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1.  Clinical fellowship training in pathology informatics: A program description 
Background:
In 2007, our healthcare system established a clinical fellowship program in pathology informatics. In 2011, the program benchmarked its structure and operations against a 2009 white paper “Program requirements for fellowship education in the subspecialty of clinical informatics”, endorsed by the Board of the American Medical Informatics Association (AMIA) that described a proposal for a general clinical informatics fellowship program.
Methods:
A group of program faculty members and fellows compared each of the proposed requirements in the white paper with the fellowship program's written charter and operations. The majority of white paper proposals aligned closely with the rules and activities in our program and comparison was straightforward. In some proposals, however, differences in terminology, approach, and philosophy made comparison less direct, and in those cases, the thinking of the group was recorded. After the initial evaluation, the remainder of the faculty reviewed the results and any disagreements were resolved.
Results:
The most important finding of the study was how closely the white paper proposals for a general clinical informatics fellowship program aligned with the reality of our existing pathology informatics fellowship. The program charter and operations of the program were judged to be concordant with the great majority of specific white paper proposals. However, there were some areas of discrepancy and the reasons for the discrepancies are discussed in the manuscript.
Conclusions:
After the comparison, we conclude that the existing pathology informatics fellowship could easily meet all substantive proposals put forth in the 2009 clinical informatics program requirements white paper. There was also agreement on a number of philosophical issues, such as the advantages of multiple fellows, the need for core knowledge and skill sets, and the need to maintain clinical skills during informatics training. However, there were other issues, such as a requirement for a 2-year fellowship and for informatics fellowships to be done after primary board certification, that pathology should consider carefully as it moves toward a subspecialty status and board certification.
doi:10.4103/2153-3539.93893
PMCID: PMC3327041  PMID: 22530179
Pathology informatics fellowship; clinical informatics; clinical informatics fellowship; pathology informatics; pathology informatics teaching; clinical informatics teaching
2.  Accreditation council for graduate medical education (ACGME) annual anesthesiology residency and fellowship program review: a "report card" model for continuous improvement 
BMC Medical Education  2010;10:13.
Background
The Accreditation Council for Graduate Medical Education (ACGME) requires an annual evaluation of all ACGME-accredited residency and fellowship programs to assess program quality. The results of this evaluation must be used to improve the program. This manuscript describes a metric to be used in conducting ACGME-mandated annual program review of ACGME-accredited anesthesiology residencies and fellowships.
Methods
A variety of metrics to assess anesthesiology residency and fellowship programs are identified by the authors through literature review and considered for use in constructing a program "report card."
Results
Metrics used to assess program quality include success in achieving American Board of Anesthesiology (ABA) certification, performance on the annual ABA/American Society of Anesthesiology In-Training Examination, performance on mock oral ABA certification examinations, trainee scholarly activities (publications and presentations), accreditation site visit and internal review results, ACGME and alumni survey results, National Resident Matching Program (NRMP) results, exit interview feedback, diversity data and extensive program/rotation/faculty/curriculum evaluations by trainees and faculty. The results are used to construct a "report card" that provides a high-level review of program performance and can be used in a continuous quality improvement process.
Conclusions
An annual program review is required to assess all ACGME-accredited residency and fellowship programs to monitor and improve program quality. We describe an annual review process based on metrics that can be used to focus attention on areas for improvement and track program performance year-to-year. A "report card" format is described as a high-level tool to track educational outcomes.
doi:10.1186/1472-6920-10-13
PMCID: PMC2830223  PMID: 20141641
3.  A Critical Appraisal of and Recommendations for Faculty Development 
The 2009-2010 American Association of Colleges of Pharmacy (AACP) Council of Faculties Faculty Affairs Committee reviewed published literature assessing the scope and outcomes of faculty development for tenure and promotion. Relevant articles were identified via a PubMed search, review of pharmacy education journals, and identification of position papers from major healthcare professions academic organizations. While programs intended to enhance faculty development were described by some healthcare professions, relatively little specific to pharmacy has been published and none of the healthcare professions have adequately evaluated the impact of various faculty-development programs on associated outcomes.
The paucity of published information strongly suggests a lack of outcomes-oriented faculty-development programs in colleges and schools of pharmacy. Substantial steps are required toward the development and scholarly evaluation of faculty-development programs. As these programs are developed and assessed, evaluations must encompass all faculty subgroups, including tenure- and nontenure track faculty members, volunteer faculty members, women, and underrepresented minorities. This paper proposes AACP, college and school, and department-level recommendations intended to ensure faculty success in achieving tenure and promotion.
doi:10.5688/ajpe756122
PMCID: PMC3175674  PMID: 21931460
faculty development; colleges and schools of pharmacy; tenure; promotion; outcomes
4.  A retrospective review of general surgery training outcomes at the University of Toronto 
Canadian Journal of Surgery  2009;52(5):E131-E136.
Background
Surgical educators have struggled with achieving an optimal balance between the service workload and education of surgical residents. In Ontario, a variety of factors during the past 12 years have had the net impact of reducing the clinical training experience of general surgery residents. We questioned what impact the reductions in trainee workload have had on general surgery graduates at the University of Toronto.
Methods
We evaluated graduates from the University of Toronto general surgery training program from 1995 to 2006. We compared final-year In-Training Evaluation Reports (ITERs) of trainees during this interval. For purposes of comparison, we subdivided residents into 4 groups according to year of graduation (1995–1997, 1998–2000, 2001–2003 and 2004–2006). We evaluated postgraduate “performance” by categorizing residents into 1 of 4 groups: first, residents who entered directly into general surgery practice after graduation; second, residents who entered into a certification subspecialty program of the Royal College of Physicians and Surgeons of Canada (RCPSC); third, residents who entered into a noncertification program of the RCPSC; and fourth, residents who entered into a variety of nonregulated “clinical fellowships.”
Results
We assessed and evaluated 118 of 134 surgical trainees (88%) in this study. We included in the study graduates for whom completed ITER records were available and postgraduate training records were known and validated. The mean scores for each of the 5 evaluated residency training parameters included in the ITER (technical skills, professional attitudes, application of knowledge, teaching performance and overall performance) were not statistically different for each of the 4 graduating groups from 1995 to 2006. However, we determined that there were statistically fewer general surgery graduates (p < 0.05) who entered directly into general surgery practice in the 2004–2006 group compared with the 1998–2000 and 2001–2003 groups. The graduates from 2004 to 2006 who did not enter into general surgery practice appeared to choose a clinical fellowship.
Conclusion
These observations may indicate that recent surgical graduates possess an acceptable skill set but may lack the clinical confidence and experience to enter directly into general surgery practice. Evidence seems to indicate that the clinical fellowship has become an unregulated surrogate extension of the training program whereby surgeons can gain additional clinical experience and surgical expertise.
PMCID: PMC2769098  PMID: 19865542
5.  Journal publications by pharmacy practice faculty evaluated by institution and region of the United States (2001-2003) 
Pharmacy Practice  2007;5(4):151-156.
Objective
To compare the quantity of manuscripts published in journals by departments of pharmacy practice at schools and colleges of pharmacy in the United States for the years 2001-2003.
Methods
We utilized the Web of Science bibliographic database to identify publication citations for the years 2001 to 2003 which were then evaluated in a number of different ways. Faculty were identified via American Association of Colleges of Pharmacy rosters for 2000-2001, 2001-2002, and 2002-2003 academic years.
Results
Rankings were done based on the number of publications per institution and average number of publications per faculty member at an institution. Upon linear regression analysis, a relationship exists between an institution’s faculty size and the total number of publications but not for tenure/nontenure-track faculty ratio. Rating highest in overall publication number did not guarantee high rankings in the average number of publications per faculty member at an institution assessment. Midwestern schools were responsible for more publications per institution than other regions. Many schools only generated minimal scholarship over this evaluative period.
Conclusion
While many schools have pharmacy practice faculty that strongly contributed to the biomedical literature, other schools have not. Pharmacy practice faculty in the Midwest publish more journal manuscripts than faculty in other regions of the country. More pharmacy schools need to engage their faculty in scholarly endeavors by providing support and incentives.
PMCID: PMC4147793  PMID: 25170351
Bibliometrics; Faculty; Pharmacy Schools; United States
6.  The Role of Cultural Diversity Climate in Recruitment, Promotion, and Retention of Faculty in Academic Medicine 
BACKGROUND
Ethnic diversity among physicians may be linked to improved access and quality of care for minorities. Academic medical institutions are challenged to increase representation of ethnic minorities among health professionals.
OBJECTIVES
To explore the perceptions of physician faculty regarding the following: (1) the institution's cultural diversity climate and (2) facilitators and barriers to success and professional satisfaction in academic medicine within this context.
DESIGN
Qualitative study using focus groups and semi-structured interviews.
PARTICIPANTS
Nontenured physicians in the tenure track at the Johns Hopkins University School of Medicine.
APPROACH
Focus groups and interviews were audio-taped, transcribed verbatim, and reviewed for thematic content in a 3-stage independent review/adjudication process.
RESULTS
Study participants included 29 faculty representing 9 clinical departments, 4 career tracks, and 4 ethnic groups. In defining cultural diversity, faculty noted visible (race/ethnicity, foreign-born status, gender) and invisible (religion, sexual orientation) dimensions. They believe visible dimensions provoke bias and cumulative advantages or disadvantages in the workplace. Minority and foreign-born faculty report ethnicity-based disparities in recruitment and subtle manifestations of bias in the promotion process. Minority and majority faculty agree that ethnic differences in prior educational opportunities lead to disparities in exposure to career options, and qualifications for and subsequent recruitment to training programs and faculty positions. Minority faculty also describe structural barriers (poor retention efforts, lack of mentorship) that hinder their success and professional satisfaction after recruitment. To effectively manage the diversity climate, our faculty recommended 4 strategies for improving the psychological climate and structural diversity of the institution.
CONCLUSIONS
Soliciting input from faculty provides tangible ideas regarding interventions to improve an institution's diversity climate.
doi:10.1111/j.1525-1497.2005.0127.x
PMCID: PMC1490155  PMID: 16050848
cultural diversity; academic medicine; ethnic minorities; recruitment; promotion
7.  Postgraduate specialties interest, career choices and qualifications earned by male dentists graduated from King Saud University 
The Saudi Dental Journal  2010;23(2):81-86.
Objectives: To study the career development of male graduates of King Saud University (KSU), College of Dentistry in terms of pursuit of postgraduate dental education, higher degrees or Board Certification, choice of universities and countries of study, and place of work after qualification.
Methods: A questionnaire survey was carried out through face to face or telephone interview among 666 KSU graduates of 1982–2004.
Results: 80% (532 graduates) response rate. (77%) finished postgraduate dental education. 17% specialized in Prosthodontics, 16% in Saudi Board Advanced Restorative Dentistry, 14% in Advanced General Dentistry, 10.5% in Orthodontics, 10% in Oral and Maxillofacial Surgery, 8.3% in Pediatric Dentistry, 7.7% in Endodontics, 6% in Periodontics, 5.5% in Operative Dentistry, 5% in other Specialties. 61% had a Master’s degree and 16% had a Doctorate degree. 23% had Board Certificates and 8% had a Fellowship Certificate. (78%) are working in the government, 15% at the university and 6% in private, and 19% in administrative positions.
Conclusion: Most of the dental graduates were motivated and eager to continue their postgraduate education to get either clinical specialty or academic degrees from nationally and internationally well recognized and known Universities and programs.
doi:10.1016/j.sdentj.2010.11.004
PMCID: PMC3723123  PMID: 23960503
Graduate; Dental; Specialty; Career; Education; Postgraduate
8.  Attitudes and experiences of residents in pursuit of postgraduate fellowships: A national survey of Canadian trainees 
Introduction:
There have been significant pressures on urology training in North America over the last decade due to both the constantly evolving skill set required and the external demands around delivery of urological care, particularly in Canada. We explore the attitudes and experience of Canadian urology residents toward their postgraduate decisions on fellowship opportunities.
Methods:
The study consisted of a self-report questionnaire of 4 separate cohorts of graduating urology residents from 2008 to 2011. The first cohort graduating in 2008 and 2009 were sent surveys through SurveyMonkey.com after graduation from residency; those graduating in 2010 and 2011 were prospectively invited as a convenience sample attending a Queen’s Urology Examination Skills Training Program review course just prior to graduation. The survey included both open- and closed-ended questions, employing a 5-point Likert scale, and explored the attitudes and experience of fellowship choices. Likert scores for each question were reported as means ± standard deviation (SD). Descriptive and correlative statistics were used to analyze the responses. In addition, an agreement score was created for those responding with “strongly agree” and “agree” on the Likert scale.
Results:
A total of 104 surveys were administered, with 84 respondents (80.8% response rate). As a whole, 84.9% of respondents agreed that they pursued fellowships; oncology and minimally invasive urology were the most popular choices throughout the 4 years. Respondents stated that reasons for pursuing a fellowship included: interest in pursuing an academic career (mean 3.73± 1.1 (SD): agreement score 61.1%) as well as acquiring marketable skills to obtain an urology position (3.59 ± 1.3: 64.4%). Most agreed or strongly agreed (84.9%) that a reason for pursing a fellowship was an interest in focusing their practice to this sub-specialty area. In comparison, most graduates disagreed that a reason for pursuing a fellowship was that residency did not equip them with the necessary skills to practice urology (2.49 ± 1.2: 19%). Most (81.2%) of graduates agreed they knew enough about academic urology to know if it would be a suitable career choice for them versus 54.7% regarding community urology (p < 0.0001). Surprisingly, only 61.7% of residents agreed that they completed a community elective during training, and most felt they would have benefited from additional elective time in the community.
Conclusions:
Urology residents graduating from Canadian programs pursue postgraduate training to enhance their surgical skill set and to achieve marketability, but also to facilitate a potential academic career. Responses from the trainees suggest that exposure to community practice appears suboptimal and may be an area of focus for programs to aid in career counselling and professional development.
doi:10.5489/cuaj.2136
PMCID: PMC4277525  PMID: 25553159
9.  Career characteristics and postgraduate education of female dentist graduates of the College of Dentistry at King Saud University, Saudi Arabia 
The Saudi Dental Journal  2011;24(1):29-34.
Objectives
The aims of this study were to investigate the number of female bachelor of dental surgery graduates who earned postgraduate education degrees from King Saud University, their specialties, degrees of qualification, and countries of graduation.
Methods
A questionnaire survey was conducted through face-to-face or phone interview among 677 female dentists who graduated from the College of Dentistry at King Saud University between 1984 and 2006.
Results
Five hundred forty-five (81%) graduate female dentists responded, of whom 54% had completed postgraduate dental education. In the Saudi Board, 17% had obtained degrees in advanced restorative dentistry, 15% in pediatric dentistry, 14% in advanced general dentistry, 11% in orthodontics, 10% in prosthodontics, 8% in operative dentistry, 5% in endodontics, 5% in periodontics, 3% in oral and maxillofacial surgery, and 11% in other specialties. Fifty-nine percent had master’s degrees, 7% had doctorates, 32% had board certificates, and 2% had fellowship certificates.
Conclusion
More than half (54%) the female dentists surveyed had pursued postgraduate education. This investigation highlighted the different specialties enrolled by female dentists. Orthodontic post graduate program displayed the highest percentage of interest. Understanding the unavoidable social family needs and the demand for higher education by female dentists provides ideas as more programs should be planned to accommodate the needs of Saudi female dentists. This type of study should be repeated due to the increasing interest of female dentists in higher education.
doi:10.1016/j.sdentj.2011.10.005
PMCID: PMC3723372  PMID: 23960525
Postgraduate; Specialties; Qualification; Education; Dental; Career
10.  The General Surgery Job Market: Analysis of Current Demand for General Surgeons and Their Specialized Skills 
BACKGROUND
The majority of general surgery residents pursue fellowships. However the relative demand for general surgical skills versus more specialization is not understood. Our objective was to describe the current job market for general surgeons and compare the skills required by the market to those of graduating trainees.
STUDY DESIGN
Positions for board eligible/certified general surgeons in Oregon and Wisconsin from 2011 to 2012 were identified by review of job postings and telephone calls to hospitals, private practice groups, and physician recruiters. Data was gathered on each job to determine if fellowship training or specialized skills were required, preferred, or not requested. Information on resident pursuit of fellowship training was obtained from all residency programs within the represented states.
RESULTS
Of 71 general surgery positions available, 34% of positions required fellowship training. Rural positions made up 46% of available jobs. Thirty five percent of positions were in non-academic metropolitan settings and 17% were in academic metropolitan settings. Fellowship training was required or preferred for 18%, 28%, and 92% of rural, non-academic, and academic metropolitan positions respectively. From 2008 to 2012, 67% of general surgery residents pursued fellowship training.
CONCLUSIONS
Most general surgery residents pursue fellowship despite the fact that the majority of available jobs do not require fellowship training. The motivation for fellowship training is unclear but residency programs should tailor training to the skills needed by the market with the goal of improving access to general surgical services.
doi:10.1016/j.jamcollsurg.2013.07.400
PMCID: PMC4120248  PMID: 24246624
11.  Multi-Institutional Study of Women and Underrepresented Minority Faculty Members in Academic Pharmacy 
Objectives. To examine trends in the numbers of women and underrepresented minority (URM) pharmacy faculty members over the last 20 years, and determine factors influencing women faculty members’ pursuit and retention of an academic pharmacy career.
Methods. Twenty-year trends in women and URM pharmacy faculty representation were examined. Women faculty members from 9 public colleges and schools of pharmacy were surveyed regarding demographics, job satisfaction, and their academic pharmacy career, and relationships between demographics and satisfaction were analyzed.
Results. The number of women faculty members more than doubled between 1989 and 2009 (from 20.7% to 45.5%), while the number of URM pharmacy faculty members increased only slightly over the same time period. One hundred fifteen women faculty members completed the survey instrument and indicated they were generally satisfied with their jobs. The academic rank of professor, being a nonpharmacy practice faculty member, being tenured/tenure track, and having children were associated with significantly lower satisfaction with fringe benefits. Women faculty members who were tempted to leave academia for other pharmacy sectors had significantly lower salary satisfaction and overall job satisfaction, and were more likely to indicate their expectations of academia did not match their experiences (p<0.05).
Conclusions. The significant increase in the number of women pharmacy faculty members over the last 20 years may be due to the increased number of female pharmacy graduates and to women faculty members’ satisfaction with their careers. Lessons learned through this multi-institutional study and review may be applicable to initiatives to improve recruitment and retention of URM pharmacy faculty members.
doi:10.5688/ajpe7617
PMCID: PMC3298405  PMID: 22412206
underrepresented minority faculty members; women faculty members; recruitment; retention; diversity
12.  The medical students’ perspective of faculty and informal mentors: a questionnaire study 
Background
Student mentoring is an important aspect of undergraduate medical education. While medical schools often assign faculty advisors to medical students as mentors to support their educational experience, it is possible for the students to pursue mentors informally. The possible role of these informal mentors and their interactions with the students in a faculty mentorship program has not been reported. This study builds upon previous work that suggested many students have informal mentors, and that there might be interplay between these two types of mentors. This study was conducted to report the experience of undergraduate medical students in a faculty mentorship program of their faculty mentors and if applicable, of their informal mentors.
Methods
One month before residency (post-graduate training for Canadians) ranking, the survey was administered to the graduating class of 2014 at the University of Calgary’s Cumming School of Medicine. The survey was created from focus groups of the previous graduating class of 2013. The survey investigated meeting characteristics and the students’ perceptions of faculty advisors and informal mentors, and the students’ intended choice for residency.
Results
The study response rate was 86 % (95 of 111); 58 % (54 of 93) of the students reported having an informal mentor. There was no reported difference in satisfaction ratings of the Faculty mentorship program between students with only faculty mentors and those with also informal mentors. Students’ reporting of their satisfaction with the Facultymentorship program and the faculty mentors did not differ between the students with informal mentors and those with faculty mentors only. The students’ meeting frequency, discussed topics, and perceived characteristics of faculty mentors were not associated with having an informal mentor. The students generally perceived their informal mentors more positively than their faculty mentors. The reported student career intention was associated with the discipline of informal mentors and not with the discipline of faculty mentors.
Conclusions
Informal mentorship was common for medical students. The presence of an informal mentor was not associated with dissatisfaction with the Faculty advisor or with the mentorship program. It is likely students may pursue informal mentorship for career-related reasons.
Electronic supplementary material
The online version of this article (doi:10.1186/s12909-016-0526-3) contains supplementary material, which is available to authorized users.
doi:10.1186/s12909-016-0526-3
PMCID: PMC4706722  PMID: 26746690
Undergraduate medical education; Student mentoring; Faculty mentorship program; Faculty advisors; Informal mentors
13.  Junior Pharmacy Faculty Members’ Perceptions of Their Exposure to Postgraduate Training and Academic Careers During Pharmacy School 
Objective. To determine the perceptions of junior pharmacy faculty members with US doctor of pharmacy (PharmD) degrees regarding their exposure to residency, fellowship, and graduate school training options in pharmacy school. Perceptions of exposure to career options and research were also sought.
Methods. A mixed-mode survey instrument was developed and sent to assistant professors at US colleges and schools of pharmacy.
Results. Usable responses were received from 735 pharmacy faculty members. Faculty members perceived decreased exposure to and awareness of fellowship and graduate education training as compared to residency training. Awareness of and exposure to academic careers and research-related fields was low from a faculty recruitment perspective.
Conclusions. Ensuring adequate exposure of pharmacy students to career paths and postgraduate training opportunities could increase the number of PharmD graduates who choose academic careers or other pharmacy careers resulting from postgraduate training.
doi:10.5688/ajpe76339
PMCID: PMC3327237  PMID: 22544956
pharmacy faculty members; residency programs; fellowships; graduate education; careers
14.  Training Internists to Meet Critical Care Needs in the United States: A Consensus Statement from the Critical Care Societies Collaborative (CCSC) 
Critical care medicine  2014;42(5):1272-1279.
Objectives
Multiple training pathways are recognized by the Accreditation Council for Graduate Medical Education (ACGME) for internal medicine (IM) physicians to certify in critical care medicine (CCM) via the American Board of Internal Medicine. While each involves 1 year of clinical fellowship training in CCM, substantive differences in training requirements exist among the various pathways. The Critical Care Societies Collaborative convened a task force to review these CCM pathways and to provide recommendations for unified and coordinated training requirements for IM-based physicians.
Participants
A group of CCM professionals certified in pulmonary-CCM and/or IM-CCM from ACGME-accredited training programs who have expertise in education, administration, research, and clinical practice.
Data Sources and Synthesis
Relevant published literature was accessed through a MEDLINE search and references provided by all task force members. Material published by the ACGME, American Board of Internal Medicine, and other specialty organizations was also reviewed. Collaboratively and iteratively, the task force reached consensus using a roundtable meeting, electronic mail, and conference calls.
Main Results
Internal medicine-CCM–based fellowships have disparate program requirements compared to other internal medicine subspecialties and adult CCM fellowships. Differences between IM-CCM and pulmonary-CCM programs include the ratio of key clinical faculty to fellows and a requirement to perform 50 therapeutic bronchoscopies. Competency-based training was considered uniformly desirable for all CCM training pathways.
Conclusions
The task force concluded that requesting competency-based training and minimizing variations in the requirements for IM-based CCM fellowship programs will facilitate effective CCM training for both programs and trainees.
doi:10.1097/CCM.0000000000000250
PMCID: PMC4165588  PMID: 24637881
training; critical care medicine; internal medicine; fellowship education; requirements; workforce
15.  Training the Trainers of Tomorrow Today - driving excellence in medical education 
BMJ Quality Improvement Reports  2013;2(1):u201078.w715.
Training the Trainers of Tomorrow Today (T4) is a new way to deliver “Training for Trainers”. Responding to local dissatisfaction with existing arrangements, T4 builds on 3 essential requirements for a future shape of training:
1. Clinical Leadership and a Collaborative Approach
2. Cross-Specialty Design and Participation
3. Local Delivery and Governance Networks
Design principles also included: 3 levels of training to reflect differing needs of clinical supervisors, educational supervisors and medical education leader, mapping to GMC requirements and the London Deanery's Professional Development Framework; alignment of service, educational theory and research; recognition of challenges in delivering and ensuring attendance in busy acute and mental health settings, and the development of a faculty network.
The delivery plan took into account census of professional development uptake and GMC Trainee Surveys. Strong engagement and uptake from the 11 Trusts in NW London has been achieved, with powerful penetration into all specialties. Attendance has exceeded expectations. Against an initial 12 month target of 350 attendances, 693 were achieved in the first 8 months.
Evaluation of content demonstrates modules are pitched appropriately to attendees needs, with positive feedback from trainers new to the role. Delivery style has attracted high ratings of satisfaction: 87% attendees rating delivery as “good\excellent”. External evaluation of impact demonstrated improved training experiences through changes in supervision, the learning environment and understanding of learning styles.
We have addressed sustainability of the programme by advertising and recruiting Local Faculty Development Trainers. Volunteer consultants and higher trainees are trained to deliver the programme on a cascade model, supported by the Specialty Tutors, individual coaching and educational bursaries. The Trainers are local champions for excellence in training, provide a communication between the programme and local providers, are a repository of expertise in their service, and trouble shoot local barriers to engagement.
doi:10.1136/bmjquality.u201078.w715
PMCID: PMC4652711  PMID: 26734181
16.  Thank you for the privilege 
Thank you for the privilege to serve as the EFOST President.
I am deeply humbled for having been selected to serve as the new President of EFOST: this is not for the work that I have undertaken, but for what others around me have done.
I hope that my past duties as President of BOSTAA, and as president of the Sports and Exercise Medicine of the Royal Society of Medicine will help me in performing these my new duties.
It all started in 1992, and the EFOST is now just leaving its adolescent phase, with all its teenager problems.
There is truth in Newton’s quote about standing on the shoulders of giants. Francois, you and the other leaders at EFOST have generated the momentum to keep moving EFOST forward, and the wisdom to keep it moving in the right direction. We all benefited from your contributions, dedication and volunteerism.
To step into this role feels a little like steering a train. EFOST operates under a strategic plan which sets our direction and controls how the changing succession of leaders navigates. This plan is critical to helping us maintain focus, direction, and purpose.
It is crucial that we focus on our strategic direction. However, we must continue to monitor the environment around us. We must recognize the changing influences so that we can respond appropriately. Europe is in a state of flux, with great challenges, both scientifically and economically. Strategically, we recognized all this a while ago, and we have tried, and succeeded, to be inclusive. The policy has worked, and we have embraced, and we have been embraced, by several countries during Dr Kelberine’s tenure. I can only thank him and the Board for this vision, and can confirm that I wish this train to continue to move in this direction.
A train can only move if it is on the right tracks: I look forward to work with the great engineers of the organization, and welcome the help of the Board of Trustees to keep us on track.
EFOST was born as a get together of a group of friends, and is the baby that was born from the ideas and ideals of several individuals who are in this room today. To them, my thanks for such ideas and ideals, and an assurance: I wish to uphold them. EFOST will need to move forward, and to ensure that the needs of the Sports Trauma Societies which form, sustain, foster and nurture it are satisfied. For this, one of the charges given to me was to change the bylaws. The process was thorny, but the results have been here for all to see: a flexible, dynamic Executive Board, and a Board at Large which is really representative of all Europe. From you, I expect support. To you, I offer dedication.
The life of a President is often lonely. I am a social animal, and I do not wish to be lonely. I intend to use the help and advice of my Past President, Francois, and to have the support of my Vice President, Gernot. I take this opportunity to thank them in advance, and to apologise to them in advance: I know that it is difficult to work with me. I want things yesterday, and, despite 28 years outside of Italy, my Italian quick fire temper can still surface.
EFOST is a great organization, and it has forged great links. You have all seen how the work that Burt has undertaken and the endless meetings that Francois has held have borne fruits: the EFOST-AOSSM traveling fellowship is now a reality, and the support given by all of you on the Board has been superb: many thanks.
One of our Past Presidents, Paco Biosca, is now the Chief Medical Officer of Chelsea: with him, we have succeeded in establishing a football Team Physician fellowship, and we look forward to strengthening these ties.
More on fellowships during the years of my tenure. But remember: it will not be my doing, it will be the work of all of you, of all of us.
EFOST will need to speak with one voice to the world and the sister organizations. In Europe, we have all too often projected the wrong image of weak leadership and of having more than one train controller. The work that Francois has undertaken has ensured that everybody on the Executive Board sang from the same hymn sheet, and that the front that EFOST presents is united and strong. I intend to continue along these lines: too many at the helm is never too good. Each two years, there can only be one.
No doubt somebody and some organizations will feel challenged. Let me remind all of you that EFOST was never on a conquest trip: EFOST wants to build bridges, not to burn them. EFOST wants to have friends, not enemies. EFOST wants a friendly efficient network, not destructive wars.
We are grateful to our mother, EFORT, and we thank it for its support.
We are close to our sister organisation, ESSKA, and we welcome its President to our Congress: Thank you, Joao. ISAKOS has graced us with unending support: we thank Philippe Neyret, the President Elect, for having graced us with such great scientific input.
ECOSEP is a natural sister organisation and ally: Nikos, you are welcome amongst us today.
Communication is always important: my thanks will have to be conveyed to Dr Doral and Dr Mann and their team for the Newsletter. Only if you have never read it will you ignore the endless hours that Mahmut and Gideon put into it: to them, my vote of thanks.
A scientific organization cannot progress without a journal. You all know about Muscles, Ligaments and Tendons Journal (MLTJ), the official journal of EFOST and ISMuLT. I intend to continue to be the Chief Editor of MLTJ, and I can just see the challenges ahead. Let me tell you: the first two years have been hard, and only now we are starting to see the evidence of the hard work that my Associate Editor, Dr Oliva, has undertaken. It is a baby. Its nourishing milk is the high quality work that it publishes. Unless EFOST and its members nurture it, it will not thrive. Unless we send work to it, it will not flourish. Unless we find funds to keep the spirit of EFOST going through it, it will not be: as the President of EFOST and as the Editor in Chief of MLTJ, I prompt you to keep it going. Please remember that all the abstracts of this congress are available, for free, on the MLTJ platform: please visit it, and contribute to the Journal.
An organization cannot survive without appropriate finances: many thanks, Jose, for having put in place the infrastructure for our safety and financial survival. I am sure that you will keep us right, and that you will reassure the membership that their dues are well spent.
We would not have been able to mount such a great congress without the help of our trade partners: to them, my thanks for the continuing support of EFOST.
We are now coming to the end of the WSTC – EFOST congress. GCO has helped us, and will continue to do so. Claudine, Simon: my thanks to you. In difficult personal circumstances, you have been close to EFOST, and you have believed in us. We look forward to continuing to work with you.
I look forward to continuing to work with the organisation of which I have been President, BOSTAA: the deep friendship that ties me to Roger, the ougoing president, and Mike, who will be president starting in a couple of hours, will make things easier.
This is an exciting time. Not just for me, as the new leader EFOST, but for all of you, for all of us. The opportunities are endless. I will work to ensure that, when my tenure is over and the new President will step into this role, he can see even farther down the tracks. The goal is to help usher the EFOST to a new place; not because we changed direction, but because we moved forward even faster.
Thank you again for this opportunity to serve you as president of EFOST. I appreciate your faith: I will do all I can to make these two years successful, enjoyable, and fun.
Nicola Maffulli
PMCID: PMC3671359
17.  Relationship of residency program characteristics with pass rate of the American Board of Internal Medicine certifying exam 
Medical Education Online  2015;20:10.3402/meo.v20.28631.
Objectives
To evaluate the relationship between the pass rate of the American Board of Internal Medicine (ABIM) certifying exam and the characteristics of residency programs.
Methods
The study used a retrospective, cross-sectional design with publicly available data from the ABIM and the Fellowship and Residency Electronic Interactive Database. All categorical residency programs with reported pass rates were included. Using univariate and multivariate, linear regression analyses, I analyzed how 69 factors (e.g., location, general information, number of faculty and trainees, work schedule, educational environment) are related to the pass rate.
Results
Of 371 programs, only one region had a significantly different pass rate from the other regions; however, as no other characteristics were reported in this region, I excluded program location from further analysis. In the multivariate analysis, pass rate was significantly associated with four program characteristics: ratio of full-time equivalent paid faculty to positions, percentage of osteopathic doctors, formal mentoring program, and on-site child care (OCC). Numerous factors were not associated at all, including minimum exam scores, salary, vacation days, and average hours per week.
Conclusions
As shown through the ratio of full-time equivalent paid faculty to positions and whether there was a formal mentoring program, a highly supervised training experience was strongly associated with the pass rate. In contrast, percentage of osteopathic doctors was inversely related to the pass rate. Programs with OCC significantly outperformed programs without OCC. This study suggested that enhancing supervision of training programs and offering parental support may help attract and produce competitive residents.
doi:10.3402/meo.v20.28631
PMCID: PMC4590350  PMID: 26426400
ABIM; pass rate; program characteristics; internal medicine residency
18.  Tobacco Industry Manipulation of Tobacco Excise and Tobacco Advertising Policies in the Czech Republic: An Analysis of Tobacco Industry Documents 
PLoS Medicine  2012;9(6):e1001248.
Risako Shirane and colleagues examined the the Legacy Tobacco Documents Library and found evidence of transnational tobacco company influence over tobacco advertising and excise policy in the Czech Republic, a country with one of the poorest tobacco control records in Europe.
Background
The Czech Republic has one of the poorest tobacco control records in Europe. This paper examines transnational tobacco companies' (TTCs') efforts to influence policy there, paying particular attention to excise policies, as high taxes are one of the most effective means of reducing tobacco consumption, and tax structures are an important aspect of TTC competitiveness.
Methods and Findings
TTC documents dating from 1989 to 2004/5 were retrieved from the Legacy Tobacco Documents Library website, analysed using a socio-historical approach, and triangulated with key informant interviews and secondary data. The documents demonstrate significant industry influence over tobacco control policy. Philip Morris (PM) ignored, overturned, and weakened various attempts to restrict tobacco advertising, promoting voluntary approaches as an alternative to binding legislation. PM and British American Tobacco (BAT) lobbied separately on tobacco tax structures, each seeking to implement the structure that benefitted its own brand portfolio over that of its competitors, and enjoying success in turn. On excise levels, the different companies took a far more collaborative approach, seeking to keep tobacco taxes low and specifically to prevent any large tax increases. Collective lobbying, using a variety of arguments, was successful in delaying the tax increases required via European Union accession. Contrary to industry arguments, data show that cigarettes became more affordable post-accession and that TTCs have taken advantage of low excise duties by raising prices. Interview data suggest that TTCs enjoy high-level political support and continue to actively attempt to influence policy.
Conclusion
There is clear evidence of past and ongoing TTC influence over tobacco advertising and excise policy. We conclude that this helps explain the country's weak tobacco control record. The findings suggest there is significant scope for tobacco tax increases in the Czech Republic and that large (rather than small, incremental) increases are most effective in reducing smoking.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Every year, about 5 million people die from tobacco-related diseases and, if current trends continue, annual tobacco-related deaths will increase to 10 million by 2030. Faced with this global tobacco epidemic, national and international bodies have drawn up conventions and directives designed to control tobacco. For example, European Union (EU) Directives on tobacco control call for member states to ban tobacco advertising, promotion, and sponsorship and to adopt taxation policies (for example, high levels of tobacco excise tax) aimed at reducing tobacco consumption. Within the EU, implementation of tobacco control policies varies widely but the Czech Republic, which was formed in 1993 when Czechoslovakia split following the 1989 collapse of communism, has a particularly poor record. The Czech Republic, which joined the EU in 2004, is the only EU Member State not to have ratified the World Health Organization's Framework Convention on Tobacco Control, which entered into force in 2005, and its tobacco control policies were the fourth least effective in Europe in 2010.
Why Was This Study Done?
During the communist era, state-run tobacco monopolies controlled the supply of cigarettes and other tobacco products in Czechoslovakia. Privatization of these monopolies began in 1991 and several transnational tobacco companies (TTCs)—in particular, Philip Morris and British American Tobacco—entered the tobacco market in what was to become the Czech Republic. In this socio-historical study, which aims to improve understanding of both effective tobacco excise policy and the ways in which TTCs seek to influence policy in emerging markets, the researchers analyze publically available internal TTC documents and interview key informants to examine efforts made by TTCs to influence tobacco advertising and tobacco excise tax policies in the Czech Republic. A socio-historical study examines the interactions between individuals and groups in a historical context.
What Did the Researchers Do and Find?
The researchers analyzed 511 documents (dated 1989 onwards) in the Legacy Tobacco Documents Library website (a collection of internal tobacco industry documents released through US litigation cases) that mentioned tobacco control policies in the Czech Republic. They also analyzed information obtained from sources such as tobacco industry journals and data obtained in 2010 in interviews with key Czech informants (including a tobacco industry representative and a politician). The researchers' analysis of the industry documents indicates that Philip Morris ignored, overturned, and weakened attempts to restrict tobacco advertising and promoted voluntary approaches as an alternative to binding legislation. Importantly, while the internal documents show that Philip Morris lobbied for a specific excise tax (a fixed amount of tax per cigarette, a tax structure that favors the expensive brands that Philip Morris mainly markets), the European strategy employed at that time by British American Tobacco was to lobby for a mixed excise structure that combined an “ad valorem” tax (a tax levied as a proportion of price) and a specific tax, an approach that favors a mixed portfolio of tobacco brands. By contrast, the documents show that TTCs collaborated in trying to keep tobacco taxes low and in trying to prevent any large tax increases. This collective lobbying successfully delayed the tobacco tax increases required as a condition of the Czech Republic's accession to the EU. Finally, the interview data suggest that TTCs had high-level political support in the Czech Republic and continue actively to attempt to influence policy.
What Do These Findings Mean?
These findings provide clear evidence that Philip Morris and British American Tobacco (the two TTCs that have dominated the Czech market since privatization of the tobacco industry) have significantly influenced tobacco advertising and excise policy in the Czech Republic since 1989. The findings, which also suggest that this influence is ongoing, help to explain the Czech Republic's poor tobacco control record, which was reflected in a fall in the real price of cigarettes between 1990 and 2000. More generally, this study provides valuable insight into how TTCs might try to influence policy in other emerging markets. Improvements in global tobacco control, the researchers conclude, will be possible only if efforts are made to protect tobacco control policies from the vested interests of the tobacco industry, a principle enshrined in the WHO Framework Convention on Tobacco control, and if public and political attitudes to the industry shift.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001248.
The World Health Organization provides information about the dangers of tobacco (in several languages) and about its Framework Convention on Tobacco Control
For information about the tobacco industry's influence on policy, see the 2009 World Health Organization report Tobacco interference with tobacco control
The Framework Convention Alliance more information about the FCTC
Details of European Union legislation on excise duty applied to manufactured tobacco and on the manufacture, presentation and sale of tobacco products are available (in several languages)
The Legacy Tobacco Documents Library is a searchable public database of tobacco company internal documents detailing their advertising, manufacturing, marketing, sales, and scientific activities
The UK Centre for Tobacco Control Studies is a network of UK universities that undertakes original research, policy development, advocacy, and teaching and training in the field of tobacco control
SmokeFree, a website provided by the UK National Health Service, offers advice on quitting smoking and includes personal stories from people who have stopped smoking
Smokefree.gov, from the US National Cancer Institute, offers online tools and resources to help people quit smoking and not start again
doi:10.1371/journal.pmed.1001248
PMCID: PMC3383744  PMID: 22745606
19.  Arthroplasty of the Elbow 
Willis Cohoon Campbell was born in Jackson, Mississippi in 1880. He received his undergraduate training in his home state and medical training at the University of Virginia, Charlottesville, where he graduated in 1924 [5]. After serving a two-year internship, he went into private practice in Memphis, Tennessee. As with other prominent orthopaedic surgeons (Ryerson among them), he visited medical centers in Europe, particularly London and Vienna. He evidently then spent some time in postgraduate work in New York City prior to returning to private practice in Memphis. (Most formal residencies were not established until the 1930s coincident with the formation of the American Board of Orthopaedic Surgery in 1934, although many doctors took “postgraduate” work following one or two years of internship in general medicine or surgery.) In 1910, he was asked to organize a Department of Orthopaedic Surgery at the University of Tennessee Medical School as the first Professor of Orthopaedics, a post he held until his death.
In addition to forming a department for the university, Campbell helped establish one of the first hospitals for crippled children in the south, then the Willis Cohoon Campbell Clinic in 1920 [1], and finally in 1923 the Hospital for Crippled Adults. The Campbell clinic provided postgraduate training, meeting the requirements of the American Board for the Certification of Specialists. Dr. Campbell, while not one of the original nine board members of the American Board of Orthopaedic Surgery, was influential in establishing the Board in 1934. According to Wickstrom [4], a “...persistent rumor, repeatedly denied, held that Henderson (Melvin) and Campbell were the primary movers behind the establishment of both the American Academy of Orthopaedic surgeons and the American Board in Orthopaedic Surgery; their actions were said to be a retaliatory response to their rejection by the orthopaedic establishment ‘in the East.’” Be that as it may, Dr. Campbell served as President of a number of professional organizations [1]. He published many papers and three monographs, including the classic “Operative Orthopaedics” [3], which has gone through 10 editions, was the standard textbook for orthopaedic surgeons for decades and remains one of the most widely read references. Dr. Campbell was widely known as a kind, courteous man [5].
The article reproduced here describes arthroplasty of the elbow to restore motion to ankylosed joints [2]. In this article Campbell recognized some of the described resection arthroplasties (usually with interposition of various materials) left the elbow unstable and weak. He advocated creating a “double flap” of the triceps aponeurosis and underlying periosteum and suturing that to the anterior capsule of the elbow after resecting bone. This, he suggested, allowed functional motion within 6 months in the two cases he described. Interestingly, in his “Operative Orthopaedics” published in 1939, he recommends covering the exposed bony surfaces with fascia lata, and does not describe attaching the flap of the triceps to the anterior capsule, but rather suggests attaching “at a lower point than its former attachment to permit free play of the joint in flexion” [3].
Willis Cohoon Campbell, MD is shown. Photograph is reproduced with permission and ©American Academy of Orthopaedic Surgeons. Fifty Years of Progress, 1983.
References
Calandruccio RA. The history of the Campbell Clinic. Clin Orthop Relat Res. 2000:157–170.Campbell WC. Arthroplasty of the elbow. Ann Surg. 1922;76:615–623.Campbell WC. Operative Orthopedics. Saint Louis: CV Mosby Co; 1939.Wickstrom JK. Fifty years of the American Board of Orthopaedic Surgery: 1934. Clin Orthop Relat Res. 1990;257:3–10.Willis Cohoon Campbell 1880–1941. J Bone Joint Surg Am. 1941;23:716–717.
doi:10.1007/s11999-007-0032-3
PMCID: PMC2505280  PMID: 18196369
20.  Implementing the 2009 Institute of Medicine recommendations on resident physician work hours, supervision, and safety 
Long working hours and sleep deprivation have been a facet of physician training in the US since the advent of the modern residency system. However, the scientific evidence linking fatigue with deficits in human performance, accidents and errors in industries from aeronautics to medicine, nuclear power, and transportation has mounted over the last 40 years. This evidence has also spawned regulations to help ensure public safety across safety-sensitive industries, with the notable exception of medicine.
In late 2007, at the behest of the US Congress, the Institute of Medicine embarked on a year-long examination of the scientific evidence linking resident physician sleep deprivation with clinical performance deficits and medical errors. The Institute of Medicine’s report, entitled “Resident duty hours: Enhancing sleep, supervision and safety”, published in January 2009, recommended new limits on resident physician work hours and workload, increased supervision, a heightened focus on resident physician safety, training in structured handovers and quality improvement, more rigorous external oversight of work hours and other aspects of residency training, and the identification of expanded funding sources necessary to implement the recommended reforms successfully and protect the public and resident physicians themselves from preventable harm.
Given that resident physicians comprise almost a quarter of all physicians who work in hospitals, and that taxpayers, through Medicare and Medicaid, fund graduate medical education, the public has a deep investment in physician training. Patients expect to receive safe, high-quality care in the nation’s teaching hospitals. Because it is their safety that is at issue, their voices should be central in policy decisions affecting patient safety. It is likewise important to integrate the perspectives of resident physicians, policy makers, and other constituencies in designing new policies. However, since its release, discussion of the Institute of Medicine report has been largely confined to the medical education community, led by the Accreditation Council for Graduate Medical Education (ACGME).
To begin gathering these perspectives and developing a plan to implement safer work hours for resident physicians, a conference entitled “Enhancing sleep, supervision and safety: What will it take to implement the Institute of Medicine recommendations?” was held at Harvard Medical School on June 17–18, 2010. This White Paper is a product of a diverse group of 26 representative stakeholders bringing relevant new information and innovative practices to bear on a critical patient safety problem. Given that our conference included experts from across disciplines with diverse perspectives and interests, not every recommendation was endorsed by each invited conference participant. However, every recommendation made here was endorsed by the majority of the group, and many were endorsed unanimously. Conference members participated in the process, reviewed the final product, and provided input before publication. Participants provided their individual perspectives, which do not necessarily represent the formal views of any organization.
In September 2010 the ACGME issued new rules to go into effect on July 1, 2011. Unfortunately, they stop considerably short of the Institute of Medicine’s recommendations and those endorsed by this conference. In particular, the ACGME only applied the limitation of 16 hours to first-year resident physicans. Thus, it is clear that policymakers, hospital administrators, and residency program directors who wish to implement safer health care systems must go far beyond what the ACGME will require. We hope this White Paper will serve as a guide and provide encouragement for that effort.
Resident physician workload and supervision
By the end of training, a resident physician should be able to practice independently. Yet much of resident physicians’ time is dominated by tasks with little educational value. The caseload can be so great that inadequate reflective time is left for learning based on clinical experiences. In addition, supervision is often vaguely defined and discontinuous. Medical malpractice data indicate that resident physicians are frequently named in lawsuits, most often for lack of supervision. The recommendations are: The ACGME should adjust resident physicians workload requirements to optimize educational value. Resident physicians as well as faculty should be involved in work redesign that eliminates nonessential and noneducational activity from resident physician dutiesMechanisms should be developed for identifying in real time when a resident physician’s workload is excessive, and processes developed to activate additional providersTeamwork should be actively encouraged in delivery of patient care. Historically, much of medical training has focused on individual knowledge, skills, and responsibility. As health care delivery has become more complex, it will be essential to train resident and attending physicians in effective teamwork that emphasizes collective responsibility for patient care and recognizes the signs, both individual and systemic, of a schedule and working conditions that are too demanding to be safeHospitals should embrace the opportunities that resident physician training redesign offers. Hospitals should recognize and act on the potential benefits of work redesign, eg, increased efficiency, reduced costs, improved quality of care, and resident physician and attending job satisfactionAttending physicians should supervise all hospital admissions. Resident physicians should directly discuss all admissions with attending physicians. Attending physicians should be both cognizant of and have input into the care patients are to receive upon admission to the hospitalInhouse supervision should be required for all critical care services, including emergency rooms, intensive care units, and trauma services. Resident physicians should not be left unsupervised to care for critically ill patients. In settings in which the acuity is high, physicians who have completed residency should provide direct supervision for resident physicians. Supervising physicians should always be physically in the hospital for supervision of resident physicians who care for critically ill patientsThe ACGME should explicitly define “good” supervision by specialty and by year of training. Explicit requirements for intensity and level of training for supervision of specific clinical scenarios should be providedCenters for Medicare and Medicaid Services (CMS) should use graduate medical education funding to provide incentives to programs with proven, effective levels of supervision. Although this action would require federal legislation, reimbursement rules would help to ensure that hospitals pay attention to the importance of good supervision and require it from their training programs
Resident physician work hours
Although the IOM “Sleep, supervision and safety” report provides a comprehensive review and discussion of all aspects of graduate medical education training, the report’s focal point is its recommendations regarding the hours that resident physicians are currently required to work. A considerable body of scientific evidence, much of it cited by the Institute of Medicine report, describes deteriorating performance in fatigued humans, as well as specific studies on resident physician fatigue and preventable medical errors.
The question before this conference was what work redesign and cultural changes are needed to reform work hours as recommended by the Institute of Medicine’s evidence-based report? Extensive scientific data demonstrate that shifts exceeding 12–16 hours without sleep are unsafe. Several principles should be followed in efforts to reduce consecutive hours below this level and achieve safer work schedules. The recommendations are: Limit resident physician work hours to 12–16 hour maximum shiftsA minimum of 10 hours off duty should be scheduled between shiftsResident physician input into work redesign should be actively solicitedSchedules should be designed that adhere to principles of sleep and circadian science; this includes careful consideration of the effects of multiple consecutive night shifts, and provision of adequate time off after night work, as specified in the IOM reportResident physicians should not be scheduled up to the maximum permissible limits; emergencies frequently occur that require resident physicians to stay longer than their scheduled shifts, and this should be anticipated in scheduling resident physicians’ work shiftsHospitals should anticipate the need for iterative improvement as new schedules are initiated; be prepared to learn from the initial phase-in, and change the plan as neededAs resident physician work hours are redesigned, attending physicians should also be considered; a potential consequence of resident physician work hour reduction and increased supervisory requirements may be an increase in work for attending physicians; this should be carefully monitored, and adjustments to attending physician work schedules made as needed to prevent unsafe work hours or working conditions for this group“Home call” should be brought under the overall limits of working hours; work load and hours should be monitored in each residency program to ensure that resident physicians and fellows on home call are getting sufficient sleepMedicare funding for graduate medical education in each hospital should be linked with adherence to the Institute of Medicine limits on resident physician work hours
Moonlighting by resident physicians
The Institute of Medicine report recommended including external as well as internal moonlighting in working hour limits. The recommendation is: All moonlighting work hours should be included in the ACGME working hour limits and actively monitored. Hospitals should formalize a moonlighting policy and establish systems for actively monitoring resident physician moonlighting
Safety of resident physicians
The “Sleep, supervision and safety” report also addresses fatigue-related harm done to resident physicians themselves. The report focuses on two main sources of physical injury to resident physicians impaired by fatigue, ie, needle-stick exposure to blood-borne pathogens and motor vehicle crashes. Providing safe transportation home for resident physicians is a logistical and financial challenge for hospitals. Educating physicians at all levels on the dangers of fatigue is clearly required to change driving behavior so that safe hospital-funded transport home is used effectively. Fatigue-related injury prevention (including not driving while drowsy) should be taught in medical school and during residency, and reinforced with attending physicians; hospitals and residency programs must be informed that resident physicians’ ability to judge their own level of impairment is impaired when they are sleep deprived; hence, leaving decisions about the capacity to drive to impaired resident physicians is not recommendedHospitals should provide transportation to all resident physicians who report feeling too tired to drive safely; in addition, although consecutive work should not exceed 16 hours, hospitals should provide transportation for all resident physicians who, because of unforeseen reasons or emergencies, work for longer than consecutive 24 hours; transportation under these circumstances should be automatically provided to house staff, and should not rely on self-identification or request
Training in effective handovers and quality improvement
Handover practice for resident physicians, attendings, and other health care providers has long been identified as a weak link in patient safety throughout health care settings. Policies to improve handovers of care must be tailored to fit the appropriate clinical scenario, recognizing that information overload can also be a problem. At the heart of improving handovers is the organizational effort to improve quality, an effort in which resident physicians have typically been insufficiently engaged. The recommendations are: Hospitals should train attending and resident physicians in effective handovers of careHospitals should create uniform processes for handovers that are tailored to meet each clinical setting; all handovers should be done verbally and face-to-face, but should also utilize written toolsWhen possible, hospitals should integrate hand-over tools into their electronic medical records (EMR) systems; these systems should be standardized to the extent possible across residency programs in a hospital, but may be tailored to the needs of specific programs and services; federal government should help subsidize adoption of electronic medical records by hospitals to improve signoutWhen feasible, handovers should be a team effort including nurses, patients, and familiesHospitals should include residents in their quality improvement and patient safety efforts; the ACGME should specify in their core competency requirements that resident physicians work on quality improvement projects; likewise, the Joint Commission should require that resident physicians be included in quality improvement and patient safety programs at teaching hospitals; hospital administrators and residency program directors should create opportunities for resident physicians to become involved in ongoing quality improvement projects and root cause analysis teams; feedback on successful quality improvement interventions should be shared with resident physicians and broadly disseminatedQuality improvement/patient safety concepts should be integral to the medical school curriculum; medical school deans should elevate the topics of patient safety, quality improvement, and teamwork; these concepts should be integrated throughout the medical school curriculum and reinforced throughout residency; mastery of these concepts by medical students should be tested on the United States Medical Licensing Examination (USMLE) stepsFederal government should support involvement of resident physicians in quality improvement efforts; initiatives to improve quality by including resident physicians in quality improvement projects should be financially supported by the Department of Health and Human Services
Monitoring and oversight of the ACGME
While the ACGME is a key stakeholder in residency training, external voices are essential to ensure that public interests are heard in the development and monitoring of standards. Consequently, the Institute of Medicine report recommended external oversight and monitoring through the Joint Commission and Centers for Medicare and Medicaid Services (CMS). The recommendations are: Make comprehensive fatigue management a Joint Commission National Patient Safety Goal; fatigue is a safety concern not only for resident physicians, but also for nurses, attending physicians, and other health care workers; the Joint Commission should seek to ensure that all health care workers, not just resident physicians, are working as safely as possibleFederal government, including the Centers for Medicare and Medicaid Services and the Agency for Healthcare Research and Quality, should encourage development of comprehensive fatigue management programs which all health systems would eventually be required to implementMake ACGME compliance with working hours a “ condition of participation” for reimbursement of direct and indirect graduate medical education costs; financial incentives will greatly increase the adoption of and compliance with ACGME standards
Future financial support for implementation
The Institute of Medicine’s report estimates that $1.7 billion (in 2008 dollars) would be needed to implement its recommendations. Twenty-five percent of that amount ($376 million) will be required just to bring hospitals into compliance with the existing 2003 ACGME rules. Downstream savings to the health care system could potentially result from safer care, but these benefits typically do not accrue to hospitals and residency programs, who have been asked historically to bear the burden of residency reform costs. The recommendations are: The Institute of Medicine should convene a panel of stakeholders, including private and public funders of health care and graduate medical education, to lay down the concrete steps necessary to identify and allocate the resources needed to implement the recommendations contained in the IOM “Resident duty hours: Enhancing sleep, supervision and safety” report. Conference participants suggested several approaches to engage public and private support for this initiativeEfforts to find additional funding to implement the Institute of Medicine recommendations should focus more broadly on patient safety and health care delivery reform; policy efforts focused narrowly upon resident physician work hours are less likely to succeed than broad patient safety initiatives that include residency redesign as a key componentHospitals should view the Institute of Medicine recommendations as an opportunity to begin resident physician work redesign projects as the core of a business model that embraces safety and ultimately saves resourcesBoth the Secretary of Health and Human Services and the Director of the Centers for Medicare and Medicaid Services should take the Institute of Medicine recommendations into consideration when promulgating rules for innovation grantsThe National Health Care Workforce Commission should consider the Institute of Medicine recommendations when analyzing the nation’s physician workforce needs
Recommendations for future research
Conference participants concurred that convening the stakeholders and agreeing on a research agenda was key. Some observed that some sectors within the medical education community have been reluctant to act on the data. Several logical funders for future research were identified. But above all agencies, Centers for Medicare and Medicaid Services is the only stakeholder that funds graduate medical education upstream and will reap savings downstream if preventable medical errors are reduced as a result of reform of resident physician work hours.
doi:10.2147/NSS.S19649
PMCID: PMC3630963  PMID: 23616719
resident; hospital; working hours; safety
21.  Fellow or foe: the impact of fellowship training programs on the education of Canadian urology residents 
Objective
Throughout North America, increasing emphasis is being placed on surgical fellowships. Surgical educators and trainees have raised concerns that the escalating focus on fellowships may threaten the educational mission of more novice trainees. Our objective was to collect opinions from multiple perspectives (faculty, fellows and residents) regarding fellowship structure, fellow selection and the impact of clinical fellowships on urology resident training.
Methods
We anonymously surveyed 52 members of a major academic urology training program (University of Toronto) with established fellowship training programs for their opinions regarding fellowship structure, fellow selection, and the impact on resident training and education.
Results
The overall response rate was 88%. We identified significant differences of opinion among faculty, fellows and residents regarding fellowship structure, fellow selection and the impact on resident education. Specifically, faculty and fellows supported the addition of more fellows, felt that certain complex cases should be designated as “fellow cases” and that residents' research opportunities were not restricted. Residents felt that fellows “steal” operative cases, that performing operations with the fellow is not equivalent to performing operations with faculty alone and that fellowship candidates should perform an operation with division faculty as part of the application process. There was agreement that fellowship programs add value to residents' overall education, that fellows should participate in the call schedule and that fellows' role in the operating room needs to be better defined with respect to case volume and selection. Proficiency in technical skills, clinical knowledge, teaching and teamwork were cited as the most attractive characteristics of an effective clinical fellow.
Conclusion
Residency and fellowship program directors must clearly define the role of the fellow and outline the limits of surgical practice, establish clear and consistent guidelines outlining responsibilities (operative, clinical and on-call), and open lines of communication to ensure that all opinions are recognized and addressed. Finally, they must select fellows with proficient technical skills, clinical knowledge, teaching ability and work ethic to ensure that they focus on “specialized” training.
PMCID: PMC2422895  PMID: 18542725
22.  Tracking Residents Through Multiple Residency Programs: A Different Approach for Measuring Residents' Rates of Continuing Graduate Medical Education in ACGME-Accredited Programs 
Background
Increased focus on the number and type of physicians delivering health care in the United States necessitates a better understanding of changes in graduate medical education (GME). Data collected by the Accreditation Council for Graduate Medical Education (ACGME) allow longitudinal tracking of residents, revealing the number and type of residents who continue GME following completion of an initial residency. We examined trends in the percent of graduates pursuing additional clinical education following graduation from ACGME-accredited pipeline specialty programs (specialties leading to initial board certification).
Methods
Using data collected annually by the ACGME, we tracked residents graduating from ACGME-accredited pipeline specialty programs between academic year (AY) 2002–2003 and AY 2006–2007 and those pursuing additional ACGME-accredited training within 2 years. We examined changes in the number of graduates and the percent of graduates continuing GME by specialty, by type of medical school, and overall.
Results
The number of pipeline specialty graduates increased by 1171 (5.3%) between AY 2002–2003 and AY 2006–2007. During the same period, the number of graduates pursuing additional GME increased by 1059 (16.7%). The overall rate of continuing GME increased each year, from 28.5% (6331/22229) in AY 2002–2003 to 31.6% (7390/23400) in AY 2006–2007. Rates differed by specialty and for US medical school graduates (26.4% [3896/14752] in AY 2002–2003 to 31.6% [4718/14941] in AY 2006–2007) versus international medical graduates (35.2% [2118/6023] to 33.8% [2246/6647]).
Conclusion
The number of graduates and the rate of continuing GME increased from AY 2002–2003 to AY 2006–2007. Our findings show a recent increase in the rate of continued training for US medical school graduates compared to international medical graduates. Our results differ from previously reported rates of subspecialization in the literature. Tracking individual residents through residency and fellowship programs provides a better understanding of residents' pathways to practice.
doi:10.4300/JGME-D-10-00105.1
PMCID: PMC3010950  PMID: 22132288
23.  Expansion of the Coordinator Role in Orthopaedic Residency Program Management 
The Accreditation Council of Graduate Medical Education’s (ACGME) Data Accreditation System indicates 124 of 152 orthopaedic surgery residency program directors have 5 or fewer years of tenure. The qualifications and responsibilities of the position based on the requirements of orthopaedic surgery residency programs, the institutions that support them, and the ACGME Outcome Project have evolved the role of the program coordinator from clerical to managerial. To fill the void of information on the coordinators’ expanding roles and responsibilities, the 2006 Association of Residency Coordinators in Orthopaedic Surgery (ARCOS) Career survey was designed and distributed to 152 program coordinators in the United States. We had a 39.5% response rate for the survey, which indicated a high level of day-to-day managerial oversight of all aspects of the residency program; additional responsibilities for other department or division functions for fellows, rotating medical students, continuing medical education of the faculty; and miscellaneous business functions. Although there has been expansion of the role of the program coordinator, challenges exist in job congruence and position reclassification. We believe use of professional groups such as ARCOS and certification of program coordinators should be supported and encouraged.
doi:10.1007/s11999-007-0110-6
PMCID: PMC2505208  PMID: 18196362
24.  Correlation of the Emergency Medicine Resident In-Service Examination with the American Osteopathic Board of Emergency Medicine Part I 
Introduction: Eligible residents during their fourth postgraduate year (PGY-4) of emergency medicine (EM) residency training who seek specialty board certification in emergency medicine may take the American Osteopathic Board of Emergency Medicine (AOBEM) Part 1 Board Certifying Examination (AOBEM Part 1). All residents enrolled in an osteopathic EM residency training program are required to take the EM Resident In-service Examination (RISE) annually. Our aim was to correlate resident performance on the RISE with performance on the AOBEM Part 1. The study group consisted of osteopathic EM residents in their PGY-4 year of training who took both examinations during that same year.
Methods: We examined data from 2009 to 2012 from the National Board of Osteopathic Medical Examiners (NBOME). The NBOME grades and performs statistical analyses on both the RISE and the AOBEM Part 1. We used the RISE exam scores, as reported by percentile rank, and compared them to both the score on the AOBEM Part 1 and the dichotomous outcome of passing or failing. A receiver operating characteristic (ROC) curve was generated to depict the relationship.
Results: We studied a total of 409 residents over the 4-year period. The RISE percentile score correlated strongly with the AOBEM Part 1 score for residents who took both exams in the same year (r=0.61, 95% confidence interval [CI] 0.54 to 0.66). Pass percentage on the AOBEM Part 1 increased by resident percent decile on the RISE from 0% in the bottom decile to 100% in the top decile. ROC analysis also showed that the best cutoff for determining pass or fail on the AOBEM Part 1 was a 65th percentile score on the RISE.
Conclusion: We have shown there is a strong correlation between a resident's percentile score on the RISE during their PGY-4 year of residency training and first-time success on the AOBEM Part 1 taken during the same year. This information may be useful for osteopathic EM residents as an indicator as to how well prepared they are for the AOBEM Part 1 Board Certifying Examination.
doi:10.5811/westjem.2013.7.17904
PMCID: PMC3952889  PMID: 24696749
25.  Increasing Faculty Attendance at Emergency Medicine Resident Conferences: Does CME Credit Make a Difference? 
Background
Faculty involvement in resident teaching events is beneficial to resident education, yet evidence about the factors that promote faculty attendance at resident didactic conferences is limited.
Objective
To determine whether offering continuing medical education (CME) credits would result in an increase in faculty attendance at weekly emergency medicine conferences and whether faculty would report the availability of CME credit as a motivating factor.
Methods
Our prospective, multi-site, observational study of 5 emergency medicine residency programs collected information on the number of faculty members present at CME and non-CME lectures for 9 months and collected information from faculty on factors influencing decisions to attend resident educational events and from residents on factors influencing their learning experience.
Results
Lectures offering CME credit on average were attended by 5 additional faculty members per hour, compared with conferences that did not offer CME credit (95% confidence interval [CI], 3.9–6.1; P < .001). Faculty reported their desire to “participate in resident education” was the most influential factor prompting them to attend lectures, followed by “explore current trends in emergency medicine” and the lecture's “specific topic.” Faculty also reported that “clinical/administrative duties” and “family responsibilities” negatively affected their ability to attend. Residents reported that the most important positive factor influencing their conference experience was “lectures given by faculty.”
Conclusions
Although faculty reported that CME credit was not an important factor in their decision to attend resident conferences, offering CME credit resulted in significant increases in faculty attendance. Residents reported that “lectures given by faculty” and “faculty attendance” positively affected their learning experience.
doi:10.4300/JGME-D-12-00030.1
PMCID: PMC3613316  PMID: 24404225

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