%), and encouraged interprofessional learning (94%). Discussion: Intraoperative cardiac arrest is a devastating event that can result in poor patient outcomes if the care team is not thoroughly prepared for crisis management. This simulation case scenario was implemented to train multidisciplinary learners in the identification and management of such an event.

Peer-Assisted Analysis of Resident Feedback Improves Clinical Teaching: A Case Report.

Anesthesiologists play an important role in educating future clinicians. Yet few residency programs incorporate teaching skills into faculty development. Consequently, many anesthesiologists have limited training to supervise and educate residents. In turn, these attendings may receive negative feedback and poor evaluations from residents without a means to effectively improve. Peer-assisted teaching between faculty members may serve as a strategy to improve teaching skills. We report a case of peer-assisted analysis of resident feedback to identify specific areas of concern that were targeted for improvement. This approach resulted in improved teaching scores and feedback for the faculty member.

Pediatric transport medicine and the dawn of the pediatric anesthesiology and critical care medicine subspecialty: an interview with pioneer Dr. Alvin Hackel.

Dr. Alvin 'Al' Hackel (1932-) Professor Emeritus of Anesthesiology, Perioperative and Pain Medicine, and Pediatrics at the Stanford University School of Medicine, has been an influential pioneer in shaping the scope and practice of pediatric anesthesia. His leadership helped to formally define the subspecialty of pediatric anesthesiology ('who is a pediatric anesthesiologist?') and the importance of specialization and regionalization of expertise in both patient transport and perioperative care. His enduring impact on pediatric anesthesia and critical care practice was recognized in 2006 by the American Academy of Pediatrics when it bestowed upon him the profession's highest lifetime achievement award, the Robert M. Smith Award. Of his many contributions, Dr. Hackel identifies his early involvement in the development of pediatric transport medicine as well as the subspecialty of pediatric anesthesiology as his defining contribution. Based on a series of interviews held with Dr. Hackel between 2009 and 2014, this article reviews the early development of transportation medicine and the remarkable career of a pioneering pediatric anesthesiologist.

Malignant hyperthermia in the early days of pediatric anesthesia: an interview with anesthesiology pioneer, Dr. John F. Ryan.

Dr. John F. Ryan (1935 - ), Associate Professor of Anaesthesia at the Harvard Medical School, influenced the careers of hundreds of residents and fellows-in-training while instilling in them his core values of resilience, hard work, and integrity. His authoritative textbook, A Practice of Anesthesia for Infants and Children, remains as influential today as it did when first published decades ago. Although he had had many accomplishments, he identified his experiences caring for patients with malignant hyperthermia and characterizing the early discovery of this condition as his defining contribution to medicine. Based on a series of interviews with Dr. Ryan, this article reviews a remarkable career that coincides with the dawn of modern pediatric anesthetic practice.

The development of pediatric anesthesiology and critical care medicine at the Cincinnati Children's Hospital: an interview with Dr. Theodore Striker.

Dr. Theodore W. 'Ted' Striker (1936-), Professor of Anesthesiology and Pediatrics at the University of Cincinnati, has played a pioneering role in the development of pediatric anesthesiology in the United States. As a model educator, clinician, and administrator, he shaped the careers of hundreds of physicians-in-training and imbued them with his core values of honesty, integrity, and responsibility.

Continuous noninvasive cardiac output in children: is this the next generation of operating room monitors? Initial experience in 402 pediatric patients.

BACKGROUND: Electrical Cardiometry(™) (EC) estimates cardiac parameters by measuring changes in thoracic electrical bioimpedance during the cardiac cycle. The ICON(®), using four electrocardiogram electrodes (EKG), estimates the maximum rate of change of impedance to peak aortic blood acceleration (based on the premise that red blood cells change from random orientation during diastole (high impedance) to an aligned state during systole (low impedance)). OBJECTIVE: To determine whether continuous cardiac output (CO) data provide additional information to current anesthesia monitors that is useful to practitioners. METHODS: After IRB approval and verbal consent, 402 children were enrolled. Data were uploaded to our anesthesia record at one-minute intervals. Ten-second measurements (averaged over the previous 20 heart beats) were downloaded to separate files for later comparison with routine OR monitors. RESULTS: Data from 374 were in the final cohort (loss of signal or improper lead placement); 292,012 measurements during 58,049 min of anesthesia were made in these children (1 day to 19 years and 1 to 107 kg). Four events had a ≥25% reduction in cardiac index at least 1 min before a clinically important change in other monitored parameters; 18 events in 14 children confirmed manifestations of other hemodynamic measures; eight events may have represented artifacts because the observed measurements did not seem to fit the clinical parameters of the other monitors; three other events documented decreased stroke index with extreme tachycardia. CONCLUSIONS: Electrical cardiometry provides real-time cardiovascular information regarding developing hemodynamic events and successfully tracked the rapid response to interventions in children of all sizes. Intervention decisions must be based on the combined data from all monitors and the clinical situation. Our experience suggests that this type of monitor may be an important addition to real-time hemodynamic monitoring.

The development of a specialty: an interview with Dr. Mark C. Rogers, a pioneering pediatric intensivist.

Dr. Mark C. Rogers (1942-), Professor of Anesthesiology, Critical Care Medicine, and Pediatrics at the Johns Hopkins University, was recruited by the Department of Pediatrics at Johns Hopkins Hospital in 1977 to become the first director of its pediatric intensive care unit. After the dean of the medical school appointed him to chair the Department of Anesthesia in 1979, Rogers changed the course and culture of the department. He renamed it the Department of Anesthesiology and Critical Care Medicine, and developed a long-term strategy of excellence in clinical care, research, and education. However, throughout this period, he never lost his connection to pediatric intensive care. He has made numerous contributions to pediatric critical care medicine through research and his authoritative textbook, Rogers' Textbook of Pediatric Intensive Care. He established a training programme that has produced a plethora of leaders, helped develop the pediatric critical care board examination, and initiated the first World Congress of Pediatric Intensive Care. Based on a series of interviews with Dr. Rogers, this article reviews his influential career and the impact he made on developing pediatric critical care as a specialty.