Factors Affecting Entrustment and Autonomy in Emergency Medicine: "How much rope do I give them?"

INTRODUCTION: During residency, the faculty's role is to provide supervision while granting the trainee autonomy. This concept is termed entrustment. The goal is appropriate progression from supervision to autonomy while decreasing oversight as residents train. The objective of this study was to better understand the factors affecting the degree of autonomy or supervision faculty choose to provide residents. METHODS: This was a qualitative study of resident and faculty perceptions. We conducted two faculty and two resident focus groups. We then transcribed the transcripts of the audiotaped discussions and coded them using grounded theory. RESULTS: Analysis of the transcripts yielded four major factors affecting entrustment of residents.Patient Factors included the acuity of the patient, sociomedical issues of patient/family, and complexity of risk with patient or procedure. For example, "sometimes there are families and patients who are exceedingly difficult that immediately sort of force me [to allow less autonomy]."Environmental Factors included patient volume and systems protocols (i.e., trauma). "If you're very busy and you have a resident that you already trust, you will give them more rope because you're trying to juggle more balls."Resident Factors included the year of training, resident performance, clinical direct observation, and patient presentations. "But if you have a resident that you do not trust […] I tell them you're going to do this, this, this, this, this."Faculty Factors included confidence in his/her own practice, risk-averse attitude, degree of ownership of the patient, commitment to education, and personality (e.g., micro-manager). Significant variability in entrustment by faculty existed, from being "micromanagers" to not seeing the patients. One resident noted: "There are some attendings, no matter how much they like you and how much you've worked with them, they're always going to be in your face in the trauma bay. And there's some attendings that are going to be ghosts." CONCLUSION: Multiple factors affect the amount of autonomy and entrustment given to residents and their level of supervision by faculty, leading to wide variability in entrustment. In the end, regardless of resident, patient, or environment, some faculty are more likely to entrust than others.

Model for Developing Educational Research Productivity: The Medical Education Research Group.

INTRODUCTION: Education research and scholarship are essential for promotion of faculty as well as dissemination of new educational practices. Educational faculty frequently spend the majority of their time on administrative and educational commitments and as a result educators often fall behind on scholarship and research. The objective of this educational advance is to promote scholarly productivity as a template for others to follow. METHODS: We formed the Medical Education Research Group (MERG) of education leaders from our emergency medicine residency, fellowship, and clerkship programs, as well as residents with a focus on education. First, we incorporated scholarship into the required activities of our education missions by evaluating the impact of programmatic changes and then submitting the curricula or process as peer-reviewed work. Second, we worked as a team, sharing projects that led to improved motivation, accountability, and work completion. Third, our monthly meetings served as brainstorming sessions for new projects, research skill building, and tracking work completion. Lastly, we incorporated a work-study graduate student to assist with basic but time-consuming tasks of completing manuscripts. RESULTS: The MERG group has been highly productive, achieving the following scholarship over a three-year period: 102 abstract presentations, 46 journal article publications, 13 MedEd Portal publications, 35 national didactic presentations and five faculty promotions to the next academic level. CONCLUSION: An intentional focus on scholarship has led to a collaborative group of educators successfully improving their scholarship through team productivity, which ultimately leads to faculty promotions and dissemination of innovations in education.

Training in childhood obesity management in the United States: a survey of pediatric, internal medicine-pediatrics and family medicine residency program directors.

BACKGROUND: Information about the availability and effectiveness of childhood obesity training during residency is limited. METHODS: We surveyed residency program directors from pediatric, internal medicine-pediatrics (IM-Peds), and family medicine residency programs between September 2007 and January 2008 about childhood obesity training offered in their programs. RESULTS: The response rate was 42.2% (299/709) and ranged by specialty from 40.1% to 45.4%. Overall, 52.5% of respondents felt that childhood obesity training in residency was extremely important, and the majority of programs offered training in aspects of childhood obesity management including prevention (N = 240, 80.3%), diagnosis (N = 282, 94.3%), diagnosis of complications (N = 249, 83.3%), and treatment (N = 242, 80.9%). However, only 18.1% (N = 54) of programs had a formal childhood obesity curriculum with variability across specialties. Specifically, 35.5% of IM-Peds programs had a formal curriculum compared to only 22.6% of pediatric and 13.9% of family medicine programs (p < 0.01). Didactic instruction was the most commonly used training method but was rated as only somewhat effective by 67.9% of respondents using this method. The most frequently cited significant barrier to implementing childhood obesity training was competing curricular demands (58.5%). CONCLUSIONS: While most residents receive training in aspects of childhood obesity management, deficits may exist in training quality with a minority of programs offering a formal childhood obesity curriculum. Given the high prevalence of childhood obesity, a greater emphasis should be placed on development and use of effective training strategies suitable for all specialties training physicians to care for children.

Membrane-type matrix metalloproteinases mediate curcumin-induced cell migration in non-tumorigenic colon epithelial cells differing in Apc genotype.

Colonic epithelial cell migration is required for normal differentiated cell function. This migratory phenotype is dependent upon wild-type adenomatous polyposis coli (Apc) expression. Non-tumorigenic murine colon epithelial cell lines with distinct Apc genotypes, i.e. young adult mouse colon (YAMC; Apc(+/+)) and immortomouse/Min colon epithelial (IMCE; Apc(Min/+) cells) were used to assess the association between the Apc genotype, cell motility and matrix metalloproteinase (MMP) activity. Cells were treated with epidermal growth factor (EGF; 1, 10 and 25 ng/ml), hepatocyte growth factor (HGF; 1, 10 and 25 ng/ml) and/or curcumin (0.1-100 microM). EGF (25 ng/ml) and HGF (25 ng/ml) induced a greater migratory response in YAMC compared with IMCE cells after 24 h (P < 0.05). Treatment with curcumin induced a greater or equivalent migratory response in IMCE than YAMC cells. When migrating cells were treated with Ilomastat (MMP inhibitor), migration was inhibited in both cell types. High concentrations of Ilomastat (25 and 50 microM) inhibited migration in both cell types, while low concentrations (10 microM) inhibited HGF-induced IMCE migration. Curcumin-induced migration was inhibited in both cell types at the highest concentration of Ilomastat (50 microM). Immuno-localization analysis of membrane type-1 (MT1)-MMP indicated that migration is associated with the redistribution of this protein from the endoplasmic reticulum to the plasma membrane. Addition of neutralizing polyclonal antibodies against MT1-MMP or a mixture of MT1, 2- and 3-MMPs demonstrated partial or complete inhibition of cell migration in both cell types, respectively. The data provide the first evidence that migration in non-tumorigenic murine colon epithelial cells is: (i) inducible by EGF and HGF in an Apc genotype-dependent manner, (ii) dependent on MT-MMP activity and (iii) inducible by curcumin in an Apc genotype-independent manner. The data suggest a potential mechanism by which curcumin may induce cells heterozygous for Apc to overcome defective cell migration, a phenotype associated with cell differentiation and apoptosis.