Use of Simulation-Based Mastery Learning Curriculum to Improve Difficult Conversation Skills Among Anesthesiologists: A Pilot Study.

Background: Breaking bad news (BBN) is an important clinical task for physicians. Unfortunately, there is no standard method to teach and assess these skills of anesthesiologists. Although anesthesiology has become a relatively safe medical specialty, complications still occur that require disclosure to patients and their families. Disclosure of bad news can be a significant source of stress for clinicians, especially for those who have low confidence in their BBN skills. Anesthesiologists' skills in BBN can be improved with simulation-based mastery learning (SBML), an intense form of competency-based learning. Methods: An SBML curriculum was developed using the SPIKES (Situation, Perception, Invitation, Knowledge, Emotion, Summarize) framework for BBN and the NURSE (Naming, Understanding, Respecting, Supporting, Exploring) statements for expressing empathy. A pretest-posttest study was conducted from March 2020 to June 2022 to evaluate anesthesiologists' performance in BBN. Participants completed a 2-hour curriculum consisting of a pretest, didactic session, deliberate practice with feedback, and a posttest. Anesthesiologists were assessed using a 16-item skills checklist. Results: Six anesthesiology attendings and 14 anesthesiology fellows were enrolled in the study. Three of 20 participants met the minimum passing score (MPS) at the time of their pretest. All study participants met the MPS on their first posttest (P < .001). The median participant confidence in BBN significantly increased (3 to 4, P < .001). Overall course satisfaction in the curriculum was high, with a median score of 5. Conclusions: Our study demonstrates that a BBN SBML curriculum for anesthesiologists significantly improved communication skills and confidence in a simulated environment. Because only 3 participants met the MPS before training, our results suggest that anesthesiologists could benefit from further education to gain effective communication skills and that SBML training may be effective to achieve this result.

Mixed Methods Assessment of Incivility During Surgical Mortality and Morbidity Conference.

OBJECTIVE: This study assessed incivility during Mortality and Morbidity (M&M) Conference. BACKGROUND: A psychologically safe environment at M&M Conference enables generative discussions to improve care. Incivility and exclusion demonstrated by "shame and blame" undermine generative discussion. METHODS: We used a convergent mixed-methods design to collect qualitative data through non-participant observations of M&M conference and quantitative data through standardized survey instruments of M&M participants. The M&M conference was attended by attending surgeons (all academic ranks), fellows, residents, medical students on surgery rotation, advanced practice providers, and administrators from the department of surgery. A standardized observation guide was developed, piloted and adapted based on expert non-participant feedback. The Positive and Negative Affect Schedule Short-Form (PANAS) and the Uncivil Behavior in Clinical Nursing Education (UBCNE) survey instruments were distributed to the Department of Surgery clinical faculty and categorical general surgery residents in an academic medical center. RESULTS: We observed 11 M&M discussions of 30 cases, over six months with four different moderators. Case presentations (virtual format) included clinical scenario, decision-making, operative management, complications, and management of the complications. Discussion was free form, without a standard structure. The central theme that limited discussion participation from attending surgeon of record, as well as absence of a systems-approach discussion led to blame and blame then set the stage for incivility. Among 147 eligible to participate in the survey, 54 (36.7%) responded. Assistant professors had a 2.60 higher Negative Affect score (p-value=0.02), a 4.13 higher Exclusion Behavior score (p-value=0.03), and a 7.6 higher UBCNE score (p-value=0.04) compared to associate and full professors. Females had a 2.7 higher Negative Affect Score compared to males (p-value=0.04). CONCLUSION: Free-form M&M discussions led to incivility. Structuring discussion to focus upon improving care may create inclusion and more generative discussions to improve care.

Burnout in Medicine: Are We Asking the Right Questions?

After reviewing a substantial amount of published data on academic physician burnout, we were left pondering the question, "Are we on the right track with combating burnout?" This point-counterpoint manuscript details two opposing viewpoints: 1) the current approach to fighting burnout is working, and 2) resources should be diverted and focus placed on other areas because current interventions are failing physicians. In addressing these points, we discuss four poignant questions that we discovered researching this multifaceted issue: 1) Why do current burnout interventions have limited effects on prevalence over time? 2) Who benefits from the current health care structure (is burnout a profitable and desirable consequence of our work environment)? 3) What organizational conceptual frameworks are most beneficial to improve burnout? 4) How do we take responsibility and seize the ground for our own well-being? Though these differing viewpoints provoked an engaging and lively conversation among our writing team, we all agree on one point. Burnout is an immense problem that affects physicians, patients, and society; therefore, it demands our attention and resources.

Burnout in Academic Physicians.

The prevalence of burnout is much higher in physicians than in other occupations. Academic physicians serve important functions, training future physicians and advancing medical research in addition to doing clinical work. However, they are particularly vulnerable to burnout for reasons including low compensation for teaching, pressure to publish despite a lack of time and declining research funds, and a redistribution of clinical workload due to restrictions on trainee work hours. Junior faculty, women, and marginalized groups are the most affected. Beyond poor physician health and worse patient outcomes, burnout is strongly associated with reduced work effort and an intent to leave the profession. Moreover, physicians are leaving the workforce in record numbers, further increasing the stress on remaining physicians. Combined with a worsening of quality of patient care, this increased rate of physician burnout threatens the viability of health care organizations. This review discusses the causes and consequences of faculty burnout, as well as interventions undertaken for its mitigation.

Transitional care and clinical management of adolescents, young adults, and suspected new adult patients with congenital central hypoventilation syndrome.

PURPOSE: With contemporaneous advances in congenital central hypoventilation syndrome (CCHS), recognition, confirmatory diagnostics with PHOX2B genetic testing, and conservative management to reduce the risk of early morbidity and mortality, the prevalence of identified adolescents and young adults with CCHS and later-onset (LO-) CCHS has increased. Accordingly, there is heightened awareness and need for transitional care of these patients from pediatric medicine into a multidisciplinary adult medical team. Hence, this review summarizes key clinical and management considerations for patients with CCHS and LO-CCHS and emphasizes topics of particular importance for this demographic. METHODS: We performed a systematic review of literature on diagnostics, pathophysiology, and clinical management in CCHS and LO-CCHS, and supplemented the review with anecdotal but extensive experiences from large academic pediatric centers with expertise in CCHS. RESULTS: We summarized our findings topically for an overview of the medical care in CCHS and LO-CCHS specifically applicable to adolescents and adults. Care topics include genetic and embryologic basis of the disease, clinical presentation, management, variability in autonomic nervous system dysfunction, and clarity regarding transitional care with unique considerations such as living independently, family planning, exposure to anesthesia, and alcohol and drug use. CONCLUSIONS: While a lack of experience and evidence exists in the care of adults with CCHS and LO-CCHS, a review of the relevant literature and expert consensus provides guidance for transitional care areas.

Patient and Technical Factors Associated with Difficult Arterial Access and Ultrasound Use in the Operating Room.

Arterial catheterization enables continuous hemodynamic monitoring but has been shown to cause severe complications, especially when multiple attempts are required. The aim of this study was to explore what factors were associated with multiple attempts and ultrasound use in the operating room. We performed a retrospective analysis of patients who had arterial catheters inserted at a tertiary care children's hospital from January 2018 to March 2022, identifying clinical factors that were associated with both outcomes. A total of 3946 successful arterial catheter insertions were included. Multivariable analysis showed multiple attempts were associated with noncardiac surgery: pediatric (OR: 1.79, 95% CI: 1.30-2.51), neurologic (OR: 2.63, 95% CI: 1.89-3.57), orthopedic (OR: 3.23, 95% CI: 2.27-4.55), and non-radial artery placement (OR: 5.00, 95% CI: 3.33-7.14) (all p < 0.001). Multivariable analysis showed ultrasound use was associated with neonates (OR: 9.6, 95% CI: 4.1-22.5), infants (OR: 6.98, 95% CI: 4.67-10.42), toddlers (OR: 6.10, 95% CI: 3.8-9.8), and children (OR: 2.0, 95% CI: 1.7-2.5) compared to teenagers, with cardiac surgery being relative to other specialties-pediatric (OR: 0.48, 95% CI: 0.3-0.7), neurologic (OR: 0.27, 95% CI: 0.18-0.40), and orthopedic (OR: 0.38, 95% CI: 0.25-0.58) (all p < 0.001). In our exploratory analysis, increased odds of first-attempt arterial catheter insertion success were associated with cardiac surgery, palpation technique, and radial artery placement. Younger patient age category, ASA III and IV status, cardiac surgery, and anesthesiologist placement were associated with increased odds of ultrasound use.

Educational Review: Error traps in anesthesia for pediatric liver transplantation.

Anesthetic and surgical techniques for the liver transplantation have progressed considerably over the past sixty years; however, this procedure is still fraught with substantial morbidity. To increase the safety culture associated with the liver transplantation, we detail nine error traps associated with anesthesia for pediatric liver transplantation. These potential pitfalls are divided into the operative phases: pre-operative preparation (Failure to have a dedicated anesthesia team for pediatric liver transplantation); pre-anhepatic (Failure to prepare for massive blood loss, Failure to monitor for coagulation abnormalities); anhepatic including reperfusion (Failure to prepare for clamping of the inferior vena cava, Failure to recognize metabolic changes, Failure to maintain homeostasis for reperfusion, Failure to prepare for Post-reperfusion syndrome); and post-anhepatic (Failure to optimize liver perfusion, Failure to maintain hemostatic balance). By offering practical advice on the preparation and treatment of these error traps, we aim to better prepare anesthesiologists to take care of pediatric patients undergoing the liver transplantation.

Comparison of two point-of-care measurements of hemoglobin against standard laboratory values during pediatric liver transplantation: A retrospective review.

BACKGROUND: Point-of-care hemoglobin testing devices play an important role in intraoperative anesthetic management where significant hemorrhage is anticipated; however, the reliability of these devices has not been examined in the context of pediatric liver transplantation. In this retrospective observational study, we aimed to determine whether 95% of results from two point-of-care hemoglobinometers, the HemoCue and iSTAT, would fall within a difference of ±1 g/dl, our a priori-defined clinically acceptable level of agreement, of the hemoglobin measures on a core laboratory complete blood count. METHODS: We retrospectively collected data from 70 patients presenting for a liver transplant at a single center, tertiary care pediatric hospital over a 3.5-year period. We analyzed 92 contemporaneous pairs of hemoglobin values from the HemoCue and complete blood count, and 252 pairs of hemoglobin values from the iSTAT and complete blood count. Agreement between the point-of-care devices and complete blood count was assessed using Bland-Altman analysis, which was the primary outcome. Secondary analyses included an error grid analysis and Cohen's kappa statistic. RESULTS: Both point-of-care devices underestimated complete blood count hemoglobin values and neither device satisfied our a priori-defined clinically acceptable level of agreement that 95% of values would fall within ±1 g/dl of the complete blood count measurement. The mean difference [limits of agreement] of the HemoCue was 0.4 g/dl (p < .001) [-0.9 to 1.6 g/dl] and of the iSTAT was 0.6 g/dl (p < .001) [-1.4 to 2.6 g/dl]. Secondary error grid analysis revealed that neither device performed well enough to replace a complete blood count at critical thresholds of hemoglobin values. CONCLUSIONS: While the HemoCue and iSTAT contribute information in a timely manner during dynamic intraoperative situations, there is significant imprecision compared to the gold standard complete blood count. If clinical stability allows, the results of these point-of-care hemoglobinometers should be confirmed with a complete blood count, rather than being used as the sole factor in determining transfusion needs during pediatric liver transplantation.

Invisible Work: Advanced Practice Providers' Role in the Education of Surgeons.

OBJECTIVE: As the composition and work of surgical teams evolve, the role of advanced practice providers (APPs) has expanded. We explored how APPs influence the training experience of surgeons from the perspectives of faculty, residents, and APPs. DESIGN: Qualitative data were obtained from semi-structured open-ended interviews. A codebook was developed blending deductive and inductive logics. Dyads independently coded the transcripts using a constant comparative approach; differences were reconciled by consensus. RESULTS: During 2-day site visits to 15 general surgery programs, 393 individual and small focus group interviews were conducted with residents, faculty, staff, and program leadership. Forty transcripts representing 51 interviewees (15 APPs, 23 residents, 13 faculty) were collected. We identified 4 major themes:1 APP as Educator: APPs play a significant role in resident education to ensure seamless patient care while allowing trainees room for clinical growth.2 Canary in the Coal Mine: APPs often are the first to notice a surgical trainee's mood and provide support to improve wellness.3 Division of Labor: Distribution of clinical workload has a direct impact on surgical trainees' educational experience and APP job satisfaction.4 Second-Class Citizen: APPs described experiences in which their expertise was disrespected, and their contributions were unrecognized. CONCLUSIONS: APPs have an active and essential role in the well-being and education of surgeons during training. Surgical residency programs and hospitals have an opportunity to decrease the "invisibility" of the work of APPs through increased recognition of these roles and elevation of APP expertise through formal career development pathways.

Clinical and demographic factors associated with pediatric difficult intravenous access in the operating room.

BACKGROUND: Pediatric intravenous catheter insertion can be difficult in the operating room due to the technical challenges of small diameter vessels and the need to rapidly gain intravenous access in anesthetized children. Few studies have examined factors associated with difficult vascular access in the operating room, especially accounting for the increased possibility to use ultrasound guidance. AIMS: The primary aim of the study was to identify factors associated with pediatric difficult vascular access in the operating room. Our primary hypothesis was that Black race, Hispanic ethnicity, and ultrasound use would be associated with pediatric difficult vascular access. METHODS: We performed a retrospective analysis of prospectively collected data from a cohort of pediatric patients who had intravenous catheters inserted in the operating room at an academic tertiary care children's hospital from March 2020 to February 2021. We measured associations among patients who were labeled as having difficult vascular access (>2 attempts at access) with demographic, clinical, and hospital factors. RESULTS: 12 728 intravenous catheter insertions were analyzed. Multivariable analysis showed significantly higher odds of difficult vascular access with Black non-Hispanic race (1.43, 95% CI: 1.06-1.93, p = .018), younger age (0.93, 95% CI: 0.89-0.98, p = .005), overweight (1.41, 95% CI: 1.04-1.90, p = .025) and obese body mass index (1.56, 95% 95% CI: 1.12-2.17, p = .008), and American Society of Anesthesiologists physical status III (1.54, 95% CI:1.11-2.13, p = .01). The attending anesthesiologist compared to all other practitioners (certified registered nurse anesthetist: (0.41, 95% CI: 0.31-0.56, p < .001, registered nurse: 0.25, 95% CI: 0.13-0.48, p < .001, trainee: 0.21, 95% CI: 0.17-0.28, p-value <.001 with attending as reference variable) and ultrasound use (2.61, 95% CI: 1.85-3.69, p < .001) were associated with successful intravenous catheter placement. CONCLUSIONS: Black non-Hispanic race/ethnicity, younger age, obese/overweight body mass index, American Society of Anesthesiologists physical status III, and ultrasound were all associated with pediatric difficult vascular access in the operating room.

Use of an ultrasound-guided intravenous catheter insertion simulation-based mastery learning curriculum to improve paediatric anaesthesia care.

Background: We previously showed that an ultrasound-guided i.v. catheter insertion (USGIV) simulation-based mastery learning (SBML) curriculum improves the simulated USGIV skills of paediatric anaesthesiologists. It remains unclear if improvements in simulated USGIV skills translate to improved patient care. Methods: A cohort study was conducted from August 2018 to August 2020 to evaluate paediatric anaesthesiologists' USGIV performance in the operating theatre before and after they participated in the USGIV SBML curriculum. Paediatric anaesthesiologists' use of ultrasound for successful i.v. insertion and first-attempt i.v. insertion success rate with ultrasound were compared before and after training. Results: Twenty-nine paediatric anaesthesiologists completed training. Unadjusted analysis showed a significant increase in the percentage of i.v. catheters inserted with ultrasound for successful i.v. catheter insertion (9.5-14.5%; P<0.001) and first i.v. catheter insertion attempt success with ultrasound (5.5-8.9%; P<0.001) from before to after training. Multivariable regression analysis showed higher odds of ultrasound use for a successful i.v. catheter attempt (1.79; 95% confidence interval [CI]: 1.11-2.90; P=0.018) and first-attempt success with ultrasound (4.11; 95% CI: 2.02-8.37; P<0.001) after training. Conclusions: After completing the USGIV SBML curriculum, paediatric anaesthesiologists increased their ultrasound use for successful i.v. catheter insertion and first-attempt success rate with ultrasound for patients in the operating theatre.

Gender differences in paediatric hospital chief executive officer compensation.

Though there is a well-established gender pay gap in medicine, studies on compensation disparities between women and men chief executive officers (CEO) showed mixed results. We conducted a cross-sectional study of children's hospitals in the USA to evaluate whether CEO gender was associated with compensation differences. Nine out of 31 children's hospitals employed a female CEO. There was no significant difference between men and women CEOs in terms of hospital characteristics (location, size or ranking in US News and World report) or CEO characteristics (advanced degrees, tenure or compensation). Gender was not associated with significant differences in CEO compensation.

Carer and staff perceptions of end-of-life care provision: case of a hospice-at-home service.

People requiring palliative care should have their needs met by services acting in accordance with their wishes. A hospice in the south of England provides such care via a 24/7 hospice at home service. This study aimed to establish how a nurse-led night service supported patients and family carers to remain at home and avoid hospital admissions. Semi-structured interviews were carried out with family carers (n=38) and hospice-at-home staff (n=9). Through night-time phone calls and visits, family carers felt supported by specialist hospice staff whereby only appropriate hospital admission was facilitated. Staff provided mediation between family carer and other services enabling more integrated care and support to remain at home. A hospice-at-home night service can prevent unnecessary hospital admissions and meet patient wishes through specialist care at home.