Resident Wellness and Social Support: Development and Cognitive Validation of a Resident Social Capital Assessment Tool.

OBJECTIVE: The purpose of this study is to develop and generate validity evidence for an instrument to measure social capital in residents. DESIGN: Mixed-methods, phased approach utilizing a modified Delphi technique, focus groups, and cognitive interviews. SETTING: Four residency training institutions in Washington state between February 2016 and March 2017. PARTICIPANTS: General surgery, anesthesia, and internal medicine residents ranging from PGY-1 to PGY-6. RESULTS: The initial resident-focused instrument underwent revision via Delphi process with 6 experts; 100% expert consensus was achieved after 4 cycles. Three focus groups were conducted with 19 total residents. Focus groups identified 6 of 11 instrument items with mean quality ratings ≤4.0 on a 1-5 scale. The composite instrument rating of the draft version was 4.1 ± 0.5. After refining the instrument, cognitive interviews with the final version were completed with 22 residents. All items in the final version had quality ratings >4.0; the composite instrument rating was 4.8 ± 0.1. CONCLUSIONS: Social capital may be an important factor in resident wellness as residents rely upon each other and external social support to withstand fatigue, burnout, and other negative sequelae of rigorous training. This instrument for assessment of social capital in residents may provide an avenue for data collection and potentially, identification of residents at-risk for wellness degradation.

"I got it on Ebay!": cost-effective approach to surgical skills laboratories.

BACKGROUND: Surgical education is witnessing a surge in the use of simulation. However, implementation of simulation is often cost-prohibitive. Online shopping offers a low budget alternative. The aim of this study was to implement cost-effective skills laboratories and analyze online versus manufacturers' prices to evaluate for savings. MATERIALS AND METHODS: Four skills laboratories were designed for the surgery clerkship from July 2014 to June 2015. Skills laboratories were implemented using hand-built simulation and instruments purchased online. Trademarked simulation was priced online and instruments priced from a manufacturer. Costs were compiled, and a descriptive cost analysis of online and manufacturers' prices was performed. Learners rated their level of satisfaction for all educational activities, and levels of satisfaction were compared. RESULTS: A total of 119 third-year medical students participated. Supply lists and costs were compiled for each laboratory. A descriptive cost analysis of online and manufacturers' prices showed online prices were substantially lower than manufacturers, with a per laboratory savings of: $1779.26 (suturing), $1752.52 (chest tube), $2448.52 (anastomosis), and $1891.64 (laparoscopic), resulting in a year 1 savings of $47,285. Mean student satisfaction scores for the skills laboratories were 4.32, with statistical significance compared to live lectures at 2.96 (P < 0.05) and small group activities at 3.67 (P < 0.05). CONCLUSIONS: A cost-effective approach for implementation of skills laboratories showed substantial savings. By using hand-built simulation boxes and online resources to purchase surgical equipment, surgical educators overcome financial obstacles limiting the use of simulation and provide learning opportunities that medical students perceive as beneficial.

Defining Honors in the Surgery Clerkship.

BACKGROUND: Although highly influential, no published criteria exist that define who should receive the highest grade in the core surgery clerkship ("honors"). Therefore, significant variability exists in how this evaluation is assigned. Identifying the critical characteristics of the student receiving this grade can improve its usefulness in residency selection, class standing, and direct students' efforts. The purpose of this study was to attain expert consensus on the characteristics of an honors student in the core surgery clerkship. STUDY DESIGN: A 3-round modified Delphi technique was used in 2 parallel cycles to obtain expert consensus from the major stakeholders-program directors and clerkship directors in surgery. Experts were recruited from across the United States, although not from the same institutions. The 2 consensus lists were evaluated for congruency. RESULTS: All 15 of the invited clerkship directors and 14 of 15 invited program directors participated. A total of 65 unique characteristics were submitted by program directors and consensus was reached on 23. Clerkship directors submitted 62 characteristics and achieved agreement on 22. Ten of the final characteristics were identical between the 2 groups. These were communication skills, "shelf" exam score, synthetic ability (organizing data into meaningful care plans), absence of professionalism issues, outstanding work ethic, taking advantage of learning opportunities, accurate and complete history and physicals, enthusiasm, becoming an essential member of the care team, and outstanding clinical acumen. CONCLUSIONS: Expert consensus on the characteristics of an honors student in the core surgery clerkship was achieved. By using these criteria, the honors grade becomes emblematic of these 10 characteristics. This might reduce grade inflation within and between institutions, provide program directors with a consistent and reliable assessment of excellence, and effectively direct student efforts.

We Wear Suits and Lie to Each Other.

OBJECTIVE: The residency match process is stressful and costly for fourth-year medical students with significant personal and professional implications. We hypothesize that students use impression management (IM) tactics such as conforming to the perceived expectations of program directors and interviewers and to improve their chances of matching. DESIGN: After institutional review board approval, a piloted survey tool was administered to fourth-year medical students at 17 schools. Questions were divided into interviewing behavior categories-slight image creation (embellishing and tailoring), extensive image creation (constructing, inventing, and borrowing), image protection (omitting), and ingratiation (opinion conforming). Descriptive statistics are presented as percentages. Data were analyzed using chi-square test, Fischer exact test, and Bonferroni-adjusted p values where appropriate with statistical significance set at p < 0.05. SETTING: Allopathic medical schools in the United States. PARTICIPANTS: Fourth-year medical students in the United States. RESULTS: The response rate was 21.3%. Respondents were equally male (49.7%)/female (50.3%), primarily 25 to 27-year old (65.9%) and located in the midwest (78.8%). Most attended public medical schools (73.1%). Statistically significant findings are presented in the Tables. CONCLUSIONS: Fourth-year medical students feel the need, and in some instances, actually engage in IM tactics. This study demonstrates that IM tactics are used, and vary by interviewee characteristics. Program directors' awareness of IM tactics may help improving the quality of residency interviews and therefore select more suitable candidates.

Evolving Educational Techniques in Surgical Training.

Training competent and professional surgeons efficiently and effectively requires innovation and modernization of educational methods. Today's medical learner is quite adept at using multiple platforms to gain information, providing surgical educators with numerous innovative avenues to promote learning. With the growth of technology, and the restriction of work hours in surgical education, there has been an increase in use of simulation, including virtual reality, robotics, telemedicine, and gaming. The use of simulation has shifted the learning of basic surgical skills to the laboratory, reserving limited time in the operating room for the acquisition of complex surgical skills".

The sum is greater than its parts: clinical evaluations and grade inflation in the surgery clerkship.

BACKGROUND: This study examines grading component distributions to determine whether alterations in clinical grade determination reduce skew and improve predictive capability of the clinical evaluation. METHODS: Rotation evaluations, examination scores, and final grades were collected for third-year medical students over a 2-year period. Conditional logistic regression and ordinary least squares regression models were run using SAS 9.3. RESULTS: Conditional logistic regression demonstrated significant association between global clinical score and final grade and between average clinical evaluation score and final grade. Inclusion of shelf score into either model demonstrated increase in overall final grade. CONCLUSIONS: Regressions using global and average clinical evaluation score indicate that average score is a better fit for a norm-based grading system. Arguably, the Shelf measures clinical knowledge more objectively than clinical evaluation, but both were significant. Clinical evaluation is prone to inflation because of its subjective nature; conceivably, inflation leads to the decreased correlation with shelf score.

The role of gender and distance mentoring in the surgical education research fellowship.

OBJECTIVE: The nature of the mentor-mentee relationship is important in the pursuit of successful research projects. The purpose of this study is to evaluate the mentor-mentee relationships in the Surgical Education Research Fellowship (SERF) based on gender and geographical distances regarding program completion. We hypothesize that there are no differences for SERF program completion rates based on gender pairs and distances between pairs. METHODS: This was a retrospective study from 2006 to 2011. Mentor-mentee rosters were retrospectively reviewed for program completion, demographics, and PubMeD indexing. Time zone differences and geographic distances between pairs were found with online applications. Chi-square tests were used for categorical variables and nonparametric statistics were carried out using α = 0.05. RESULTS: Of the 82 individuals accepted into the SERF program, 43 (52%) completed the SERF program during the study period. There were no differences in program completion rates based on fellow gender and gender pairing (all p > 0.05). Different-gender pairs that completed the program (n = 17) were indexed more frequently on PubMed than same-gender pairs that completed the program (n = 24) (41% vs 12%, p = 0.04). There were no differences in program completion based on time zone differences (p = 0.20). The median distance between pairs completing the program (n = 35) was greater than that for pairs not completing the program (n = 36) (1741 km [IQR: 895-3117 km] vs 991 km [IQR: 676-2601 km]; p = 0.03). CONCLUSION: Completion of the SERF program was independent of mentor-mentee gender pairs and time zone differences. There was greater geographical distance separating mentor-mentee pairs that completed the SERF program compared with pairs that did not complete the program. Distance mentoring is a successful and crucial element of the SERF program.

Workplace bullying of general surgery residents by nurses.

OBJECTIVE: Workplace bullying is at the forefront of social behavior research, garnering significant media attention. Most of the medical research has addressed bullying of nurses by physicians and demonstrates that patient care and outcomes may suffer. The intent of this study was to determine if general surgery residents are bullied by nurses. DESIGN: A survey instrument previously validated (Negative Acts Questionnaire-Revised) to evaluate for workplace bullying was modified to reflect the resident-nurse relationship. After institutional review board approval, the piloted online survey was sent to general surgery program directors to forward to general surgery residents. Demographic data are presented as percentages, and for negative acts, percentages of daily, weekly, and monthly frequencies are combined. SETTING: Allopathic general surgery residencies in the United States. PARTICIPANTS: General surgery residents. RESULTS: The response rate was 22.1% (n = 452). Most respondents were men (55%) and had a mean age of 29 years (standard deviation = 7). Although 27.0% of the respondents were interns, the remaining classes were equally represented (12%-18% of responses/class). The respondents were primarily from medium-sized residency programs (45%), in the Midwest (28%), training in university programs (72%), and rotating primarily in a combined private and county hospital that serves both insured and indigent patients (59%). The residents had experienced each of the 22 negative acts (11.5%-82.5%). Work-related bullying occurs more than person-related bullying and physical intimidation. Ignoring of recommendations or orders by nurses occurs on a daily, weekly, or monthly basis for 30.2% of residents (work-related bullying). The most frequent person-related bullying act is ignoring the resident when they approach or reacting in a hostile manner (18.0%), followed by ignoring or excluding the resident (17.1%). CONCLUSIONS: Workplace bullying of general surgery residents by nurses is prominent. Future research is needed to determine the toll on the resident's well-being and patient outcomes.

It was the night before the interview: perceptions of resident applicants about the preinterview reception.

OBJECTIVE: Hosting a reception for prospective interns the evening before the interview has become a well-established expectation. It is thought that these initial impressions significantly influence the ranking process. Despite these well-held beliefs, there has been a paucity of studies exploring the preinterview reception. DESIGN: A survey tool was created and piloted to ensure validity. The survey was then administered to a fourth-year class of allopathic medical students immediately after interviews but before Match Day. SETTING: A university, teaching hospital. PARTICIPANTS: Fourth-year allopathic medical students. RESULTS: The response rate was 100% (n = 69). Ninety-six percent of programs hosted an event. Although these events were minimally stressful (86%), the same percent felt that not attending would limit their knowledge of the program, and 66% felt that it would negatively affect their application. Forty percent believe this event to be extremely important to residency programs in selecting interns. Ninety-five percent are attended by residents only, and approximately half were at a casual restaurant. Most applicants (97%) never paid for their own meal, and 69% felt that if they did, it would leave a negative impression of the program. CONCLUSIONS: Candidates believe the preinterview reception is important in the selection process, that failing to attend would negatively affect their application, and provides insight about the program. Alcohol is often provided but rarely has a negative effect. Applicants prefer an informal setting with unfettered interactions with the residents.

Educational impact of the electronic medical record.

INTRODUCTION: The electronic medical record (EMR) is commonly thought to improve the safety and quality of care; however, there is scant information on the impact the EMR has on graduate medical education (GME). METHODS: A review of English language literature was performed using MEDLINE and OVID databases using or combining the terms, EMR, GME, electronic health record, education, medical student, resident, clinical decisions support systems, quality, and safety. RESULTS: The EMR has a negative effect on teacher and learner interactions, clinical reasoning, and has an inconsistent impact on resident workflow. Data on the impact of the EMR on patient safety, quality of care, and medical finances are mixed. DISCUSSION: Based on the literature to date, the EMR has not had as dramatic an effect on patient outcomes is commonly believed. While the overall impact of the EMR on education seems to be negative, there are actions that can be taken to mitigate this impact.

Using elements from an acute abdominal pain Objective Structured Clinical Examination (OSCE) leads to more standardized grading in the surgical clerkship for third-year medical students.

BACKGROUND: There is poor reliability in the Likert-based assessments of patient interaction and general knowledge base for medical students in the surgical clerkship. The Objective Structured Clinical Examination (OSCE) can be used to assess these competencies. OBJECTIVE: We hypothesize that using OSCE performance to replace the current Likert-based patient interaction and general knowledge base assessments will not affect the pass/fail rate for third-year medical students in the surgical clerkship. METHODS: In this retrospective study, third-year medical student clerkship data from a three-station acute abdominal pain OSCE were collected from the 2009-2010 academic year. New patient interaction and general knowledge base assessments were derived from the performance data and substituted for original assessments to generate new clerkship scores and ordinal grades. Two-sided nonparametric statistics were used for comparative analyses, using an α = 0.05. RESULTS: Seventy third-year medical students (50.0% female) were evaluated. A sign test showed a difference in the original (4.45/5) and the new (4.20/5) median patient interaction scores (p < 0.01). A sign test did not show a difference in the original (4.00/5) and the new (4.11/5) median general knowledge base scores (p = 0.28). Nine clerkship grades changed between these different grading schemes (p = 0.045), with an overall agreement of 87.1% and a kappa statistic of 0.81. There were no differences in the pass/fail rate (p > 0.99). CONCLUSIONS: We conclude that there are no differences in pass/fail rate, but there is a more standardized distribution of patient interaction assessments and utilization of the full spectrum of possible passing grades. We recommend that the current patient interaction assessment for third-year medical students in the surgical clerkship be replaced with that found through trained standardized patients in this three-station acute abdominal pain OSCE.

Is your residency program ready for Generation Y?

Current residency applicants are members of Generation Y and are significantly different from previous generations of trainees as well as the faculty who attract, recruit, and manage them. Generation Y has been affected by globalization, diversification, terrorism, and international crisis. They are products of the self-esteem movement in child rearing, education, and extracurricular activities where they were all declared winners. Children's activities no longer had winners and losers or first, second, and third place; every child received a participation trophy. Even though they were raised to be a team player, their parents always told them they are special. Technology is ingrained into their daily lives, and they expect its use to be effective and efficient. Generation Y-ers desire to impact the world and give back to their communities and demand immediate access to leadership. This generation poses a challenge to residency programs that will need to attract, recruit, and manage them effectively. This article will provide an overview of Generation Y, contrast Generation Y with Generation X, and discuss how to use generation-specific strategies to attract, recruit, and manage a Generation Y resident.

What do surgical nurses know about surgical residents?

OBJECTIVE: A fundamental premise of establishing collaborative relationships between residents and nurses is a basic understanding of the attributes of each group. The intent of this study was to determine what surgical nurses know about surgical residents. DESIGN: A piloted survey tool was administered to a cross-section of nurses working in 3 surgical intensive care units, a surgical intermediate unit, and 2 general surgical floors. Surgical residents completed the same survey tool. The percentage of residents giving the most frequent response was compared with the percentage of nurses giving the same response. SETTING: A university, teaching hospital. PARTICIPANTS: One hundred twenty-four of 129 surgical nurses and 24 of 25 surgical residents who completed the survey tool. RESULTS: The response rate for nurses on the 2 survey days was 94%, or 54% of all surgical nurses employed by the hospital, and 96% for residents. The nurses surveyed were equally distributed between the units. Ninety-nine percent of nurses did not have a surgical resident as a significant other, 55% of nurses had greater than 5 years experience, and 95% were licensed registered nurses. Seventy-eight percent of nurses correctly indicated that a medical doctorate is the highest degree required to start residency (p = 0.01), but only 57% accurately identified the length of surgical residency (p = 0.02). Nurses perceived residents devoted less time to patient care (p < 0.01) and more time to studying (p < 0.01). Forty percent of nurses do not think interns are legally physicians (p < 0.01) or hold a medical license (p < 0.01). Forty percent of nurses are aware of the 80-hour work week restriction (p < 0.01). Eighteen percent of nurses have the perception that residents are not allowed to perform bedside procedures without an attending physician present (p = 0.03), while 56% have the perception that residents are not allowed to perform any part of an operation without an attending physician (p < 0.01). There is a misperception among 32% of nurses that residents pay tuition for residency (p < 0.01), while only 52% accurately identified the range of a resident's salary (p = 0.01) and 11% the amount of resident debt (p < 0.01). CONCLUSIONS: Despite the importance of the collaborative relationship in surgical patient care, surgical nurses have a limited understanding of surgical residents. Educating nurses about the education, roles, and responsibilities of surgical residents might improve collaborative relationships and ultimately patient care.

Preclinical predictors of surgery NBME exam performance.

BACKGROUND: The passing score for the National Board of Medical Examiner's Surgery Subject Examination (NBME-SS) was raised at an urban academic medical school, resulting in a doubling of the number of students failing their surgical clerkship. We hypothesized that at-risk students could be accurately identified and offered an intense tutorial program to enhance success on their exam. METHODS: Preclinical academic records for the graduating class of 2006 were obtained and included gender, ethnicity, preclinical grades, and preclinical NBME's exams, MCAT, and USMLE scores. Simple and multiple linear regression analyses were used to identify correlates with the surgery shelf exam scores and data from the class of 2007 were used for validation. RESULTS: Data were collected on 194 students. On univariate analysis, MCAT, USMLE, and all individual preclinical NBME scores were positively correlated with the NBME-SS (P<0.05). Variables that remained predictive using multiple linear regression were scores on the pathology and physical diagnosis exams (model r(2)=0.48). The single strongest predictor of failure was performance on the pathology shelf exam (ROC area was 0.85 with P<0.0001), which also held true for the class of 2007. CONCLUSIONS: There is a strong correlation between poor performance on the third-year NBME-SS and the second-year pathology NBME scores. The reason for this correlation is unclear but may be related to the integrative thinking and clinical application skills requisite for surgical decision-making first required by preclinical students during their pathology course. Whether efforts to assist medical students with this skill set will be effective warrants further study.

Myths and realities of the 80-hour work week.

BACKGROUND: Myths are so ingrained into cultural traditions that emotion frequently overshadows a rational evaluation of the facts. The reduction in resident work hours has resulted in the formation of several myths. The purpose of this review is to examine the published data on resident work hours to separate out myth from reality. METHODS: An electronic database was searched for publications related to resident training, work-hours, continuity of care, sleep deprivation, quality of life, patient safety, clinical/operative experience, faculty work hours, and surgical education. RESULTS: Sleep deprivation has been shown to be harmful, and residents played a role in advocating for work-hour limits. Surgical residents have seen a less dramatic improvement in quality of life compared with other disciplines. Work-hour reductions have decreased participation in clinic but have not resulted in a significant decline in clinical or operative exposure. Limiting resident work hours will unlikely result in a decrease health-care cost. Reduction in resident work hours has not resulted in an improvement or deterioration in patient outcome. Reduction of work hours has not increased faculty work hours nor made surgery a more attractive career choice. CONCLUSIONS: Despite strongly held opinions, resident work-hour reduction has resulted in little significant change in lifestyle, clinical exposure, patient well-being, faculty work hours, or medical student recruitment.