Psychological well-being of surgery residents before the 80-hour work week: a multiinstitutional study

BACKGROUND: Accreditation Council on Graduate Medical Education work-hour restrictions are aimed at improving patient safety and resident well-being. Although surgical trainees will be dramatically affected by these changes, no comprehensive assessment of their well-being has been recently attempted. STUDY DESIGN: A multicenter study of psychological well-being of surgical residents (n = 108) across four US training programs before implementation of the 80-hour work week was performed using two validated surveys (Symptom Checklist-90-R [SCL-90-R] and Perceived Stress Scale [PSS]) during academic year 2002-03. Societal normative populations served as controls. Primary outcomes measures were psychologic distress (SCL-90-R) and perceived stress (PSS). Secondary outcomes measures (SCL-90-R) were somatization, depression, anxiety, interpersonal sensitivity, hostility, obsessive-compulsive behavior, phobic anxiety, paranoid ideation, and psychoticism. The impact of personal variables (age, gender, marital status) and programmatic variables (level of training, laboratory experience, institution) was assessed. RESULTS: Mean psychologic distress was significantly higher in general surgery residents than in the normative population (p < 0.0001), with 38% scoring above the 90th percentile and 72% above the 50th percentile. Mean perceived stress among surgery residents was higher than historic controls (p < 0.0001), with 21% scoring above the 90th percentile and 68% above the 50th percentile. Among secondary outcomes, eight of nine symptom dimensions were significantly higher in surgical residents than in societal controls. In subgroup analyses, male gender was associated with phobic anxiety (p < 0.001) and anxiety (p < 0.05), and junior level of training (PGY 1 to 3) with anxiety (p < 0.05), obsessive-compulsive behavior (p < 0.05), and interpersonal sensitivity (p < 0.05). CONCLUSIONS: More than one-third of general surgery residents meet criteria for clinical psychologic distress. Surgery residents perceive significantly more stress than societal controls. Both personal and programmatic variables likely affect resident well-being and should be considered in assessing the full impact of Accreditation Council on Graduate Medical Education directives and in guiding future restructuring efforts.     

Organ scarcity and the psychological pre-heart transplant evaluation: a simulation study using community residents

CONTEXT: Although research examining medical outcomes in heart transplantation has progressed, there are few studies examining the impact of organ scarcity and wait list demand on the transplant candidate evaluation process. OBJECTIVE: To examine the influence of transplant knowledge pertaining to organ scarcity and wait list demand on simulated ratings of psychological distress provided by community residents participating in a simulated pre-heart transplant evaluation. DESIGN: A randomized, controlled design. We used a vignette simulation to experimentally manipulate the effect of transplant knowledge pertaining to organ scarcity in a group of community residents with no previous knowledge or experience with the transplant selection process. PARTICIPANTS: One hundred forty-three community residents visiting a department of motor vehicles office in north central Florida were recruited. Community residents were randomly assigned to 1 of 2 experimental conditions, with either mention (n=66) or no mention (n=77) of organ scarcity and wait list demand statistics in their assigned vignette. Participants then served as actors and completed measures of psychological distress as part of a mock psychological pre-heart transplant evaluation. RESULTS: Participants with mention of organ scarcity reported significantly fewer symptoms of anxiety and depression compared to those with no mention of organ scarcity. This relationship remained significant even after controlling for relevant covariates, including age and simulated ratings of social desirability. CONCLUSION: Transplant knowledge pertaining to organ scarcity and wait list demand may influence transplant candidates to report fewer symptoms of psychological distress. Clinical suggestions for dealing with underreporting of psychological distress are discussed.     

Evaluation of acupuncture anesthesia: a psychophysical study.

Four volunteers judged eight levels of thermal stimuli induced by a Hardy dolorimeter, varying in intensity from extremely painful to a low level seldom even perceived. Half of the 406 stimuli were applied during acupuncture and half either before insertion or after removal of the needles. The experimental design minimized or eliminated factors other than the needles themselves, i.e., no medication was given, the subjects were scientists accustomed to objectivity and, on a preceding day or days, all had become experienced in assigning numbers (individually chosen) to the sensations produced by the different stimuli. Galvanic skin resistance was also tested. The results did not show any influence of acupuncture on perception of pain or on galvanic skin resistance.     

Mentorship in anesthesia: a survey of perspectives among Canadian anesthesia residents

Purpose

Mentorship is important for professional and academic growth; however, the role of mentorship in anesthesia is still being defined. We surveyed Canadian anesthesia residents to explore their perceptions of mentorship relationships.

Methods

We administered a 20-item cross-sectional survey to program directors and anesthesia residents in all Canadian departments of anesthesia. Program directors were asked about their mentorship programs, and residents were asked about their perceptions of benefits and barriers to effective mentoring.

Results

Sixteen of 17 (94%) program directors and 189 of 585 (32%) anesthesia residents responded to our survey. While 143 of 180 (79%) residents agreed that mentorship was beneficial to overall success as an anesthesiologist, only 11 of 16 (69%) program directors reported formal mentorship as part of their residency program, and only 119 of 189 (63%) residents reported access to a mentor. Barriers reported by residents included insufficient time with mentors, lack of formalized meeting times and objectives, mentor-mentee incompatibility (personal or professional), and lack of resident choice in mentor selection.

Conclusion

Our study confirms that, despite positive perceptions among residents, mentorship remains underutilized in anesthesia programs. We identify barriers to effective mentorship, including the need to consider resident choice as a means to improve formal anesthesia mentorship programs.

     

Femoropopliteal bypass using externally supported polytetrafluoroethylene grafts. Early results in a multiinstitutional study

A multiinstitutional retrospective study was undertaken to evaluate the externally supported PTFE graft to determine whether a nonkinking, noncompressible graft offers advantages in patency and limb salvage. We studied the results of 104 femoropopliteal arterial reconstructions performed on 99 patients between June 1981 and June 1983. The combined above-the-knee and below-the-knee cumulative patency rate at 2 years was 88 percent and the limb salvage rate was 97 percent. We found these results to be comparable to the patency typical of saphenous vein grafts and better than that of reinforced PTFE grafts. The improved patency is due to the lack of kinking and compressibility of the externally supported PTFE graft, as well as histologic evidence of excellent collagen infiltration which stabilizes the graft in position. A longer follow-up period is certainly needed to make definite recommendations, but our preliminary studies are encouraging.     

Assessing the skills of surgical residents using simulation

Much is still to be learned about the assessment of simulation-based surgical skills training. However, assessing surgery skills through simulation is a new horizon in medical education. Providing a safe environment for surgical residents to assess their performance rigorously without placing patients in jeopardy is valuable. Using simulators (both warm and cold) as a means to assess trainees has been established. However, also problems concerning the validity and reliability of such simulation-based assessment tools exist, particularly in surgery, that may need to be investigated even more to decide whether to use them as a tool for assessing the performance of surgical residents.     

Perceived sleepiness in Canadian anesthesia residents: a national survey

Purpose

To compare the self-perceived sleepiness of Canadian anesthesia residents providing modified on-call duties (12–16 h) vs. traditional on-call duties (24 h).

Methods

A 25-item online survey was distributed to all Canadian anesthesia residents who, at that time, were on anesthesia rotations. The survey assessed resident demographics, perceived work patterns, and sleepiness, as well as their opinions on resident work hour reform. Self-perceived sleepiness was quantified using the validated Epworth sleepiness scale (ESS).

Results

Three hundred eight of 400 (77%) eligible Canadian anesthesia residents completed the survey. Forty-three percent of residents who worked traditional on-call (duration 24.1 ± 0.5 h) shifts and 48% of residents who worked modified on-call (duration 15.5 ± 1.8 h) shifts met ESS criteria for excessive daytime sleepiness. Overall mean ESS scores did not differ significantly between the traditional (9.1 ± 4.9) and the modified call groups (9.5 ± 4.8). Residents with an on-call frequency of ≥1:4 days or those who slept ≤2 h while on call perceived themselves as significantly more sleepy (P = 0.045 and P = 0.008, respectively). Six percent of residents admitted to taking “something other than caffeine” to stay awake on call.

Conclusion

Many anesthesia residents do exhibit excessive daytime sleepiness, with a similar incidence for those working within either modified or traditional call systems. Our study suggests that sleepiness may be reduced by scheduling on-call duties no more frequently than one in every five nights and by ensuring that residents sleep more than 2 h while on call.     

Management of idiopathic normal-pressure hydrocephalus: a multiinstitutional study conducted in Japan.

OBJECT: A cooperative study was undertaken to identify factors that could be used to predict a favorable outcome after extracranial cerebrospinal fluid (CSF) diversion (shunting) in patients with suspected idiopathic normal-pressure hydrocephalus (NPH). METHODS: Questionnaires concerning patients with suspected idiopathic NPH were sent to 14 members of the Committee for Scientific Research on Intractable Hydrocephalus, sponsored by the Ministry of Health and Welfare of Japan. After the questionnaires were returned, a retrospective analysis of the responses was undertaken. To be included in the study, patients had to be 65 years of age or older and had to have undergone surgery between October 1995 and October 1998. Clinical measures included degrees of gait disturbance, dementia, and urinary incontinence as evaluated before. 3 months after, and 3 years after shunt placement. Diagnostic tests in various combinations included lumbar puncture in which CSF was withdrawn; intracranial pressure monitoring; measurements of CSF outflow resistance, level of serum alpha-1-antichymotrypsin, cerebral arteriovenous differences of oxygen content, and cerebral blood flow; and computerized tomography cisternography. In this study, 120 patients were identified as having idiopathic NPH and these patients underwent placement of shunts. A ventriculoperitoneal shunt with a programmable valve was used in two thirds of the patients. At the end of 3 months (early assessment), there was an 80% overall rate of clinical improvement, which dropped to 73.3% of the 105 patients who could be evaluated at the end of the 3-year study. Of the three variables, gait disturbance was most improved, both at early and late testing periods. Shunt complications occurred in 22 (18.3%) of the patients. CONCLUSIONS: Patients suspected of having idiopathic NPH did not form a homogeneous group, making it difficult to select those who would most likely respond to CSF diversion. Of the diagnostic studies, the most reliable result was improvement in clinical symptoms following a lumbar puncture in which CSF was withdrawn. The use of a programmable valve is recommended because it offers advantages in preventing problems of over- and underdrainage.     

Training residents using simulation technology: experience with ultrasound for trauma

BACKGROUND: The need for surgeons to become proficient in performing and interpreting ultrasound examinations has been well recognized in recent years, but providing standardized training remains a significant challenge. The UltraSim (MedSim, Ft. Lauderdale, Fla) ultrasound simulator is a modified ultrasound machine that stores patient data in three-dimensional images. By scanning on the UltraSim mannequin, the student can reconstruct these images in real-time, eliminating the need for finding normal and abnormal models, while providing an objective method of both teaching and testing. The objective of this study was to compare the posttest results between residents trained on a real-time ultrasound simulator versus those trained in a traditional hands-on patient format. We hypothesized that both methods of teaching would yield similar results as judged by performance on the interpretive portion of a standardized posttest. It is designed as a prospective, cohort study from two university trauma centers involving residents at the beginning of their first or second postgraduate year of training. The main outcome measure was performance on a standardized posttest, which included interpretation of ultrasound cases recorded on videotape. METHODS: Students first took a written pretest to evaluate their baseline knowledge of ultrasound physics as well as their ability to interpret basic ultrasound images. The didactic portion of the course used the same teaching materials for all residents and included lectures on ultrasound physics, ultrasound use in trauma/critical care, and a series of instructional videos. This didactic session was followed by 1 hour for each student of hands-on training on medical models/medical patients (group I) or by training on the ultrasound simulator (group II). The pretest was repeated at the completion of the course (posttest). Data were stratified by postgraduate year, i.e., PG1 or PG2. RESULTS: A total of 74 residents were trained and tested in this study (PG1 = 48, PG2 = 26). All residents showed significant improvement in their pretest and posttest scores (p = 0.00) in both their knowledge of ultrasound physics and in their interpretation of ultrasound images. Importantly, we could not demonstrate any significant difference between groups trained on models/patients (group I) versus those trained on the simulator (group II) when comparing their posttest interpretation of ultrasound images presented on videotapes (PG1, group I mean score 6.9 +/- 1.4 vs. PG1, group II mean score 6.5 +/- 1.6, p = 0.32; PG2, group I mean score 7.7 +/- 1.4 vs. PG2, group II mean score 7.9 +/- 1.2, p = 0.70). CONCLUSION: The use of a simulator is a convenient and objective method of introducing ultrasound to surgery residents and compares favorably with the experience gained with traditional hands-on patient models.     

The cost effectiveness of anesthesia workforce models: a simulation approach using decision-analysis modeling

The objective of this study was to evaluate the incremental cost effectiveness of anesthesia workforce staffing scenarios, as a function of skill mix, by using the technique of decision analysis. A decision tree model was constructed to compare the incremental cost effectiveness of alternative delivery systems for anesthesia care from the perspective of the payer. Five different staffing scenarios, ranging from physician-intensive to nurse-intensive, were modeled. In the nurse-intensive model, low- and intermediate-risk patients were cared for by solo certified registered nurse anesthetists (CRNAs) and high-risk patients were cared for by physicians. In the physician-intensive model, physicians anesthetized all patients. In the first-, second-, and third-team models, all high-risk patients were cared for by physicians working alone, and all intermediate-risk patients were cared for using an anesthesia care team approach with a ratio of one physician to two CRNAs. The low-risk patients were managed by using an anesthesia care team approach with physician to CRNA ratios of 1:2, 1:4, and 1:8 in the first-, second-, and third-team models, respectively. The findings of this decision-analysis model suggest that physician-only anesthesia is not cost effective. However, the third-team model is cost effective when compared with the nurse-intensive model. IMPLICATIONS: An anesthesia care-team approach with a physician to certified registered nurse anesthetist (CRNA) ratio of 1:2 is the preferred staffing scenario for intermediate-risk patients. Although medical direction of CRNAs caring for low-risk patients is cost-effective, the small improvement in outcome resulting from increasing the physician to CRNA ratio from 1:8 to 1:4 may not be justified by the added cost.     

A comparison of the training value of two types of anesthesia simulators: computer screen-based and mannequin-based simulators

In this study, we compared two different training simulators (the computer screen-based simulator versus the full-scale simulator) with respect to training effectiveness in anesthesia residents. Participants were evaluated in the management of a simulated preprogrammed scenario of anaphylactic shock using two variables: treatment score and diagnosis time. Our results showed that simulators can contribute significantly to the improvement of performance but that learning in treating simulated crisis situations such as anaphylactic shock did not significantly vary between full-scale and computer screen-based simulators. Consequently, the initial decision on whether to use a full-scale or computer screen-based training simulator should be made on the basis of cost and learning objectives rather than on the basis of technical or fidelity criteria. Our results support the contention that screen-based simulators are good devices to acquire technical skills of crisis management. Mannequin-based simulators would probably provide better training for behavioral aspects of crisis management, such as communication, leadership, and interpersonal conflicts, but this was not tested in the current study. IMPLICATIONS: We compared two different training simulators (computer screen-based versus full-scale) for training anesthesia residents to better document the effectiveness of such devices as training tools. This is an important issue, given the extensive use and the high cost of mannequin-based simulators in anesthesiology.     

Rapid skin anesthesia using a new topical amethocaine formulation: a preclinical study

We developed a fast-acting topical amethocaine emulsion and tested its analgesic activity against heat or mechanically induced pain in a rat paw model. The first experiment was performed in rats made hyperalgesic or allodynic after carrageenan-induced inflammation. Rats were distributed in five subgroups, each receiving topically one of the following: amethocaine microemulsion, amethocaine gel (Ametopgel), EMLA (Eutectic Mixture of Local Anesthetics) cream, amethocaine infiltration, or nothing (controls). The second experiment was conducted on healthy, selected heat- or touch-hypersensitive rats, which were distributed as in the first experiment. Paw withdrawal time from a heat and a mechanical stimulus was used as a pain index. In the first experiment, antihyperalgesic activity appeared at 4.2, 13.8, and 14 min after amethocaine microemulsion, gel, or EMLA cream, respectively. Amethocaine microemulsion was the only topical formulation with an antiallodynic effects, although less than with amethocaine infiltration. In healthy rats (second experiment), all topical formulations produced similar analgesic effects in heat-induced pain of the ipsilateral paw. Activity in the contralateral paw appeared earlier with amethocaine microemulsion, which was also the only one that increased touch-induced withdrawal time in the ipsi- and contralateral paws. Therefore, the microemulsion could be valuable for improving amethocaine skin penetration and thus bringing rapid pain relief. IMPLICATIONS: Topical anesthetics are used in several painful clinical procedures, but they tend to have a slow onset time. A new amethocaine microemulsion with a faster onset of analgesia than commercial formulations was developed and its activity tested in pain states induced by heat or mechanical stimulus in inflamed and healthy rat paws.     

Errors and omissions in anesthesia: a pilot study using a pilot's checklist

There are recent concerns that anesthesiologists are becoming less skilled in providing general anesthesia for Cesarean delivery. We considered whether a verbal checklist would help in the preparation for this event. We created a list of items to be checked when preparing to administer general anesthesia for a Cesarean delivery using expert opinion. This list was loaded onto an electronic checklist system with voice prompts and tested on 20 anesthesiologists using a high-fidelity anesthesia simulator. Participants omitted to check a median of 13 (range, 7-23) of 40 items. Common omissions included not checking that the difficult intubation trolley was available and not optimizing the patient's head position. Most (95%) participants felt that the checklist was useful and 80% would like to use it for practicing simulated scenarios; 60% preferred a written checklist and 40% preferred the verbal checklist. Important checks may be forgotten when preparing to give a general anesthetic for Cesarean delivery, and the use of a checklist could improve patient safety.     

Evaluation of local anesthesia agents using a new force-sensitive lid speculum

Three commonly used injection anesthetics, bupivacaine .75%, mepivacaine 2%, and lidocaine 2% were evaluated for onset, completeness and duration of akinesia following modified O'Brien facial nerve block, using a new force-sensitive lid speculum. All three agents provided facial akinesia that was profound within six minutes of the time of injection. The onset and the depth of anesthesia were roughly the same with all three agents. However, bupivacaine induced akinesia of greatest duration, lasting up to six hours, the time of final measurement in this study. Akinesia produced by mepivacaine was adequate for about 90 minutes, and lidocaine for 15-30 minutes. A newly-described force-sensitive speculum was utilized in this study. It is an effective instrument for measuring completeness of akinesia, and may have clinical usefulness.     

A multicenter study of the epidemiology of hepatitis B in anesthesia residents

Practicing anesthesiologists are at high risk of hepatitis B infection, but the risk for anesthesia residents has not been assessed. Anesthesia residents at seven universities were surveyed to study the epidemiology of hepatitis B in these trainees. Hepatitis B virus markers in serum were measured and data from questionnaires were used to determine characteristics of anesthetic practice, effectiveness of strategies for hepatitis B virus infection control, and nonvocational hepatitis B risk factors. Of 267 participants, 12.7% (range of the seven centers, 8.7%-22.7%) had serum markers for hepatitis B virus. The seropositivity (17.8%) in anesthesia residents who had completed more than 12 months of nonanesthesia postgraduate clinical training, or who had practiced medicine in another specialty prior to anesthesia, was greater than in the other trainees (9.4%). Based on their risk and the ineffectiveness of current control measures, anesthesia residents who lack hepatitis B virus immunity should be vaccinated prior to or as early as possible in their training.