Implementation of entrustable professional activities in multiple surgical residencies: A quality improvement approach.

BACKGROUND: The COVID-19 pandemic decreased the operative case volume for surgical residents. Our institution implemented Entrustable Professional Activities (EPAs) in all core surgical training programs to document the competency of graduating residents. Continuation of this project aimed to improve implementation. METHODS: This project occurred at a large academic center with eight surgical specialties during the 2020-21 (Year 1) and 2021-22 (Year 2) academic years. Each specialty chose five EPAs, and residents were asked to obtain three micro-assessments per EPA. After the initial pilot year, program directors were surveyed regarding perceptions of EPA utility and barriers to implementation. RESULTS: Seventy senior residents completed 732/906 (80.8%) micro-assessments. Of these, 99.6% were deemed practice ready. Total micro-assessment completion rates in four specialties, four specific EPAs (including one EPA identified "at risk" due to the COVID-19 pandemic), and overall were significantly higher in Year 2 than Year 1 (p â€‹< â€‹0.05) CONCLUSIONS: Implementing EPAs in all core surgical specialties at an institution is achievable, though expectedly initially imperfect. An ongoing quality collaborative initiative focused on barriers to implementation can improve completion rates.

The Prevalence of Faculty Physician Burnout in Military Graduate Medical Education Training Programs: A Cross-Sectional Study of Academic Physicians in the United States Department of Defense.

INTRODUCTION: In military populations, physician burnout has potential to adversely affect medical readiness to deploy in support of joint operations. Burnout among Graduate Medical Education (GME) faculty may further threaten the welfare of the medical force given the central role these officers have in training and developing junior physicians. The primary aim of this investigation was to estimate the prevalence of burnout among faculty physicians in United States (US) Army, Navy, and Air Force GME programs. MATERIALS AND METHODS: We conducted a cross-sectional study of faculty physicians at US military GME training programs between January 2018 and July 2018. Through direct coordination with Designated Institutional Officials, we administered the Maslach Burnout Inventory Health Services Survey (MBI-HSS) via online web link to faculty physicians listed in Accreditation Data System at each sponsoring institution. In addition to the MBI-HSS, we collected demographic data and queried physicians about common occupational stressors in order to assist institutional leaders with identifying at-risk physicians and developing future interventions to address burnout. RESULTS: Sixteen of 21 institutions that currently sponsor military GME programs agreed to distribute the MBI-HSS survey to core faculty. We received completed assessments from 622 of the 1,769 (35.1%) reported physician core faculty at these institutions. Of the 622 physician respondents, 162 demonstrated high levels of emotional exhaustion and depersonalization for an estimated 26% prevalence of burnout. We identified only one independent risk factor for burnout: increasing numbers of deployments (OR 1.38, 95% CI 1.07-1.77). Physicians in our cohort who reported a desire to stay beyond their initial active duty service obligation were less likely to be classified with burnout (OR 0.45, 95% CI 0.26-0.77). The most common drivers of occupational distress were cumbersome bureaucratic tasks, insufficient administrative support, and overemphasis on productivity metrics. CONCLUSIONS: We estimate that 26% of physician faculty in military GME programs are experiencing burnout. No specialty, branch of service, or specific demographic was immune to burnout in our sample. Institutional leaders in the MHS should take action to address physician burnout and consider using our prevalence estimate to assess effectiveness of future interventions.

Assessing Mentorship Experiences of Faculty at a Military Academic Center: Challenge and Opportunity.

OBJECTIVES: Mentor relationships are a key component of professional development within academic medicine. To date, there are no investigations into the prevalence and effects of mentor relationships within military academic medicine. This quality improvement initiative aimed to establish the prevalence and effects of mentorship, including whether sex differences exist among faculty at a military academic center, the San Antonio Uniformed Services Health Education Consortium, and identify opportunities to improve faculty development efforts for mentorship to benefit faculty at this institution. METHODS: A 17-item survey was developed using an iterative process. Using the SurveyMonkey platform, the survey was distributed to each faculty member within the 33 Accreditation Council for Graduate Medical Education-accredited programs. RESULTS: A total of 104 responses (26%) were received from 393 total faculty members, including 48 Air Force, 45 Army, 3 Navy, and 8 Contractor/Government Service respondents. Thirty-four respondents were women (33%) and 70 were men (67%). Only 42% of faculty reported currently having a mentor. Thirty-nine respondents (38%; 44% men and 27% women) received formal mentorship at their first staff physician position after residency training. Mentorship helped respondents the most in the areas of clinical skills, understanding departmental/institutional culture, professionalism/officership, academic promotion/advancement, and clarification of priorities/goals. When asked whether more effective mentorship would affect their own decision to remain on active-duty military service, 14% responded "yes" and 28% responded "possibly." CONCLUSIONS: Increased mentorship has the potential to positively affect career development in military academic military medicine. Results from this study affirm previous reports that effective mentorship potentially represents a powerful tool for faculty retention. Future study should include other military medical academic centers to assess the generalizability of these results across US military medicine.

Self vs. Other Focus: Predicting Professionalism Remediation of Emergency Medicine Residents.

INTRODUCTION: Unprofessionalism is a major reason for resident dismissal from training. Because of the high stakes involved, residents and educators alike would benefit from information predicting whether they might experience challenges related to this competency. Our objective was to correlate the outcome of professionalism-related remedial actions during residency with the predictor variable of resident response to a standardized interview question: "Why is Medicine important to you?" METHODS: We conducted a professional development quality improvement (QI) initiative to improve resident education and mentorship by achieving a better understanding of each resident's reasons for valuing a career in medicine. This initiative entailed an interview administered to each resident beginning emergency medicine training at San Antonio Military Medical Center during 2006-2013. The interviews uniformly began with the standardized question "Why is Medicine important to you?" The residency program director documented a free-text summary of each response to this question, the accuracy of which was confirmed by the resident. We analyzed the text of each resident's response after a review of the QI data suggested an association between responses and professionalism actions (retrospective cohort design). Two associate investigators blinded to all interview data, remedial actions, and resident identities categorized each text response as either self-focused (e.g., "I enjoy the challenge") or other-focused (e.g., "I enjoy helping patients"). Additional de-identified data collected included demographics, and expressed personal importance of politics and religion. The primary outcome was a Clinical Competency Committee professionalism remedial action. RESULTS: Of 114 physicians starting residency during 2006-2013, 106 (93.0%) completed the interview. There was good inter-rater reliability in associate investigator categorization of resident responses as either self-focused or other-focused (kappa coefficient 0.85). Thirteen of 50 residents (26.0%) expressed self-focus versus three of 54 (5.4%) residents expressed other-focus experienced professionalism remedial actions (p<0.01). This association held in a logistic regression model controlling for measured confounders (p=0.02). CONCLUSION: Self-focused responses to the question "Why is Medicine important to you?" correlated with professionalism remedial actions during residency.

Structures of riboswitch RNA reaction states by mix-and-inject XFEL serial crystallography.

Riboswitches are structural RNA elements that are generally located in the 5' untranslated region of messenger RNA. During regulation of gene expression, ligand binding to the aptamer domain of a riboswitch triggers a signal to the downstream expression platform. A complete understanding of the structural basis of this mechanism requires the ability to study structural changes over time. Here we use femtosecond X-ray free electron laser (XFEL) pulses to obtain structural measurements from crystals so small that diffusion of a ligand can be timed to initiate a reaction before diffraction. We demonstrate this approach by determining four structures of the adenine riboswitch aptamer domain during the course of a reaction, involving two unbound apo structures, one ligand-bound intermediate, and the final ligand-bound conformation. These structures support a reaction mechanism model with at least four states and illustrate the structural basis of signal transmission. The three-way junction and the P1 switch helix of the two apo conformers are notably different from those in the ligand-bound conformation. Our time-resolved crystallographic measurements with a 10-second delay captured the structure of an intermediate with changes in the binding pocket that accommodate the ligand. With at least a 10-minute delay, the RNA molecules were fully converted to the ligand-bound state, in which the substantial conformational changes resulted in conversion of the space group. Such notable changes in crystallo highlight the important opportunities that micro- and nanocrystals may offer in these and similar time-resolved diffraction studies. Together, these results demonstrate the potential of 'mix-and-inject' time-resolved serial crystallography to study biochemically important interactions between biomacromolecules and ligands, including those that involve large conformational changes.

Air Force academic medicine: a climate survey.

Air Force (AF) Medical Service leadership considers education, training, and research as key priorities. However, AF academic physicians' perceptions about the academic environment and challenges to success are not well described. AF faculty physicians were surveyed in autumn 2009. One hundred seventy-two responded and rated the academic environment as needing improvement (median Likert-like score 2 [interquartile range 1] on 1-5 scale). The impact of stepping away from an academically oriented career path for other executive positions was rated negatively (median Likert-like score 2, interquartile range 1). Concerns included loss of clinical skills, career disruption, and the challenge of returning to and/or competing for positions within the academic pathway. New policies limiting deployment of Program Directors and/or key teaching faculty were viewed favorably. Most physicians (59%) completing this survey expressed concerns about the AF academic environment and identified numerous challenges. Information from this survey can guide future initiatives to enhance leadership's goals.

Dynamics of biological macromolecules: not a simple slaving by hydration water.

We studied the dynamics of hydrated tRNA using neutron and dielectric spectroscopy techniques. A comparison of our results with earlier data reveals that the dynamics of hydrated tRNA is slower and varies more strongly with temperature than the dynamics of hydrated proteins. At the same time, tRNA appears to have faster dynamics than DNA. We demonstrate that a similar difference appears in the dynamics of hydration water for these biomolecules. The results and analysis contradict the traditional view of slaved dynamics, which assumes that the dynamics of biological macromolecules just follows the dynamics of hydration water. Our results demonstrate that the dynamics of biological macromolecules and their hydration water depends strongly on the chemical and three-dimensional structures of the biomolecules. We conclude that the whole concept of slaving dynamics should be reconsidered, and that the mutual influence of biomolecules and their hydration water must be taken into account.

Dynamics of tRNA at different levels of hydration.

The influence of hydration on the nanosecond timescale dynamics of tRNA is investigated using neutron scattering spectroscopy. Unlike protein dynamics, the dynamics of tRNA is not affected by methyl group rotation. This allows for a simpler analysis of the influence of hydration on the conformational motions in RNA. We find that hydration affects the dynamics of tRNA significantly more than that of lysozyme. Both the characteristic length scale and the timescale of the conformational motions in tRNA depend strongly on hydration. Even the characteristic temperature of the so-called "dynamical transition" appears to be hydration-dependent in tRNA. The amplitude of the conformational motions in fully hydrated tRNA is almost twice as large as in hydrated lysozyme. We ascribe these differences to a more open and flexible structure of hydrated RNA, and to a larger fraction and different nature of hydrophilic sites. The latter leads to a higher density of water that makes the biomolecule more flexible. All-atom molecular-dynamics simulations are used to show that the extent of hydration is greater in tRNA than in lysozyme. We propose that water acts as a "lubricant" in facilitating enhanced motion in solvated RNA molecules.

Persistence length changes dramatically as RNA folds.

We determine the persistence length l(p) for a bacterial group I ribozyme as a function of concentration of monovalent and divalent cations by fitting the distance distribution functions P(r) obtained from small angle x-ray scattering intensity data to the asymptotic form of the calculated P(WLC)(r) for a wormlike chain. The l(p) values change dramatically over a narrow range of Mg(2+) concentration from approximately 21 Angstroms in the unfolded state (U) to approximately 10 Angstroms in the compact (I(C)) and native states. Variations in l(p) with increasing Na(+) concentration are more gradual. In accord with the predictions of polyelectrolyte theory we find l(p) alpha 1/kappa(2) where kappa is the inverse Debye-screening length.

An intentional modeling process to teach professional behavior: students' clinical observations of preceptors.

BACKGROUND: Most formal instruction in professionalism and communication occurs in the preclinical years of medical school, with an acknowledged need to fortify and apply these competencies during the clinical years. Role modeling provides a powerful way to teach professionalism, particularly when mentors identify specific learning goals and focus the learners' observations. DESCRIPTION: The authors discuss an innovative process, called Students' Clinical Observations of Preceptors (SCOOP), which reverses the traditional direction of structured observations. With written cues to focus their observations, students observe their preceptors, who intentionally model professionalism and communication during clinical encounters. Students and preceptors discuss the observed patient-physician interaction during postencounter sessions. EVALUATION: Most medical students rated the SCOOP process highly and reported professional behaviors they gained. CONCLUSION: As educators seek methods for learners to attain greater competence in communication and interpersonal skills, the SCOOP provides an explicit framework to optimize modeling for the learning of professionalism.

Assessment of pediatric residents' otoscopic interpretive skills by videotaped examinations.

BACKGROUND: Accurate diagnosis of otitis media is essential to facilitate appropriate management. Few residency programs assess formally their residents' competency in diagnosing middle ear disease. OBJECTIVE: To evaluate the performance of pediatric residents' otoscopic interpretive skills by level of training, with a videotaped otoendoscopic examination (VOE). METHODS: A VOE was used to assess and compare the performance of a cross-sectional sample of 141 residents with one another by level of training as well as with novice and expert groups. Total score, sensitivity, specificity, and kappa coefficients were calculated for each subject by comparing the subject's answers on the 50-ear test with the VOE's expert panel-derived answers, and averages were determined for each training level. RESULTS: Each pediatric resident training group had moderate agreement (mean kappa coefficient range: .45-.56) with the VOE answers, compared with the novice group (mean kappa: .31, fair) and expert group (mean kappa: .80, substantial). Twenty-eight residents (20%) had fair or less agreement (kappa<.41) with the VOE answers. The mean total scores of all pediatric resident training levels were significantly (P<.05) lower than the expert group and significantly (P<.05) higher than the novice group (with exception of the early postgraduate year-1 group). Subjects with more training had higher kappa levels (r=.33,<.001, Spearman) when results were compared among novice, residents, and experts. CONCLUSIONS: We found the VOE to be a feasible and reliable instrument to accurately distinguish novice, resident, and expert level skills in the determination of middle ear effusion status.

How helpful is pneumatic otoscopy in improving diagnostic accuracy?

BACKGROUND: Pneumatic otoscopy is believed to be helpful in optimally assessing the presence or absence of middle ear effusion (MEE). Although expert clinicians teach the importance of this diagnostic skill to trainees, evidence exists that many pediatric providers do not typically perform pneumatic otoscopy. OBJECTIVE: To determine if the otoscopic accuracy within a group of clinicians improves with the pneumatic assessment when compared with the static assessment using videotaped otoendoscopic examinations (VOEs). METHODS: Residents and faculty from 2 pediatric training programs served as subjects. All viewed a set of 50 video otoscopic examinations of tympanic membranes (TMs) from a validated VOE developed previously for training purposes. The video displays each TM in a static presentation and then in a pneumatic (mobile) presentation, followed by a final static presentation. Each subject first viewed the initial static presentation of each TM and responded "yes/no" to the presence of MEE, and then viewed the pneumatic presentation of the same TM and again responded "yes/no" to the presence of MEE. We compared the accuracy of assessment for both the static and the pneumatic tests. RESULTS: Thirty-four pediatric residents and 6 clinical faculty participated. Accuracy (percent of total test items correct) on the pneumatic test was uniformly greater than accuracy on the static test. The mean absolute improvement in the accuracy from the static test (61%) to the pneumatic test (76%) was 15% (95% confidence interval [CI] = 12%-18%). The mean relative improvement in accuracy from the static test to the pneumatic test was 26% (95% CI = 19%-32%). Higher accuracy on the VOE was associated with greater absolute (r = 0.57) and greater relative (r = 0.47) improvement. The mean relative improvement in sensitivity and specificity from static viewing to pneumatic viewing was 24% (95% CI = 15%-33%) and 42% (95% CI = 27%-58%), respectively. CONCLUSIONS: Using a video otoendoscopic test, we found that accurate identification of both the presence and the absence of MEE improved after pneumatic assessment of TM mobility. Providers who were more accurate at otoscopy, defined by higher video total test scores, benefited more from the pneumatic component than providers with lower scores.

Folding mechanisms of group I ribozymes: role of stability and contact order.

The mechanism by which RNA molecules assemble into unique three-dimensional conformations is important for understanding their function, regulation and interactions with substrates. The Tetrahymena group I ribozyme is an excellent model system for understanding RNA folding mechanisms, because the catalytic activity of the native RNA is easily measured. Folding of the Tetrahymena ribozyme is dominated by intermediates in which the stable P4-P6 domain is correctly formed, but the P3-P9 domain is partially misfolded. The propensity of the RNA to misfold depends on the relative stability of native and non-native interactions. Circular permutation of the Tetrahymena ribozyme shows that the distance in the primary sequence between native interactions also influences the folding pathway.

Role of counterion condensation in folding of the Tetrahymena ribozyme. II. Counterion-dependence of folding kinetics.

Condensed counterions contribute to the stability of compact structures in RNA, largely by reducing electrostatic repulsion among phosphate groups. Varieties of cations induce a collapsed state in the Tetrahymena ribozyme that is readily transformed to the catalytically active structure in the presence of Mg2+. Native gel electrophoresis was used to compare the effects of the valence and size of the counterion on the kinetics of this transition. The rate of folding was found to decrease with the charge of the counterion. Transitions in monovalent ions occur 20- to 40-fold faster than transitions induced by multivalent metal ions. These results suggest that multivalent cations yield stable compact structures, which are slower to reorganize to the native conformation than those induced by monovalent ions. The folding kinetics are 12-fold faster in the presence of spermidine3+ than [Co(NH3)6]3+, consistent with less effective stabilization of long-range RNA interactions by polyamines. Under most conditions, the observed folding rate decreases with increasing counterion concentration. In saturating amounts of counterion, folding is accelerated by addition of urea. These observations indicate that reorganization of compact intermediates involves partial unfolding of the RNA. We find that folding of the ribozyme is most efficient in a mixture of monovalent salt and Mg2+. This is attributed to competition among counterions for binding to the RNA. The counterion dependence of the folding kinetics is discussed in terms of the ability of condensed ions to stabilize compact structures in RNA.