Resident Autonomy in the Operating Room: How Faculty Assess Real-time Entrustability.

OBJECTIVE: This study aimed to identify the empirical processes and evidence that expert surgical teachers use to determine whether to take over certain steps or entrust the resident with autonomy to proceed during an operation. BACKGROUND: Assessing real-time entrustability is inherent in attending surgeons' determinations of residents' intraoperative autonomy in the operating room. To promote residents' autonomy, it is necessary to understand how attending surgeons evaluate residents' performance and support opportunities for independent practice based on the assessment of their entrustability. METHODS: We conducted qualitative semi-structured interviews with 43 expert surgical teachers from 21 institutions across 4 regions of the United States, using purposeful and snowball sampling. Participants represented a range of program types, program size, and clinical expertise. We applied the Framework Method of content analysis to iteratively analyze interview transcripts and identify emergent themes. RESULTS: We identified a 3-phase process used by most expert surgical teachers in determining whether to take over intraoperatively or entrust the resident to proceed, including 1) monitoring performance and "red flags," 2) assessing entrustability, and 3) granting autonomy. Factors associated with individual surgeons (eg, level of comfort, experience, leadership role) and the context (eg, patient safety, case, and time) influenced expert surgical teachers' determinations of entrustability and residents' final autonomy. CONCLUSION: Expert surgical teachers' 3-phase process of decisions on take-over provides a potential framework that may help surgeons identify appropriate opportunities to develop residents' progressive autonomy by engaging the resident in the determination of entrustability before deciding to take over.

Entrustment Evidence Used by Expert Gynecologic Surgical Teachers to Determine Residents' Autonomy.

OBJECTIVE: To identify entrustment evidence used by expert gynecologic surgical teachers to determine obstetrics and gynecology residents' level of autonomy in the operating room. METHODS: A qualitative interview study was undertaken from March to November 2016. Four selection criteria were used to define and purposefully sample expert gynecologic surgical teachers across the United States to represent all four geographic regions. All interviews were audio-recorded and transcribed. We applied the Framework Method of content analysis. Transcripts were iteratively analyzed and emergent themes identified. RESULTS: Twenty-seven expert gynecologic surgical teachers from 15 institutions across the United States participated in 30-minute interviews. We identified four domains of entrustment evidence (resident characteristics, medical knowledge, technical performance, and "beyond current surgical case") commonly reported by expert gynecologic surgical teachers to determine residents' autonomy as well as the particular evidence associated with expert gynecologic surgical teachers' determination of resident autonomy at two decision-making points (surgical time-out and taking over certain intraoperative steps) in the operating room. Onsite direct observation and conversation were two common methods used by expert gynecologic surgical teachers to obtain this evidence. CONCLUSION: Entrustment evidence from resident characteristics, medical knowledge, and technical performance domains and from "beyond current surgical case" was commonly used by expert gynecologic surgical teachers to determine residents' autonomy. Our findings provide a potential framework for designing educational interventions that aim to increase residents' readiness for autonomy and entrustment in the operating room.

How Effective are New Milestones Assessments at Demonstrating Resident Growth? 1 Year of Data.

OBJECTIVE: Assessment tools that accrue data for the Accreditation Council for Graduate Medical Education Milestones must evaluate residents across multiple dimensions, including medical knowledge, procedural skills, teaching, and professionalism. Our objectives were to: (1) develop an assessment tool to evaluate resident performance in accordance with the Milestones and (2) review trends in resident achievements during the inaugural year of Milestone implementation. DESIGN: A novel venue and postgraduate year (PGY) specific assessment tool was built, tested, and implemented for both operating room and labor and delivery "venues." Resident development of competence and independence was captured over time. To account for variable rotation schedules, the year was divided into thirds and compared using two-tailed Fisher's exact test. SETTING: Brigham and Women's and Massachusetts General Hospitals, Boston MA. PARTICIPANTS: Faculty evaluators and obstetrics and gynecology residents. RESULTS: A total of 822 assessments of 44 residents were completed between 9/2014 and 6/2015. The percentage of labor and delivery tasks completed "independently" increased monotonically across the start of all years: 8.4% for PGY-1, 60.3% for PGY-2, 73.7% for PGY-3, and 87.5% for PGY-4. Assessments of PGY-1 residents demonstrated a significant shift toward "with minimal supervision" and "independent" for the management of normal labor (p = 0.03). PGY-3 residents demonstrated an increase in "able to be primary surgeon" in the operating room, from 36% of the time in the first 2/3 of the year, to 62.3% in the last 1/3 (p < 0.01). CONCLUSION: Assessment tools developed to assist with Milestone assignments capture the growth of residents over time and demonstrate quantifiable differences in achievements between PGY classes. These tools will allow for targeted teaching opportunities for both individual residents and residency programs.

Management strategies for painful bladder syndrome.

Painful bladder syndrome/interstitial cystitis (PBS/IC) is a condition of chronic pelvic pain associated with irritative voiding symptoms. Management of PBS/IC has been a challenge for generations of physicians, owing to a lack of consensus on its definition, an incompletely understood pathophysiology, and numerous available therapies without high-quality evidence to guide their usage. This article reviews the most current conception of PBS/IC and data on effective treatments to recommend a management strategy.