Similar Deficiencies in Procedural Dermatology and Dermatopathology Fellow Evaluation despite Different Periods of ACGME Accreditation: Results of a National Survey

BACKGROUND Fellow evaluation is required by the Accreditation Council for Graduate Medical Education (ACGME). Procedural dermatology fellowship accreditation by the ACGME began in 2003 while dermatopathology accreditation began in 1976.
OBJECTIVE The objective was to compare fellow evaluation rigor between ACGME-accredited procedural dermatology and dermatopathology fellowships.
METHODS Questionnaires were mailed to fellowship directors of the ACGME-accredited (2006–2007) procedural dermatology and dermatopathology fellowship programs. Information was collected regarding evaluation form development, delivery, and collection.
RESULTS The response rates were 74% (25/34) and 53% (24/45) for procedural and dermatopathology fellowship programs, respectively. Sixteen percent (4/25) of procedural dermatology and 25% (6/24) of dermatopathology programs do not evaluate fellows. Fifty percent or less of program (4/8 procedural dermatology and 3/7 dermatopathology) evaluation forms address all six core competencies required by the ACGME.
CONCLUSION Procedural fellowships are evaluating fellows as rigorously as the more established dermatopathology fellowships. Both show room for improvement because one in five programs reported not evaluating fellows and roughly half of the evaluation forms provided do not address the six ACGME core competencies.     

Teaching ethics in surgical training programs using a case-based format

PURPOSE: To fulfill a curricular need and to address the ACGME competencies of Professionalism and Systems-based practice, we have developed a case-based approach to teaching ethics to trainees at Washington University in Saint Louis. DEVELOPMENT OF THE ACTIVITY AND MATERIALS: For the past 5 years, we have used a case-based approach to discuss ethical dilemmas with residents in an interactive conference format. Attendees and participants include medical students, residents, fellows, and surgical attendings, as well as members of the hospital ethics committee, nurses, chaplains, and attendings and trainees from other disciplines. Residents and students collect the cases from their daily experiences and discuss them with the group on a monthly basis. EVALUATION COMPONENT: Attitudinal surveys of trainees were completed just before the initiation of the conferences and again 5 years later. IMPLEMENTATION DATES AND EXPERIENCE TO DATE: The program was initiated in October 2002 and is ongoing. The format and the participants have evolved somewhat over this time period. That evolution and some lessons learned are described in this article. CONCLUSION: Our experiences have shown that a case-based approach to teaching ethics to surgical trainees is feasible, relevant, and important to the education of trainees in the current environment.     

Morbidity and mortality conferences in general surgery: a narrative systematic review

BackgroundIn medical and surgical departments around the world, morbidity and mortality conferences (MMC) serve dual roles: they are cornerstones of quality-improvement programs and provide timely opportunities for education within the urgent context of clinical care. Despite the widespread adoption of MMCs, adverse events and preventable errors remain high or incompletely characterized, and opportunities to learn from and adjust to these events are frequently lost. This review examines the published literature on strategies to improve surgical MMCs.MethodsWe searched OVID Medline, PubMed, Embase and CENTRAL. We defined our combination of search terms using a PICO (population, intervention, comparison, outcome) model, focusing on the use of MMCs in general surgery.ResultsThe MMC literature focused on 5 themes: educational value, error analysis, case selection and representation, attendance and dissemination. Strategies used to increase educational value included limiting case presentation time to 15–20 minutes, mandatory brief literature reviews, increasing audience interaction, and standardizing presentations using a PowerPoint template or SBAR (situation, background, assessment, recommendation) format. Interventions to improve error analysis included focused discussion on causative factors and taxonomic error analysis. Case selection was improved by using an electronic clinical registry, such as the National Surgery Quality Improvement Program, to better capture incidence of morbidity and mortality. Attendance was improved with teleconferencing. Dissemination strategies included MMC newsletters, incorporating MMCs into plan-do-check-act cycles, and surgeon report cards.ConclusionGreater standardization of best practices may increase the quality improvement and educational impact of MMCs and provide a baseline to measure the effect of new MMC format innovations on the clinical and educational performance of surgical systems.     

Comment évaluer l’impact des revues de morbi-mortalité sur la qualité et la sécurité des soins en réanimation ?

ObjectiveTo estimate the morbidity and mortality conferences (MMC) impact in intensive care unit (ICU) setting on quality of care and patients’ safety.Data sourcesA review of English and French articles in Medline database (1990–2011) related to MMC in the ICU. Keywords used: “morbidity (and) mortality conference(s)”, “intensive care unit”, “intensive/critical care medicine”. Additional studies identified by hand search in French national guidelines about MMCs and in the Annales Françaises d’Anesthésie Réanimation and Réanimation journals index. Identification and preliminary analysis performed using title and abstract, for every study related to MMC in the ICU.Study selectionOnly original studies about MMC in the ICU setting that reported an assessment were included. Papers reporting guidelines and methods for MMC implementation were excluded.Data extractionExtraction used predefined data fields, including study design, MMC characteristics, assessment methods and results.Data synthesisStudies about MMC in the ICU are recent and scarce. Results comparison and synthesis are impaired by discrepancies in study designs. Although the effectiveness of MMC is not evidence-based, data are consistent for their positive impact on quality of care and patient safety in the ICU.ConclusionFurther studies are required to assess the impact of MMC in the ICU. Based on this literature review, a 4-level evaluation scheme can be suggested: 1) evaluation of MMC implementation in care units and facilities; 2) evaluation of MMC organization; 3) evaluation of MMC on quality of care; 4) evaluation of MMC impact on patients’ mortality and morbidity.     

National implementation of a pragmatic quality improvement skills curriculum for urology residents in the UK: Application and results of ‘theory-of-change’ methodology

BackgroundThere is global momentum to establish scalable Quality Improvement (QI) skills training curricula. We report development of an implementation plan for national scale-up of the ‘Education in Quality Improvement’ program (EQUIP) in UK urology residencies.Materials & methodsTheory-of-Change (ToC) methodology was used, which engaged EQUIP stakeholders in developing a single-page implementation ‘Logic Model’ in 4 study phases (2 stakeholder workshops (N = 20); 10 stakeholder interviews). The framework method was used for analysis.ResultsCore elements of the EQUIP Logic Model include: (i) QI curriculum integration into national surgical curricula; (ii) resident-led, modular, team-based QI projects; (iii) development of a national web-platform as QI projects library; (iv) a train-the-trainers module to develop attendings as QI mentors; and (v) knowledge transfer activities (e.g., peer-reviewed publications of residents’ QI projects).ConclusionsToC methodology was useful in developing a stakeholder-driven, actionable implementation plan for the national scale-up of EQUIP in the UK.     

Design,delivery, and evaluation of seminars and hands-on courses worldwide on intraoperative imaging in orthopedic trauma

IntroductionAlthough intraoperative imaging is important for assessing the quality of several steps during fracture fixation, most trainees and surgeons have received little formal education on this topic and report they learn "on the job" and "through practice". A planning committee of orthopedic trauma surgeons was established to design a curriculum using "backward planning" to identify patient problems, identify gaps in surgeons' knowledge and skills, and define competencies as a framework for education in order to optimize patient care.Materials and methodsThe committee defined 8 competencies related to intraoperative imaging, with detailed learning objectives for each one (e.g. select the imaging modality, set up the operating room). An interactive, case-based half-day seminar to deliver these objectives for 2-D and 3-D intraoperative imaging during the fixation of common fractures was designed. The seminar was delivered in several locations worldwide over a 6-year period and evaluation and assessment data were gathered online. A full-day procedures course was added and delivered 6 times to address the skills component of competencies.Results17 seminars and 6 courses were delivered and attended by an average of 26 and 17 participants respectively (ranges 13–42 and 13–20). Pre-event gap analysis and assessment question scores confirmed needs and motivation to learn in all events. 97% of the 442 seminar participants and 98% of the 100 course participants would recommend the events to colleagues. An average of 88% and 90% respectively learned something new and plan to use it in their practice (range 63%-100%). Commitment to change (CTC) statements showed intended practice improvements related to all competencies.DiscussionThe large percentages of high impact ratings for all events suggest the content met the needs of many participants. Post-event reduction in gap scores and an increase in the desired level of ability for most competencies suggests the content addressed many gaps.ConclusionsCase-based, interactive seminars and courses addressing knowledge, skills, and attitudes to optimize the use of intraoperative imaging during the fixation of common fractures help address unmet educational needs for trainees and complements existing formal training.     

Patterns of Intestinal Motility Recovery during the Early Stage following Abdominal Surgery: Clinical and Manometric Study

p < 0.05). As measured by manometric examination, an MMC reappeared within a few hours after surgery. Physiologic postoperative ileus was ended when MMCs extended throughout the gastrointestinal (GI) tract with forwarding GI fluids.     

Realistic expectations and leadership in the era of work hour reform

BACKGROUND: Work hour guidelines and core competencies were introduced to improve surgical education and are changing the landscape of surgical training. We sought to examine perceptions and attitudes regarding the impetus and impact associated with these changes. MATERIALS AND METHODS: Anonymous surveys were distributed to faculty and surgeons-in-training in an Accreditation Council for Graduate Medical Education, university-based, training program. RESULTS: Faculty (F, n = 30) and trainees (T, n = 30) agree that lifestyle expectations and long work hours are the principal issues facing surgical education (F = 80%, T = 56%; P = 0.03). Implementation of ACGME guidelines is perceived as NOT improving patient care or clinical experience (F = 100%, T = 90%; P = 0.03) while reducing operative experience (F = 50%, T = 70%). More faculty (>80%) than trainees (33%) are concerned that ACGME guidelines will diminish patient care experiences. Although most (F = 77%, T = 83%; P = NS) agree that hiring additional providers will improve guideline compliance, many oppose ACGME guideline implementation fearing a loss of professionalism. Although both (F = 50%, T = 47%) admonish deficient interpersonal and communication skills as the major impediment to implementing ACGME guidelines, opinions regarding implementation differ. Most faculty (67%) believe ACGME-imposed deadlines are the most influential reason; however, trainees (57%) believe guidelines should be promptly implemented to address long-awaited changes in work environment and surgical graduate medical education. CONCLUSIONS: Although faculty and trainees' perception of the issues surrounding ACGME guidelines converge, perception of changes following implementation is quite divergent. For successful implementation, leadership must address prevailing attitudes and set realistic expectations. These trends have important implications for planning the future of surgical education, unifying multi-generational colleagues, and improving systems-based practice.     

Status of trauma quality improvement programs in the Andean region: What foundation do we have to build on

IntroductionTrauma quality improvement (QI) programs have been shown to improve outcomes and decrease cost. These are high priorities in low- and middle-income countries (LMICs), where 2,000,000 deaths due to survivable injuries occur each year. We sought to define areas for improvement in trauma QI programs in four LMICs.MethodsWe conducted a survey among trauma care providers in four Andean middle-income countries: Bolivia, Colombia, Ecuador, and Peru.Results336 physicians, medical students, nurses, administrators and paramedical professionals responded to the cross-sectional survey with a response rate greater than 90% in all included countries except Bolivia, where the response rate was 14%. Eighty-seven percent of respondents reported morbidity and mortality (M&M) conferences occur at their hospital. Conferences were often reported as infrequent – 45% occurred less than every three months and poorly attended – 63% had five or fewer staff physicians present. Only 23% of conferences had standardized selection criteria, most lacked documentation – notes were taken at only 35% of conferences. Importantly, only 13% of participants indicated that discussions were routinely followed-up with any sort of corrective action. Multivariable analysis revealed the presence of standardized case selection criteria (OR 3.48, 95% CI 1.16–10.46), written documentation of the M&M conferences (OR 5.73, 95% CI 1.73–19.06), and a clear plan for follow-up (OR 4.80, 95% CI 1.59–14.50) to be associated with effective M&M conferences. Twenty-two percent of respondents worked at hospitals with a trauma registry. Fifty-two percent worked at institutions where autopsies were conducted, but only 32% of those reported the autopsy results to ever be used to improve hospital practice.ConclusionsM&M conferences are frequently practiced in the Andean region of Latin America but often lack methodologic rigor and thus effectiveness. Next steps in the maturation of QI programs include optimizing use of data from autopsies and registries, and systematic follow-up of M&M conferences with corrective action to ensure that these activities result in appreciable changes in clinical care.     

Association of intraoperative entrustment with clinical competency amongst general surgery residents

BackgroundLack of transparency and meaningful assessment in surgical residency has led to inconsistent intraoperative entrustment and highly variable trainee competence at graduation. The relationship between faculty entrustment and resident entrustability on clinical competency remains unclear. We sought to evaluate the dynamic between entrustment/entrustability and clinical competency in general surgery residency.MethodsIntraoperative observations were conducted across a 22-month period at an academic tertiary center. Entrustment/entrustability were measured using OpTrust. Clinical competencies were appraised via ACGME Milestones and Objective Structured Assessment of Technical Skill (OSATS) scores. Mixed effects linear regression was used to investigate the relationship among overall ACGME Milestone scores, OSATS domain scores, and overall OpTrust scores.ResultsOverall OpTrust scores significantly correlated with overall Milestone scores and multiple OSATS score domains.ConclusionsOpTrust demonstrated a positive association between ACGME general surgery Milestones and OSATS scores. Overall, OpTrust may help optimize intraoperative faculty entrustment and resident entrustability, facilitating surgical trainee success during residency.     

Patient safety curriculum for surgical residency programs: results of a national consensus conference

BACKGROUND: The American College of Surgeons (ACS) and the Accreditation Council for Graduate Medical Education (ACGME) are committed to promoting patient safety through education. In view of the critical role of residents in the delivery of safe patient care, the ACS and ACGME sponsored jointly a national consensus conference to initiate the development of a curriculum on patient safety that may be used across all surgical residency programs. CONCLUSIONS: National leaders in surgery with expertise in surgical care and surgical education, patient safety experts, medical educators, key stakeholders from national organizations, and surgical residents were invited to participate in the conference. Attendees considered patient safety issues within the context of the 6 core competencies defined by the ACGME and American Board of Medical Specialties (ABMS). Discussions resulted in the development of a curriculum matrix that includes listings of patient safety topics, teaching and learning strategies, and assessment methods. Guidelines for implementation and dissemination are also provided. The curriculum content underscores the need to create an organizational culture of safety and focuses on both individuals and systems. Individual residency programs may prioritize the curriculum content based on their specific needs. The ACS and ACGME will pursue development of educational modules to address the curriculum content, disseminate helpful information, and assist in implementation of new educational interventions. This effort has the potential to positively impact residency education in surgery, help surgical program directors address the core competencies, and enhance patient safety.     

Pediatric surgery fellowship compliance to the 80-hour work week

Objective

The goal of this study was to determine the compliance of pediatric surgery fellowships with Accreditation Council for Graduate Medical Education (ACGME) duty hour restrictions while confronting a reduced resident workforce.

Materials and Methods

An evaluation of training programs was performed by surveying pediatric surgery fellows on aspects of work hours, ACGME guideline compliance, operative case volume, employment of physician extenders, and didactic education.

Results

A 74% survey response rate was achieved. Of the respondents, 95% felt fully aware of ACGME guidelines. Although 95% of programs had mechanisms for compliance in place, only 45% of fellows felt compliant. Median work hours were 80 to 90 hours per week. Although subordinate residents were felt to obtain better compliance (>86%), only 69% of fellows perceived greater service commitment as a result. No impact on volume of operative cases was perceived. Of the programs, 89% employed physician extenders and 55% used additional fellows, but no overall effect on fellow work hours was evident. Fellows did not identify an improvement in the quality of clinical fellowships with guideline implementation.

Conclusions

A minority of fellows comply with ACGME guidelines. Vigilance of duty hour tracking correlates to better compliance. A shift of patient care to fellows is perceived. Use of support personnel did not significantly aid compliance.     

Canadian Pediatric Surgeon Workforce: Characterization of Training,Trends Over Time,and 10-year Model for Pediatric Surgery Need

BackgroundGraduate and fellowship training trends for Canadian pediatric surgeons remain uncharacterized. Similarly, updated workforce planning for pediatric surgeons is required. We aimed to characterize graduate degree and fellowship trends for Canadian pediatric surgeons, with modelling to inform workforce planning.MethodsWe performed a cross sectional observational study evaluating Canadian pediatric surgeons in January 2022. Surgeon demographics collected included year of medical degree (MD) conferment, MD location, fellowship location, and graduate degree achievement. Our primary outcome was to evaluate training characteristics over time. Secondary outcomes evaluated surgeon supply and demand from 2021 to 2031. Supply was extrapolated from current Canadian pediatric surgery fellows assuming static fellowship matriculation, while retirement was estimated using a 31-, 36-, or 41-year career following MD conferral.ResultsOf included surgeons (n = 77), 64 (83%) completed fellowship training in Canada and 46 (60%) have graduate degrees. No surgeons graduating ≤1980 hold graduate degrees, compared to 8 (100%) surgeons with MD ≥ 2011 (p < 0.001). Similarly, more surgeons with MD ≥ 2011 appear to have a Canadian MD (n = 7, 87.5%) and Canadian fellowship (n = 8, 100%). Modelling predicts that 19–49 (25%–64%) surgeons will retire between 2021 and 2031, while 37 fellows will graduate with intention to work in Canada, creating between a 12 surgeon deficit up to an 18 surgeon surplus depending on career length.ConclusionsTrends in graduate degree achievement and fellowship location suggest increasing competition for Canadian pediatric surgery positions. Additionally, a substantial number of Canadian-trained fellows will need positions outside of Canada in the next decade. Overall, results support previous work demonstrating saturation of the Canadian pediatric workforce.Level of EvidenceLevel IV.ACGME Competency AddressedMedical Knowledge.     

An historical review of graduate medical education and a protocol of Accreditation Council for Graduate Medical Education compliance

PURPOSE: A brief history of American graduate medical education is discussed to provide a context for understanding the new standards set forth by the Accreditation Council on Graduate Medical Education (ACGME). The evaluation protocol of the University of Washington, which is structured around the 6 core competencies, is described. MATERIALS AND METHODS: Historical events regarding American graduate medical education, national conference information and recent ACGME recommendations according to the Outcomes Project are reviewed and summarized. These materials were used to design a reasonable program that would comply with ACGME recommendations. RESULTS: ACGME tools that represent the 6 core competencies have been incorporated into our program and should provide metrics that will demonstrate improvement in residency training and education. CONCLUSIONS: A key factor to the success of residency training and ACGME accreditation will be the education of residents and faculty about the new ACGME regulations. The University of Washington Department of Urology is poised to engage the new model by creating new call coverage strategies, applying new metrics to old teaching models and using electronic database systems.     

Revues de morbi-mortalité (RMM) en anesthésie-réanimation : retour d’expérience au CHU de Nancy

Objectives

Assessment of the morbidity mortality conferences (MMC) durableness in the Anaesthesiology and Surgical Intensive Care Department of the Urban Hospitals of Nancy University Hospital; evaluation of the proportion of medical education in the corrective actions implemented, and research for improvement ways.

Patients

All the cases of death and near-death in the operating room and all the cases deemed to be instructive or useful for security improvement.

Method

Retrospective analysis of MMC activity since its initiation in 2005.

Results

Durability of MMC and good attendance rate have been sustained over time. As in the USA, MMCs result firstly in resident's education and continued medical education actions. Medical education actions represent 75% of all corrective measures, followed by changes in practices (62%), in procedures (48%) and in organisation (5%).

Discussion

The development process of a culture of the safety has been initiated and perpetuated. Some ways of improvement have been proposed: MMC must certainly be widened as well regarding to the categories of addressees, as the topics (any event deemed to be noteworthy for the safety of care) or the time scale of the analysis. Others propositions: preparation of the presentations with a colleague experienced in MMC; participation of external MMC experts; monitoring of local markers of security of care and of corrective measures efficiency; inclusion of MMC cases presentation in the trainees pedagogic objectives.     

Quality improvement training for burn care in low-and middle-income countries: A pilot course for nurses

BackgroundThere is an urgent need to empower practitioners to undertake quality improvement (QI) projects in burn services in low-middle income countries (LMICs). We piloted a course aimed to equip nurses working in these environments with the knowledge and skills to undertake such projects.MethodsEight nurses from five burns services across Malawi and Ethiopia took part in this pilot course, which was evaluated using a range of methods, including interviews and focus group discussions.ResultsCourse evaluations reported that interactive activities were successful in supporting participants to devise QI projects. Appropriate online platforms were integral to creating a community of practice and maintaining engagement. Facilitators to a successful QI project were active individuals, supportive leadership, collaboration, effective knowledge sharing and demonstrable advantages of any proposed change. Barriers included: staff attitudes, poor leadership, negative culture towards training, resource limitations, staff rotation and poor access to information to guide practice.ConclusionsThe course demonstrated that by bringing nurses together, through interactive teaching and online forums, a supportive community of practice can be created. Future work will include investigating ways to scale up access to the course so staff can be supported to initiate and lead quality improvement in LMIC burn services.