Simulation-based Assessment to Reliably Identify Key Resident Performance Attributes.

BACKGROUND: Obtaining reliable and valid information on resident performance is critical to patient safety and training program improvement. The goals were to characterize important anesthesia resident performance gaps that are not typically evaluated, and to further validate scores from a multiscenario simulation-based assessment. METHODS: Seven high-fidelity scenarios reflecting core anesthesiology skills were administered to 51 first-year residents (CA-1s) and 16 third-year residents (CA-3s) from three residency programs. Twenty trained attending anesthesiologists rated resident performances using a seven-point behaviorally anchored rating scale for five domains: (1) formulate a clear plan, (2) modify the plan under changing conditions, (3) communicate effectively, (4) identify performance improvement opportunities, and (5) recognize limits. A second rater assessed 10% of encounters. Scores and variances for each domain, each scenario, and the total were compared. Low domain ratings (1, 2) were examined in detail. RESULTS: Interrater agreement was 0.76; reliability of the seven-scenario assessment was r = 0.70. CA-3s had a significantly higher average total score (4.9 ± 1.1 vs. 4.6 ± 1.1, P = 0.01, effect size = 0.33). CA-3s significantly outscored CA-1s for five of seven scenarios and domains 1, 2, and 3. CA-1s had a significantly higher proportion of worrisome ratings than CA-3s (chi-square = 24.1, P < 0.01, effect size = 1.50). Ninety-eight percent of residents rated the simulations more educational than an average day in the operating room. CONCLUSIONS: Sensitivity of the assessment to CA-1 versus CA-3 performance differences for most scenarios and domains supports validity. No differences, by experience level, were detected for two domains associated with reflective practice. Smaller score variances for CA-3s likely reflect a training effect; however, worrisome performance scores for both CA-1s and CA-3s suggest room for improvement.

Academic women faculty: are they finding the mentoring they need?

BACKGROUND: Although women comprise an increasing proportion of US medical school faculty, they are underrepresented at higher ranks. Lack of effective mentoring may contribute to this disparity. We examined the role of academic rank, research focus, parenting, and part-time work on mentoring importance, needs, and gaps. METHODS: In 2009, women faculty members of Harvard Medical School and Harvard School of Dental Medicine were invited by e-mail to participate in a 28-item structured questionnaire. Descriptive statistics and adjusted logistic regressions were used to identify relevant themes. RESULTS: Of the 1179 women faculty who responded, 54% had a mentor, and 72% without a mentor desired mentoring. The most important mentor characteristic identified was availability. Respondents endorsed most mentoring areas as important (range 51%-99%); 52% of respondents identified mentoring gaps (area important and unmet) in developing and achieving career goals and negotiation skills. Interest in mentorship for skills needed for advancement (research and lecturing skills and getting national recognition) was significantly associated with lower rank. Assistant professors were most likely to identify mentoring related to writing and publishing articles, whereas associate professors identified program development/strategic planning as important. Faculty who are parents identified gaps in finding collaborators and balancing work and family life. CONCLUSIONS: This survey identified a desire for both comprehensive and targeted mentoring to address gaps that varied by faculty rank, research focus, parenting, and work time status. Strategies to enhance mentoring should address career stages and include a structured framework for assessing mentoring gaps.

Iniciativas para un mejor alivio del dolor / Initiatives for better pain relief

El dolor tiene un impacto significativo en la sociedad y en nuestro sistema de cuidado de la salud. Cuarenta y cinco por ciento de los americanos buscará atención o tratamiento del dolor crónico en algún momento de sus vidas. El dolor es la causa más común por la que los americanos buscan atención médica. Diecisiete por ciento de ellos experimenta algún tipo de dolor de artritis, y quince por ciento experimenta dolor lumbar. Se estima que cada año, aproximadamente 25 millones de visitas médicas son por causa de dolor lumbar. Los estudios demuestran que el dolor es la causa principal de pérdida de productividad en la población empleada, situación que cuesta a los empleadores casi US$ 80 mil millones anuales. El dolor crónico es una causa importante de invalidez, y por lo tanto tiene como consecuencia un tremendo costo a la economía americana, además del sufrimiento de aquellos que experimentan dolor por un largo período. Los esfuerzos que hagan las organizaciones y los gobiernos son cruciales en el avance hacia un cuidado óptimo del dolor al alcance de todos.

Risk assessment of hemorrhagic complications associated with nonsteroidal antiinflammatory medications in ambulatory pain clinic patients undergoing epidural steroid injection.

UNLABELLED: We prospectively studied 1035 individuals undergoing 1214 epidural steroid injections to determine the risk of hemorrhagic complications. A history of bruising or bleeding was present in 176 (15%) patients. A platelet count was assessed in 77 patients before the epidural steroid injection; none was less than 100 x 10(9)/L. Nonsteroidal antiinflammatory drugs (NSAIDs) were reported by 383 (32%) patients, including 34 patients on multiple medications. Aspirin was the most common NSAID and was noted by 158 patients, including 104 patients on 325 mg or less per day. There were no spinal hematomas (major hemorrhagic complications). Blood was noted during needle or catheter placement in 63 (5.2%) patients (minor hemorrhagic complications). NSAIDs did not increase the frequency of minor hemorrhagic complications. However, increased age, needle gauge, needle approach, needle insertion at multiple interspaces, number of needle passes, volume of injectant, and accidental dural puncture were all significant risk factors for minor hemorrhagic complications. There were 42 patients with new neurologic symptoms or worsening of preexisting complaints that persisted more than 24 h after injection; median duration of the symptoms was 3 days (range, 1-20 days). Our results confirm those of previous studies performed in obstetric and surgical populations that document the safety of neuraxial techniques in patients receiving NSAIDs. We conclude that epidural steroid injection is safe in patients receiving aspirin-like antiplatelet medications. Minor worsening of neurologic function may occur after epidural steroid injection and must be differentiated from etiologies requiring intervention. IMPLICATIONS: Previous studies performed in obstetric and surgical populations have demonstrated that antiplatelet therapy does not increase the risk of spinal hematoma associated with spinal or epidural anesthesia and analgesia. We confirm the safety of epidural steroid injection in patients receiving aspirin-like medications.

Discitis associated with pregnancy and spinal anesthesia.

UNLABELLED: Discitis (inflammation of the intervertebral disk) most commonly develops as a rare complication of bacterial infection or chemical or mechanical irritation during spine surgery (1) with a postoperative incidence of 1%-2.8% (2). It is also a complication of discography-the intradiscal injection of saline or contrast material (3). The incidence of postdiscography discitis is 1%-4% (3); no cases have been reported when prophylactic antibiotics have been used, supporting the theory of bacterial contamination (3). Although it is controversial whether discitis can be caused by an aseptic or infectious process, recent data suggest that persistent discitis is almost always bacterial (4). Honan et al. (5) reported 16 cases of spontaneous discitis and reviewed another 52 patients from the literature. In their series, patients tended to have one or more comorbid conditions, such as diabetes, vertebral fracture, or a preexisting spine injury. Spontaneous discitis has also been associated with advanced age, IV drug abuse, IV access contamination, urinary tract infection, and immunocompromised states (5,6). No cases of infectious discitis associated with pregnancy and spinal anesthesia have been reported in the English literature. Discitis presents as spasmodic pain in the back that may be referred to the hips or groin (7). The pain may radiate to the lower extremities. The erythrocyte sedimentation rate is usually increased. Radiological changes in discitis include narrowing of the intervertebral disk space, vertebral sclerosis, and erosion of the end plates. The best diagnostic measure may be magnetic resonance imaging (MRI) or a combination of bone and gallium scanning (2). The mainstay for discitis treatment is pain control and antibiotics; surgical intervention is usually not required. Complications of discitis include intervertebral fusion, epidural abscess, and paralysis. IMPLICATIONS: This is a case report of a disk infection (discitis) caused by the bacteria, Streptococcus bovis after spinal anesthesia for cesarean delivery. S. bovis rarely causes discitis, and spinal anesthesia for labor and delivery has not been reported as a cause of discitis.