Systems-Based Practice 20 Years On: Navigating the System for Better Care.

ABSTRACT: Systems-based practice (SBP) was introduced as 1 of 6 core competencies in 1999 because of its recognized importance in the quality and safety of health care provided to patients. Nearly 25 years later, faculty and learners continue to struggle with understanding and implementing this essential competency, thus hindering the medical education community's ability to most effectively teach and learn this important competency.Milestones were first introduced in 2013 as one effort to support implementation of the general competencies. However, each specialty developed its milestones independently, leading to substantial heterogeneity in the narrative descriptions of competencies including SBP. The process to create Milestones 2.0, and more specifically, the Harmonized Milestones, took this experience into account and endeavored to create a shared language for SBP across all specialties and subspecialties. The 3 subcompetencies in SBP are now patient safety and quality improvement, systems navigation for patient-centered care (coordination of care, transitions of care, local population health), and physician's role in health care systems (components of the system, costs and resources, transitions to practice). Milestones 2.0 are also now supported by new supplemental guides that provide specific real-world examples to help learners and faculty put SBP into the context of the complex health care environment.While substantially more resources and tools are now available to aid faculty and to serve as a guide for residents and fellows, much work to effectively implement SBP remains. This commentary will explore the evolutionary history of SBP, the challenges facing implementation, and suggestions for how programs can use the new milestone resources for SBP. The academic medicine community must work together to advance this competency as an essential part of professional development.

Experiences of LGBTQ+ Residents in US General Surgery Training Programs.

Importance: Previous studies have shown high rates of mistreatment among US general surgery residents, leading to poor well-being. Lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) residents represent a high-risk group for mistreatment; however, their experience in general surgery programs is largely unexplored. Objective: To determine the national prevalence of mistreatment and poor well-being for LGBTQ+ surgery residents compared with their non-LGBTQ+ peers. Design, Setting, and Participants: A voluntary, anonymous survey adapting validated survey instruments was administered to all clinically active general surgery residents training in Accreditation Council for Graduate Medical Education-accredited general surgery programs following the 2019 American Board of Surgery In-Training Examination. Main Outcomes and Measures: Self-reported mistreatment, sources of mistreatment, perceptions of learning environment, career satisfaction, burnout, thoughts of attrition, and suicidality. The associations between LGBTQ+ status and (1) mistreatment, (2) burnout, (3) thoughts of attrition, and (4) suicidality were examined using multivariable regression models, accounting for interactions between gender and LGBTQ+ identity. Results: A total of 6956 clinically active residents completed the survey (85.6% response rate). Of 6381 respondents included in this analysis, 305 respondents (4.8%) identified as LGBTQ+ and 6076 (95.2%) as non-LGBTQ+. Discrimination was reported among 161 LGBTQ+ respondents (59.2%) vs 2187 non-LGBTQ+ respondents (42.3%; P < .001); sexual harassment, 131 (47.5%) vs 1551 (29.3%; P < .001); and bullying, 220 (74.8%) vs 3730 (66.9%; P = .005); attending surgeons were the most common overall source. Compared with non-LGBTQ+ men, LGBTQ+ residents were more likely to report discrimination (men: odds ratio [OR], 2.57; 95% CI, 1.78-3.72; women: OR, 25.30; 95% CI, 16.51-38.79), sexual harassment (men: OR, 2.04; 95% CI, 1.39-2.99; women: OR, 5.72; 95% CI, 4.09-8.01), and bullying (men: OR, 1.51; 95% CI, 1.07-2.12; women: OR, 2.00; 95% CI, 1.37-2.91). LGBTQ+ residents reported similar perceptions of the learning environment, career satisfaction, and burnout (OR, 1.22; 95% CI, 0.97-1.52) but had more frequent considerations of leaving their program (OR, 2.04; 95% CI, 1.52-2.74) and suicide (OR, 1.95; 95% CI, 1.26-3.04). This increased risk of suicidality was eliminated after adjusting for mistreatment (OR, 1.47; 95% CI, 0.90-2.39). Conclusions and Relevance: Mistreatment is a common experience for LGBTQ+ surgery residents, with attending surgeons being the most common overall source. Increased suicidality among LGBTQ+ surgery residents is associated with this mistreatment. Multifaceted interventions are necessary to develop safer and more inclusive learning environments.

Experiences of Gender Discrimination and Sexual Harassment Among Residents in General Surgery Programs Across the US.

Importance: Mistreatment is a common experience among surgical residents and is associated with burnout. Women have been found to experience mistreatment at higher rates than men. Further characterization of surgical residents' experiences with gender discrimination and sexual harassment may inform solutions. Objective: To describe the types, sources, and factors associated with (1) discrimination based on gender, gender identity, or sexual orientation and (2) sexual harassment experienced by residents in general surgery programs across the US. Design, Setting, and Participants: This cross-sectional national survey study was conducted after the 2019 American Board of Surgery In-Training Examination (ABSITE). The survey asked respondents about their experiences with gender discrimination and sexual harassment during the academic year starting July 1, 2018, through the testing date in January 2019. All clinical residents enrolled in general surgery programs accredited by the Accreditation Council for Graduate Medical Education were eligible. Exposures: Specific types, sources, and factors associated with gender-based discrimination and sexual harassment. Main Outcomes and Measures: Primary outcome was the prevalence of gender discrimination and sexual harassment. Secondary outcomes included sources of discrimination and harassment and associated individual- and program-level factors using gender-stratified multivariable logistic regression models. Results: The survey was administered to 8129 eligible residents; 6956 responded (85.6% response rate)from 301 general surgery programs. Of those, 6764 residents had gender data available (3968 [58.7%] were male and 2796 [41.3%] were female individuals). In total, 1878 of 2352 female residents (79.8%) vs 562 of 3288 male residents (17.1%) reported experiencing gender discrimination (P < .001), and 1026 of 2415 female residents (42.5%) vs 721 of 3360 male residents (21.5%) reported experiencing sexual harassment (P < .001). The most common type of gender discrimination was being mistaken for a nonphysician (1943 of 5640 residents [34.5%] overall; 1813 of 2352 female residents [77.1%]; 130 of 3288 male residents [4.0%]), with patients and/or families as the most frequent source. The most common form of sexual harassment was crude, demeaning, or explicit comments (1557 of 5775 residents [27.0%] overall; 901 of 2415 female residents [37.3%]; 656 of 3360 male residents [19.5%]); among female residents, the most common source of this harassment was patients and/or families, and among male residents, the most common source was coresidents and/or fellows. Among female residents, gender discrimination was associated with pregnancy (odds ratio [OR], 1.93; 95% CI, 1.03-3.62) and higher ABSITE scores (highest vs lowest quartile: OR, 1.67; 95% CI, 1.14-2.43); among male residents, gender discrimination was associated with parenthood (OR, 1.72; 95% CI, 1.31-2.27) and lower ABSITE scores (highest vs lowest quartile: OR, 0.57; 95% CI, 0.43-0.76). Senior residents were more likely to report experiencing sexual harassment than interns (postgraduate years 4 and 5 vs postgraduate year 1: OR, 1.77 [95% CI, 1.40-2.24] among female residents; 1.31 [95% CI, 1.01-1.70] among male residents). Conclusions and Relevance: In this study, gender discrimination and sexual harassment were common experiences among surgical residents and were frequently reported by women. These phenomena warrant multifaceted context-specific strategies for improvement.

The ACGME Single Accreditation System: Alterations in the Force of Graduate Medical Education.

The Accreditation Council for Graduate Medical Education (ACGME), the American Osteopathic Association (AOA), and the American Association of Colleges of Osteopathic Medicine (AACOM) disturbed the gravitational forces of medical education when they entered into a historic agreement in August 2014. This agreement resulted in a 6-year journey to a single accreditation pathway for all residency programs and nearly all fellowship programs in the United States. It brought together the 2 traditions of medicine in the country for the first time in more than 100 years, unifying a critical phase of medical education for all physicians in the United States. In this commentary, the authors briefly describe the Single Accreditation System and relate their perspective on the factors leading to this profoundly important event and its impact on the ACGME, AOA, and medical education.

From Medical School to Residency: Transitions During the COVID-19 Pandemic.

BACKGROUND: The start of a new academic year in graduate medical education will mark a transition for postgraduate year 1 (PGY-1) residents from medical school into residency. The relocation of individuals has significant implications given the COVID-19 pandemic and variability of the outbreak across the United States, but little is known about the extent of the geographic relocation taking place. OBJECTIVE: We reported historical trends of PGY-1 residents staying in-state and those starting residency from out-of-state to quantify the geographic movement of individuals beginning residency training each year. METHODS: We analyzed historical data collected by the Accreditation Council for Graduate Medical Education in academic years 2016-2017, 2017-2018, and 2018-2019, comparing the locations of medical school and residency programs for PGY-1 residents to determine the number of matriculants from in-state medical schools and out-of-state medical schools. International medical school graduates (IMGs) were shown separately in the analysis and then combined with out-of-state matriculants. US citizens who trained abroad were counted among IMGs. RESULTS: The total number of PGY-1s increased by 10.3% during the 3-year time period, from 29 338 to 32 348. When combined, IMGs and USMGs transitioning from one state or country to another state accounted for approximately 72% of PGY-1s each year. Approximately 63% of USMGs matriculated to a residency program in a new state, and IMGs made up 24.6% to 23.1% of PGY-1s over the 3-year period. CONCLUSIONS: Each year brings a substantial amount of movement among PGY-1s that highlights the need for policies and procedures specific to the COVID-19 pandemic.

Elevating Resident Voices in Health Systems Change: Lessons From the Closure of Hahnemann University Hospital.

The closure of Philadelphia's Hahnemann University Hospital (HUH) in summer 2019 brought an abrupt end to its status as a sponsor of graduate medical education (GME). The Accreditation Council for Graduate Medical Education (ACGME) provided assistance to ensure that more than 550 residents and fellows in HUH's 35 ACGME-accredited programs were able to transfer to new programs in which they could continue their education. As the ACGME joined other organizations in responding to HUH's closure, it was apparent that the voices of residents and fellows should be emphasized in regulatory processes and policies that address substantial disruptions to GME and affect their education, their daily lives, and their professional futures.

Using Longitudinal Milestones Data and Learning Analytics to Facilitate the Professional Development of Residents: Early Lessons From Three Specialties.

PURPOSE: To investigate the effectiveness of using national, longitudinal milestones data to provide formative assessments to identify residents at risk of not achieving recommended competency milestone goals by residency completion. The investigators hypothesized that specific, lower milestone ratings at earlier time points in residency would be predictive of not achieving recommended Level (L) 4 milestones by graduation. METHOD: In 2018, the investigators conducted a longitudinal cohort study of emergency medicine (EM), family medicine (FM), and internal medicine (IM) residents who completed their residency programs from 2015 to 2018. They calculated predictive values and odds ratios, adjusting for nesting within programs, for specific milestone rating thresholds at 6-month intervals for all subcompetencies within each specialty. They used final milestones ratings (May-June 2018) as the outcome variables, setting L4 as the ideal educational outcome. RESULTS: The investigators included 1,386 (98.9%) EM residents, 3,276 (98.0%) FM residents, and 7,399 (98.0%) IM residents in their analysis. The percentage of residents not reaching L4 by graduation ranged from 11% to 31% in EM, 16% to 53% in FM, and 5% to 15% in IM. Using a milestone rating of L2.5 or lower at the end of post-graduate year 2, the predictive probability of not attaining the L4 milestone graduation goal ranged from 32% to 56% in EM, 32% to 67% in FM, and 15% to 36% in IM. CONCLUSIONS: Longitudinal milestones ratings may provide educationally useful, predictive information to help individual residents address potential competency gaps, but the predictive power of the milestones ratings varies by specialty and subcompetency within these 3 adult care specialties.

Discrimination, Abuse, Harassment, and Burnout in Surgical Residency Training.

BACKGROUND: Physicians, particularly trainees and those in surgical subspecialties, are at risk for burnout. Mistreatment (i.e., discrimination, verbal or physical abuse, and sexual harassment) may contribute to burnout and suicidal thoughts. METHODS: A cross-sectional national survey of general surgery residents administered with the 2018 American Board of Surgery In-Training Examination assessed mistreatment, burnout (evaluated with the use of the modified Maslach Burnout Inventory), and suicidal thoughts during the past year. We used multivariable logistic-regression models to assess the association of mistreatment with burnout and suicidal thoughts. The survey asked residents to report their gender. RESULTS: Among 7409 residents (99.3% of the eligible residents) from all 262 surgical residency programs, 31.9% reported discrimination based on their self-identified gender, 16.6% reported racial discrimination, 30.3% reported verbal or physical abuse (or both), and 10.3% reported sexual harassment. Rates of all mistreatment measures were higher among women; 65.1% of the women reported gender discrimination and 19.9% reported sexual harassment. Patients and patients' families were the most frequent sources of gender discrimination (as reported by 43.6% of residents) and racial discrimination (47.4%), whereas attending surgeons were the most frequent sources of sexual harassment (27.2%) and abuse (51.9%). Proportion of residents reporting mistreatment varied considerably among residency programs (e.g., ranging from 0 to 66.7% for verbal abuse). Weekly burnout symptoms were reported by 38.5% of residents, and 4.5% reported having had suicidal thoughts during the past year. Residents who reported exposure to discrimination, abuse, or harassment at least a few times per month were more likely than residents with no reported mistreatment exposures to have symptoms of burnout (odds ratio, 2.94; 95% confidence interval [CI], 2.58 to 3.36) and suicidal thoughts (odds ratio, 3.07; 95% CI, 2.25 to 4.19). Although models that were not adjusted for mistreatment showed that women were more likely than men to report burnout symptoms (42.4% vs. 35.9%; odds ratio, 1.33; 95% CI, 1.20 to 1.48), the difference was no longer evident after the models were adjusted for mistreatment (odds ratio, 0.90; 95% CI, 0.80 to 1.00). CONCLUSIONS: Mistreatment occurs frequently among general surgery residents, especially women, and is associated with burnout and suicidal thoughts.

National Evaluation of Needlestick Events and Reporting Among Surgical Residents.

BACKGROUND: Needlestick injuries pose significant health hazards; however, the nationwide frequency of needlesticks and reporting practices among surgical residents are unknown. The objectives of this study were to examine the rate and circumstances of self-reported needlestick events in US surgery residents, assess factors associated with needlestick injuries, evaluate reporting practices, and identify reporting barriers. STUDY DESIGN: A survey administered after the American Board of Surgery In-Training Examination (January 2017) asked surgical residents how many times they experienced a needlestick during the last 6 months, circumstances of the most recent event, and reporting practices and barriers. Factors associated with needlestick events were examined using multivariable hierarchical regression models. RESULTS: Among 7,395 resident survey respondents from all 260 US general surgery residency programs (99.3% response rate), 27.7% (n = 2,051) noted experiencing a needlestick event in the last 6 months. Most events occurred in the operating room (77.5%) and involved residents sticking themselves (76.2%), mostly with solid needles (84.7%). Self-reported factors underlying needlestick events included residents' own carelessness (48.8%) and feeling rushed (31.3%). Resident-level factors associated with self-reported needlestick events included senior residents (PGY5 29.9% vs PGY1 22.4%; odds ratio 1.66; 95% CI 1.41 to 1.96), female sex (31.9% vs male 25.2%; odds ratio 1.31; 95% CI 1.18 to 1.46), or frequently working more than 80 hours per week (odds ratio 1.42; 95% CI 1.20 to 1.68). More than one-fourth (28.7%) of residents did not report the needlestick event to employee health. CONCLUSIONS: In this comprehensive national survey of surgical residents, needlesticks occurred frequently. Many needlestick events were not reported and numerous reporting barriers exist. These findings offer guidance in identifying opportunities to reduce needlesticks and encourage reporting of these potentially preventable injuries among trainees.

Navigating Tumultuous Change in the Medical Profession: The Coalition for Physician Accountability.

Collaboration among the national organizations responsible for self-regulation in medicine in the United States is critical, as achieving the quadruple aim of enhancing the patient experience and improving population health while lowering costs and improving the work life of clinicians and staff is becoming more challenging. The leaders of the national organizations responsible for accreditation, assessment, licensure, and certification recognize this and have come together as the Coalition for Physician Accountability. The coalition, which meets twice per year, was created in 2011 as a discursive space for group discussion and action related to advancing health care, promoting professional accountability, and improving the education, training, and assessment of physicians. The coalition offers a useful avenue for members to seek common ground and develop constructive, thoughtful solutions to common challenges. Its members have endorsed consensus statements about current topics relevant to health care regulation, advanced innovation in medical school curricula, encouraged a plan for single graduate medical education accreditation for physicians holding MD and DO degrees, supported interprofessional education, championed opioid epidemic mitigation strategies, and supported initiatives responsive to physician workforce shortages, including the Interstate Medical Licensure Compact, an expedited pathway by which eligible physicians may be licensed to practice in multiple jurisdictions.