Predicting Performance at Graduation From Early ACGME Milestone Ratings: Longitudinal Learning Analytics in Professionalism and Communication in Vascular Surgery.

OBJECTIVE: Program directors in surgical disciplines need more tools from the ACGME to help them use Milestone ratings to improve trainees' performance. This is especially true in competencies that are notoriously difficult to measure, such as professionalism (PROF) and interpersonal and communication skills (ICS). It is now widely understood that skills in these two areas have direct impact on patient care outcomes. This study investigated the potential for generating early predictors of final Milestone ratings within the PROF and ICS competency categories. DESIGN: This retrospective cohort study utilized Milestone ratings from all ACGME-accredited vascular surgery training programs, covering residents and fellows who completed training in June 2019. The outcome measure studied was the rate of achieving the recommended graduation target of Milestone Level 4 (possible range: 1-5), while the predictors were the Milestone ratings attained at earlier stages of training. Predictive probability values (PPVs) were calculated for each of the 3 PROF and two ICS sub-competencies to estimate the probability of trainees not reaching the recommended graduation target based on their previous Milestone ratings. SETTING: All ACGME-accredited vascular surgery training programs within the United States. PARTICIPANTS: All trainees completing a 2 year vascular surgery fellowship (VSF) in June 2019 (n = 119) or a 5 year integrated vascular surgery residency (IVSR) in June 2019 (n = 52) were included in the analyses. RESULTS: The overall rate of failing to achieve the recommended graduation target across all PROF and ICS sub-competencies ranged from 7.7% to 21.8% of all trainees. For trainees with a Milestone rating at ≤ 2.5 with 1 year remaining in their training program, the predictive probability of not achieving the recommended graduation target ranged from 37.0% to 71.5% across sub-competencies, with the highest risks observed under PROF for "Administrative Tasks" (71.5%) and under ICS for "Communication with the Healthcare Team" (56.7%). CONCLUSIONS: As many as 1 in 4 vascular surgery trainees did not achieve the ACGME vascular surgery Milestones targets for graduation in at least one of the PROF and ICS sub-competencies. Biannual ACGME Milestone assessment ratings of PROF and ICS during early training can be used to predict achievement of competency targets at time of graduation. Early clues to problems in PROF and ICS enable programs to address potential deficits early in training to ensure competency in these essential non-technical skills prior to entering unsupervised practice.

"Am I even a med-student anymore?" A Mixed-Methods Study of the Impact of the Initial Disruptions Caused by the COVID-19 Pandemic on Medical Student Professional Identity Formation.

Purpose: Developing a professional identity requires learners to integrate themselves into the medical profession and take on the role of doctor. The impact of COVID-19 on medical education has been widely investigated, but little attention has been paid to the impact of students' professional identify formation (PIF). The goal of this study was to investigate the impact that the onset of the COVID-19 pandemic had on medical students' PIF. Materials and Methods: An embedded mixed-methods design was utilized. Focus groups were conducted with a subset of year 1-4 students and coded using thematic analysis. Year 1-2 students were surveyed about their professional identity integration in the spring of 2020. Responses were analyzed using descriptive statistics and Wilcoxon signed rank and Mann-Whitney U tests. Results: Qualitative data were organized into six themes that touched on losses and challenges, reflection, and reevaluation of the physician career. Roughly 50% of MS1s and MS2s reported a change in their professional identity integration, but this was not statistically significant. Conclusions: Medical education does not occur in isolation and is influenced by disruptive local and global events. Students perceived challenges when in-person community interaction and hands-on clinical experiences were interrupted. Additionally, students reflected upon their own role and their future career goals. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-022-01652-4.

Pre-Procedure Thrombocytopenia and Leukopenia Association with Risk for Infection in Image-Guided Tunneled Central Venous Catheter Placement.

Placement of image-guided tunneled and non-tunneled large-bore central venous catheters (CVCs) are common procedures in interventional radiology. Although leukopenia and/or thrombocytopenia are common at the time of placement, the roles these factors may have in subsequent catheter-related infection have yet to be investigated. A single-institution retrospective review was performed in patients who underwent CVC placement in interventional radiology between 11/2018-6/2019. The electronic medical record was used to obtain demographics, procedure details, pre-placement laboratory values, and the subsequent 90-day follow-up. A total of 178 tunneled and non-tunneled CVCs met inclusion criteria during this time period. White blood cell (WBC) and platelet counts were found to be significant risk factors for subsequent infection. Administration of pre-procedure antibiotics was not found to be a significant factor for subsequent infection (p = 0.075). Leukopenia and thrombocytopenia at the time of CVC placement are both risk factors of line infection for tunneled large-bore CVCs. This should lead to the consideration of using a non-tunneled CVC when clinically feasible, or the delayed placement of these catheters until counts recover.

Using Learning Analytics to Examine Achievement of Graduation Targets for Systems-Based Practice and Practice-Based Learning and Improvement: A National Cohort of Vascular Surgery Fellows.

BACKGROUND: Surgeons provide patient care in complex health care systems and must be able to participate in improving both personal performance and the performance of the system. The Accreditation Council for Graduate Medical Education (ACGME) Vascular Surgery Milestones are utilized to assess vascular surgery fellows' (VSF) achievement of graduation targets in the competencies of Systems Based Practice (SBP) and Practice Based Learning and Improvement (PBLI). We investigate the predictive value of semiannual milestones ratings for final achievement within these competencies at the time of graduation. METHODS: National ACGME milestones data were utilized for analysis. All trainees entering the 2-year vascular surgery fellowship programs in July 2016 were included in the analysis (n = 122). Predictive probability values (PPVs) were obtained for each SBP and PBLI sub-competencies by biannual review periods, to estimate the probability of VSFs not reaching the recommended graduation target based on their previous milestones ratings. RESULTS: The rate of nonachievement of the graduation target level 4.0 on the SBP and PBLI sub-competencies at the time of graduation for VSFs was 13.1-25.4%. At the first time point of assessment, 6 months into the fellowship program, the PPV of the SBP and PBLI milestones for nonachievement of level 4.0 upon graduation ranged from 16.3-60.2%. Six months prior to graduation, the PPVs across the 6 sub-competencies ranged from 14.6-82.9%. CONCLUSIONS: A significant percentage of VSFs do not achieve the ACGME Vascular Surgery Milestone targets for graduation in the competencies of SBP and PBLI, suggesting a need to improve curricula and assessment strategies in these domains across vascular surgery fellowship programs. Reported milestones levels across all time point are predictive of ultimate achievement upon graduation and should be utilized to provide targeted feedback and individualized learning plans to ensure graduates are prepared to engage in personal and health care system improvement once in unsupervised practice.

A National Survey of Robotic Surgery Training Among Otolaryngology-Head and Neck Surgery Residents.

OBJECTIVE: The aim of this study is to describe the current state of robotic surgery training among Otolaryngology-Head and Neck Surgery (OHNS) residency programs in the United States. METHODS: This is a national survey study among OHNS residents. All OHNS residency programs were identified via the Accreditation Council for Graduate Medical Education website. A total of 64/127 (50.3%) of OHNS programs were selected based on a random number generator. The main outcome measure was the number of OHNS residents with access to robotic surgery training and assessment of operative experience in robotic surgery among those residents. RESULTS: A total of 140 OHNS residents participated in the survey, of which 59.3% (n = 83) were male. Response rate was 40.2%. Respondents came from middle 50.0% (n = 70), southern 17.8% (n = 25), western 17.8% (n = 25), and eastern sections 14.3% (n = 20). Most respondents (94.3%, n = 132) reported that their institution utilized a robot for head and neck surgery. Resident experience at the bedside increased in the junior years of training and console experience increased across the years particularly for more senior residents. However, 63.4% of residents reported no operative experience at the console. Only 11.4% of programs have a structured robotics training program. CONCLUSION: This survey indicated that nearly all OHNS residencies utilize robotic surgery in their clinical practice with residents receiving little formal education in robotics or experience at the console. OHNS residencies should aim to increase access to training opportunities in order to increase resident competency. LEVEL OF EVIDENCE: IV.

Sex differences in aggression: Differential roles of 5-HT2, neuropeptide F and tachykinin.

Despite the conserved function of aggression across taxa in obtaining critical resources such as food and mates, serotonin's (5-HT) modulatory role on aggressive behavior appears to be largely inhibitory for vertebrates but stimulatory for invertebrates. However, critical gaps exist in our knowledge of invertebrates that need to be addressed before definitively stating opposing roles for 5-HT and aggression. Specifically, the role of 5-HT receptor subtypes are largely unknown, as is the potential interactive role of 5-HT with other neurochemical systems known to play a critical role in aggression. Similarly, the influence of these systems in driving sex differences in aggressive behavior of invertebrates is not well understood. Here, we investigated these questions by employing complementary approaches in a novel invertebrate model of aggression, the stalk-eyed fly. A combination of altered social conditions, pharmacological manipulation and 5-HT2 receptor knockdown by siRNA revealed an inhibitory role of this receptor subtype on aggression. Additionally, we provide evidence for 5-HT2's involvement in regulating neuropeptide F activity, a suspected inhibitor of aggression. However, this function appears to be stage-specific, altering only the initiation stage of aggressive conflicts. Alternatively, pharmacologically increasing systemic concentrations of 5-HT significantly elevated the expression of the neuropeptide tachykinin, which did not affect contest initiation but instead promoted escalation via production of high intensity aggressive behaviors. Notably, these effects were limited solely to males, with female aggression and neuropeptide expression remaining unaltered by any manipulation that affected 5-HT. Together, these results demonstrate a more nuanced role for 5-HT in modulating aggression in invertebrates, revealing an important interactive role with neuropeptides that is more reminiscent of vertebrates. The sex-differences described here also provide valuable insight into the evolutionary contexts of this complex behavior.

Repigmentation of Human Vitiligo Skin by NBUVB Is Controlled by Transcription of GLI1 and Activation of the ß-Catenin Pathway in the Hair Follicle Bulge Stem Cells.

Vitiligo repigmentation is a complex process in which the melanocyte-depleted interfollicular epidermis is repopulated by melanocyte precursors from hair follicle bulge that proliferate, migrate, and differentiate into mature melanocytes on their way to the epidermis. The strongest stimulus for vitiligo repigmentation is narrow-band UVB (NBUVB), but how the hair follicle melanocyte precursors are activated by UV light has not been extensively studied. To better understand this process, we developed an application that combined laser capture microdissection and subsequent whole transcriptome RNA sequencing of hair follicle bulge melanocyte precursors and compared their gene signatures to that of regenerated mature epidermal melanocytes from NBUVB-treated vitiligo skin. Using this strategy, we found up-regulation of TNC, GJB6, and THBS1 in the hair follicle bulge melanocytes and of TYR in the epidermal melanocytes of the NBUVB-treated vitiligo skin. We validated these results by quantitative real-time-PCR using NBUVB-treated vitiligo skin and untreated normal skin. We also identified that GLI1, a candidate stem cell-associated gene, is significantly up-regulated in the melanocytes captured from NBUVB-treated vitiligo bulge compared with untreated vitiligo bulge. These signals are potential key players in the activation of bulge melanocyte precursors during vitiligo repigmentation.