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.
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.
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.
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.
Objective. Our purpose was to investigate radiology fellowship directors' and recent fellows' experiences and perceptions with regard to the fellowship application and selection process and to compare these experiences and perceptions. Materials and Methods. Institutional review board approval was obtained. We conducted an online survey of the memberships of three radiology subspecialty societies between October 2009 and December 2009 to learn about radiologists' views regarding various aspects of radiology fellowships. Results. In the process of selecting fellows, program directors and recent fellows consider performance during the radiology residency and the quality or prestige of the residency program as the most important objective factors, and the personal interview, letters of recommendation, and personality as the most important subjective factors. 25% of the program directors were in the match, and 41% of the recent fellows were in the match. Most (48%) of program directors favored a match, but most (56%) of the recent fellows disfavored participating in a match. Both program directors and recent fellows expressed satisfaction with the fellowship application and selection process. Conclusion. There was no majority support for a fellowship match among program directors and recent fellows and less support among recent fellows. Recent fellows appear more satisfied with the current selection and application process than program directors.
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.
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.
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.
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.
Pathology informatics fellowship; clinical informatics; clinical informatics fellowship; pathology informatics; pathology informatics teaching; clinical informatics teaching
Pressures on academic faculty to perform beyond their role as educators has stimulated interest in complementary approaches in resident medical education. While fellows are often believed to detract from resident learning and experience, we describe our preliminary investigations utilizing clinical fellows as a positive force in pediatric resident education. Our objectives were to implement a practical approach to engage fellows in resident education, evaluate the impact of a fellow-led education program on pediatric resident and fellow experience, and investigate if growth of a fellowship program detracts from resident procedural experience.
This study was conducted in a neonatal intensive care unit (NICU) where fellows designed and implemented an education program consisting of daily didactic teaching sessions before morning clinical rounds. The impact of a fellow-led education program on resident satisfaction with their NICU experience was assessed via anonymous student evaluations. The potential value of the program for participating fellows was also evaluated using an anonymous survey.
The online evaluation was completed by 105 residents. Scores were markedly higher after the program was implemented in areas of teaching excellence (4.44 out of 5 versus 4.67, p<0.05) and overall resident learning (3.60 out of 5 versus 4.61, p<0.001). Fellows rated the acquisition of teaching skills and enhanced knowledge of neonatal pathophysiology as the most valuable aspects of their participation in the education program. The anonymous survey revealed that 87.5% of participating residents believed that NICU fellows were very important to their overall training and education.
While fellows are often believed to be a detracting factor to residency training, we found that pediatric resident attitudes toward the fellows were generally positive. In our experience, in the specialty of neonatology a fellow-led education program can positively contribute to both resident and fellow learning and satisfaction. Further investigation into the value of utilizing fellows as a positive force in resident education in other medical specialties appears warranted.
resident education; fellow teaching; pediatrics
Pathology Informatics is a new field; a field that is still defining itself even as it begins the formalization, accreditation, and board certification process. At the same time, Pathology itself is changing in a variety of ways that impact informatics, including subspecialization and an increased use of data analysis. In this paper, we examine how these changes impact both the structure of Pathology Informatics fellowship programs and the fellows’ goals within those programs.
Materials and Methods:
As part of our regular program review process, the fellows evaluated the value and effectiveness of our existing fellowship tracks (Research Informatics, Clinical Two-year Focused Informatics, Clinical One-year Focused Informatics, and Clinical 1 + 1 Subspecialty Pathology and Informatics). They compared their education, informatics background, and anticipated career paths and analyzed them for correlations between those parameters and the fellowship track chosen. All current and past fellows of the program were actively involved with the project.
Fellows’ anticipated career paths correlated very well with the specific tracks in the program. A small set of fellows (Clinical – one or two year – Focused Informatics tracks) anticipated clinical careers primarily focused in informatics (Director of Informatics). The majority of the fellows, however, anticipated a career practicing in a Pathology subspecialty, using their informatics training to enhance that practice (Clinical 1 + 1 Subspecialty Pathology and Informatics Track). Significantly, all fellows on this track reported they would not have considered a Clinical Two-year Focused Informatics track if it was the only track offered. The Research and the Clinical One-year Focused Informatics tracks each displayed unique value for different situations.
It seems a “one size fits all” fellowship structure does not fit the needs of the majority of potential Pathology Informatics candidates. Increasingly, these fellowships must be able to accommodate the needs of candidates anticipating a wide range of Pathology Informatics career paths, be able to accommodate Pathology's increasingly subspecialized structure, and do this in a way that respects the multiple fellowships needed to become a subspecialty pathologist and informatician. This is further complicated as Pathology Informatics begins to look outward and takes its place in the growing, and still ill-defined, field of Clinical Informatics, a field that is not confined to just one medical specialty, to one way of practicing medicine, or to one way of providing patient care.
Clinical informatics training; clinical informatics; fellowship tracks; informatics fellowship training; informatics teaching; pathology informatics fellowship; pathology informatics training; pathology informatics
Fatigue in physician trainees may compromise patient safety and the well-being of the trainees and limit the educational opportunities provided by training programs. Anecdotal evidence suggests that the on-call workload and physical demands experienced by trainees are significant despite duty-hour regulation and support from nursing staff, other trainees and staff physicians.
We measured the workload and the level of fatigue and physical stress of 11 senior fellows during 35 shifts in the critical care unit at the Hospital for Sick Children in Toronto. We determined number of rostered hours, number of admissions and discharges, number and type of procedures, nurse:patient ratios and related measures of workload. Fellows self-reported the number of pages they received and the amount of time they slept. We estimated physical stress by using a commercially available pedometer to measure the distance walked, by using ambulatory electrocardiographic monitoring to determine arrhythmias and by determining urine specific gravity and ketone levels to estimate hydration.
The number of rostered hours were within current Ontario guidelines. The mean shift duration was 25.5 hours (range 24–27 hours). The fellows worked on average 69 hours (range 55–106) per week. On average during a shift, the fellows received 41 pages, were on non-sleeping breaks for 1.2 hours, slept 1.9 hours and walked 6.3 km. Ketonuria was found in participants in 7 (21%) of the 33 shifts during which it was measured. Arrhythmia (1 atrial, 1 ventricular) or heart rate abnormalities occurred in all 6 participants. These fellows were the most senior in-house physician for a mean of 9.4 hours per shift and were responsible for performing invasive procedures in two-thirds of their shifts.
Established Canadian and proposed American guidelines expose trainees to significant on-call workload, physical stress and sleep deprivation.
In recent years, there has been a rapid growth in diagnostic and therapeutic procedures performed by respirologists.
To assess the number and type of procedures performed in Canadian respirology training programs, for comparison with the American College of Chest Physicians minimum competency guidelines, and to assess fellow satisfaction with procedural training during their fellowships.
Internet-based surveys of Canadian respirology fellows and respirology fellowship program directors were conducted.
Response rates for program director and respirology fellow surveys were 71% (10 of 14) and 62% (41 of 66), respectively. Thirty-eight per cent of respirology fellows reported the presence of an interventional pulmonologist at their institution. Flexible bronchoscopy was the only procedure reported by a large majority of respirology fellows (79.5%) to meet American College of Chest Physicians recommendations (100 procedures). As reported by respirology fellows, recommended numbers of procedures were met by 59.5% of fellows for tube thoracostomy, 21% for transbronchial needle aspiration and 5.4% for closed pleural biopsy. Respirology fellows in programs with an interventional pulmonologist were more likely to have completed some form of additional interventional bronchoscopy training (80% versus 32%; P=0.003), had increased exposure to and expressed improved satisfaction with training in advanced diagnostic and therapeutic procedures, but did not increase their likelihood of achieving recommended numbers for any procedures.
Canadian respirology fellows perform lower numbers of basic respiratory procedures, other than flexible bronchoscopy, than that suggested by the American College of Chest Physicians guidelines. Exposure and training in advanced diagnostic and therapeutic procedures is minimal. A concerted effort to improve procedural training is required to improve these results.
Bronchoscopy; Education; Needle biopsy; Pulmonary training; Respirology
An early evaluation of the feasibility of training fellows in robotic surgery suggests that it is feasible to incorporate a systematic approach to robotic-assisted laparoscopic training at the onset of incorporating this technology into current practice.
Background and Objective:
The robotic surgical platform is an alternative technique to traditional laparoscopy and requires the development of new surgical skills for both the experienced surgeon and trainee. Our goal was to perform an early evaluation of the feasibility of training fellows in robotic-assisted gynecologic procedures at the outset of our incorporation of this technology into clinical practice.
A systematic approach to fellow training included (1) didactic and hands-on training with the robotic system, (2) instructional videos, (3) assistance at the operating table, and (4) performance of segments of gynecologic procedures in tandem with the attending physician. Time to complete the entire procedure, individual segments, rate of conversion to laparotomy, and complications were recorded.
Twenty-one robotic-assisted gynecologic procedures were performed from April 2006 to January 2007. Fellows participated as the console surgeon in 14/21 cases. Thirteen patients (62%) had prior abdominal surgery. Median values with ranges were age 51 years (range, 33 to 90); BMI 28 (range, 19.4 to 43.8); EBL 25 mL (range, 25 to 250); and hospital stay 1 day (range, 1 to 4). No significant difference existed between fellow and attending mean total operative and individual segment times. One conversion to laparotomy was necessary. No major surgical complications occurred.
These data suggest that it is feasible to incorporate a systematic approach to robotic-assisted laparoscopic training for trainees at the outset of incorporation of this technology into current practice.
Robotics; Laparoscopic surgery; Education; Gynecology
PURPOSE: To determine the clinical importance and relative value of reinterpreting brain CT imaging studies by subspecialty experts regarding changes in clinical management. METHODS: Computerized records were queried at two institutions during the years 2002-2003 for both primary interpretation by board-certified nonneuroradiologists and secondary interpretation by three neuroradiologists. A total of 1,081 cases were reviewed. Each case was initially interpreted as an emergent or urgent study. The reinterpreted studies were scored as concordant or discordant by the subspecialty experts. The discordant studies were then categorized as a "major discordance" if there was a change in clinical management, or as a "minor discordance" if there was no impact or change in clinical management. RESULTS: Of the 1,081 studies reviewed, 14 studies were identified as discordant (1.3%). Of those discordant studies, four were categorized as major discrepancies necessitating a change in clinical management (0.4 %). Ten were categorized as minor discrepancies (0.9%). There were no permanent adverse outcomes with respect to morbidity and mortality as a result of any discrepancy. CONCLUSION: The vast majority of interpreted head CT cases read by board-certified general radiologists do not result in discordant interpretations as verified by subspecialty experts. Discordant interpretations did not result in changes in clinical management in most cases. Double reading of head CTs by subspecialty experts appears to be an inefficient method of substantially improving imaging health quality outcomes.
Acquiring a faculty position in academia is extremely competitive and now typically requires more than just solid research skills and knowledge of one’s field. Recruiting institutions currently desire new faculty that can teach effectively, but few postdoctoral positions provide any training in teaching methods. Fellowships in Research and Science Teaching (FIRST) is a successful postdoctoral training program funded by the National Institutes of Health (NIH) providing training in both research and teaching methodology. The FIRST program provides fellows with outstanding interdisciplinary biomedical research training in fields such as neuroscience. The postdoctoral research experience is integrated with a teaching program which includes a How to Teach course, instruction in classroom technology and course development and mentored teaching. During their mentored teaching experiences, fellows are encouraged to explore innovative teaching methodologies and to perform science teaching research to improve classroom learning. FIRST fellows teaching neuroscience to undergraduates have observed that many of these students have difficulty with the topic of neuroscience. Therefore, we investigated the effects of interactive teaching methods for this topic. We tested two interactive teaching methodologies to determine if they would improve learning and retention of this information when compared with standard lectures. The interactive methods for teaching action potentials increased understanding and retention. Therefore, FIRST provides excellent teaching training, partly by enhancing the ability of fellows to integrate innovative teaching methods into their instruction. This training in turn provides fellows that matriculate from this program more of the characteristics that hiring institutions desire in their new faculty.
action potential; postdoctoral fellowship; interactive teaching; pedagogy; neuroscience; mentoring
The Accreditation Council for Graduate Medical Education requires fellows in many specialties to demonstrate attainment of 6 core competencies, yet relatively few validated assessment tools currently exist. We present our initial experience with the design and implementation of a standardized patient (SP) exercise during gastroenterology fellowship that facilitates appraisal of all core clinical competencies.
Fellows evaluated an SP trained to portray an individual referred for evaluation of abnormal liver tests. The encounters were independently graded by the SP and a faculty preceptor for patient care, professionalism, and interpersonal and communication skills using quantitative checklist tools. Trainees' consultation notes were scored using predefined key elements (medical knowledge) and subjected to a coding audit (systems-based practice). Practice-based learning and improvement was addressed via verbal feedback from the SP and self-assessment of the videotaped encounter.
Six trainees completed the exercise. Second-year fellows received significantly higher scores in medical knowledge (55.0 ± 4.2 [standard deviation], P = .05) and patient care skills (19.5 ± 0.7, P = .04) by a faculty evaluator as compared with first-year trainees (46.2 ± 2.3 and 14.7 ± 1.5, respectively). Scores correlated by Spearman rank (0.82, P = .03) with the results of the Gastroenterology Training Examination. Ratings of the fellows by the SP did not differ by level of training, nor did they correlate with faculty scores. Fellows viewed the exercise favorably, with most indicating they would alter their practice based on the experience.
An SP exercise is an efficient and effective tool for assessing core clinical competencies during fellowship training.
Learner satisfaction assessment is critical in the design and improvement of training programs. However, little is known about what influences satisfaction and whether trainee specialty is correlated. A national comparison of satisfaction among internal medicine subspecialty fellows in the Department of Veterans Affairs (VA) provides a unique opportunity to examine educational factors associated with learner satisfaction. We compared satisfaction across internal medicine fellows by subspecialty and compared factors associated with satisfaction between procedural versus non-procedural subspecialty fellows, using data from the Learners' Perceptions Survey (LPS), a validated survey tool.
We surveyed 2,221 internal medicine subspecialty fellows rotating through VA between 2001 and 2008. Learners rated their overall training satisfaction on a 100-point scale, and on a five-point Likert scale ranked satisfaction with items within six educational domains: learning, clinical, working and physical environments; personal experience; and clinical faculty/preceptor.
Procedural and non-procedural fellows reported similar overall satisfaction scores (81.2 and 81.6). Non-procedural fellows reported higher satisfaction with 79 of 81 items within the 6 domains and with the domain of physical environment (4.06 vs. 3.85, p <0.001). Satisfaction with clinical faculty/preceptor and personal experience had the strongest impact on overall satisfaction for both. Procedural fellows reported lower satisfaction with physical environment.
Internal medicine fellows are highly satisfied with their VA training. Nonprocedural fellows reported higher satisfaction with most items. For both procedural and non-procedural fellows, clinical faculty/preceptor and personal experience have the strongest impact on overall satisfaction.
The advent of digital imaging and information management within the radiology department has prompted the growth of a new radiology subspecialty: Radiology Informatics. With appropriate training, radiologists can become leaders in Medical Informatics and guide the growth of this technology throughout the medical enterprise. Radiology Informatics fellowships, as well as radiology residency programs, provide inconsistent exposure to all the elements of this subspecialty, in part because of the lack of a common curriculum. The Society for Computer Applications in Radiology (SCAR) has developed a curriculum intended to guide training in Radiology Informatics. This article is the first in a series presented by SCAR and the Journal of Digital Imaging, titled “Reviews in Radiology Informatics.” The series is designed to sample from each of the major components in the Radiology Informatics Curriculum, to spark further interest in the field and provide content for informatics education.
Informatics; education; residents
There is currently a discrepancy between Internal Medicine residents' decisions in the Canadian subspecialty fellowship match (known as the R4 match) and societal need. Some studies have been published examining factors that influence career choices. However, these were either demographic factors or factors pre-determined by the authors' opinion as possibly being important to incorporate into a survey.
A qualitative study was undertaken to identify factors that determine the residents choice in the subspecialty (R4) fellowship match using focus group discussions involving third and fourth year internal medicine residents
Based on content analysis of the discussion data, we identified five themes:
1) Practice environment including acuity of practice, ability to do procedures, lifestyle, job prospects and income
2) Exposure in rotations and to role models
3) Interest in subspecialty's patient population and common diseases
4) Prestige and respect of subspecialty
5) Fellowship training environment including fellowship program resources and length of training
There are a variety of factors that contribute to Internal Medicine residents' fellowship choice in Canada, many of which have been identified in previous survey studies. However, we found additional factors such as the resources available in a fellowship program, the prestige and respect of a subspecialty/career, and the recent trend towards a two-year General Internal Medicine fellowship in our country.
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.
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."
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.
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.
Responsibility for training paediatric medical subspecialists in Canada lies primarily with the 16 academic paediatric departments. There has been no mechanism to assess whether the number of residents in training will meet the needs of currently vacant positions and/or the predicted vacancies to be created by anticipated faculty retirement in the next five years across the different paediatric medical subspecialties.
At the present time, the training of the paediatric physician is not linked with the current and future needs of the academic centres where the vast majority of these paediatric subspecialists are employed.
The academic paediatric workforce database of the Paediatric Chairs of Canada (PCC) for the surveys obtained in 2009/2010 were analyzed. Data included the number of physicians working in each subspecialty, the number of physicians 60 years of age or older, as well as the number of residents and their level of training.
There are some paediatric subspecialties in which the actual number of trainees exceeds the currently predicted need (eg, cardiology, critical care, hematology-oncology, nephrology, neurology, emergency medicine and genetic-metabolic). On the other hand, for other specialties (eg, adolescent medicine, developmental paediatrics, gastroenterology and neonatology), assuming there is no significant change to selection patterns, an important gap will persist or appear between the need and the available human resources.
The present analysis was the first attempt to link the clinical orientation of trainees with the needs of the academic centres where the vast majority of these paediatric subspecialists work.
Human resource; Paediatric workforce; Specialists; Subspecialists
The increased demand for clinician-educators in academic medicine necessitates additional training in educational skills to prepare potential candidates for these positions. Although many teaching skills training programs for residents exist, there is a lack of reports in the literature evaluating similar programs during fellowship training.
To describe the implementation and evaluation of a unique program aimed at enhancing educational knowledge and teaching skills for subspecialty medicine fellows and chief residents.
Fellows as Clinician-Educators (FACE) program is a 1-year program open to fellows (and chief residents) in the Department of Internal Medicine at the University of Iowa.
The course involves interactive monthly meetings held throughout the academic year and has provided training to 48 participants across 11 different subspecialty fellowships between 2004 and 2009.
FACE participants completed a 3-station Objective Structured Teaching Examination using standardized learners, which assessed participants' skills in giving feedback, outpatient precepting, and giving a mini-lecture. Based on reviews of station performance by 2 independent raters, fellows demonstrated statistically significant improvement on overall scores for 2 of the 3 cases. Participants self-assessed their knowledge and teaching skills prior to starting and after completing the program. Analyses of participants' retrospective preassessments and postassessments showed improved perceptions of competence after training.
The FACE program is a well-received intervention that objectively demonstrates improvement in participants' teaching skills. It offers a model approach to meeting important training skills needs of subspecialty medicine fellows and chief residents in a resource-effective manner.
Abdominal computed tomography (CT) is widely used as a diagnostic tool in emergency medicine (EM) to accurately diagnose abdominal pain. EM residents must be able to offer preliminary interpretations of CT imaging. In this study, we evaluated the preliminary interpretation ability of a sample of emergency residents presented with adult abdominal CT images, and compared their results with those of radiology residents. We conducted a prospective observational study from November 16, 2008 to June 30, 2009. During this time, we gathered preliminary interpretations of consecutive abdominal CT made by emergency and radiology residents. We assessed the discrepancy rates of both samples by comparing their findings to the final reports from attending radiologists. A total of 884 cases were enrolled in the present study. The discrepancy rates of emergency and radiology residents were 16.7% and 12.2%, respectively. When female genital organs, peritoneum, adrenal glands, or the musculoskeletal system were abnormal, we found that emergency residents' preliminary interpretations of CT images were insufficient compared to those of radiology residents. Therefore more formal education is needed to emergency residents. If possible, the preliminary interpretations of radiology attending physicians are ideal until improving the ability of interpretations of emergency residents in abdomen CT.
Abdominal Pain; CT Scan; Emergency Medicine; Radiographic Image Interpretation
Little is known about whether and how medical knowledge relates to interest in subspecialty fellowship training. The purpose of this study was to examine the relationships between residents' interest in subspecialty fellowship training and their knowledge of internal medicine (IM).
A questionnaire was emailed to 48 categorical postgraduate-year (PGY) two and three residents at a New York university-affiliated IM residency program in 2007 using the Survey Monkey online survey instrument. Overall and content area-specific percentile scores from the IM in-training examination (IM-ITE) for the same year was used to determine objective knowledge.
Forty-five of 48 residents (response rate was 93.8%) completed the survey. Twenty-two (49%) were PG2 residents and 23(51%) were PGY3 residents. Sixty percent of respondents were male. Six (13%) residents were graduates of U.S. medical schools. Eight (18%) reported formal clinical training prior to starting internal medicine residency in the U.S. Of this latter group, 6 (75%) had training in IM and 6 (75) % reported a training length of 3 years or less. Thirty-seven of 45 (82%) residents had a subspecialty fellowship interest. Residents with a fellowship interest had a greater mean overall objective knowledge percentile score (56.44 vs. 31.67; p = 0.04) as well as greater mean percentile scores in all content areas of IM. The adjusted mean difference was statistically significant (p < 0.02) across three content areas.
More than half of surveyed residents indicated interest in pursuing a subspecialty fellowship. Fellowship interest appears positively associated with general medical knowledge in this study population. Further work is needed to explore motivation and study patterns among internal medicine residents.
In 2007, our healthcare system established a clinical fellowship program in Pathology Informatics. In 2010 a core didactic course was implemented to supplement the fellowship research and operational rotations. In 2011, the course was enhanced by a formal, structured core curriculum and reading list. We present and discuss our rationale and development process for the Core Curriculum and the role it plays in our Pathology Informatics Fellowship Training Program.
Materials and Methods:
The Core Curriculum for Pathology Informatics was developed, and is maintained, through the combined efforts of our Pathology Informatics Fellows and Faculty. The curriculum was created with a three-tiered structure, consisting of divisions, topics, and subtopics. Primary (required) and suggested readings were selected for each subtopic in the curriculum and incorporated into a curated reading list, which is reviewed and maintained on a regular basis.
Our Core Curriculum is composed of four major divisions, 22 topics, and 92 subtopics that cover the wide breadth of Pathology Informatics. The four major divisions include: (1) Information Fundamentals, (2) Information Systems, (3) Workflow and Process, and (4) Governance and Management. A detailed, comprehensive reading list for the curriculum is presented in the Appendix to the manuscript and contains 570 total readings (current as of March 2012).
The adoption of a formal, core curriculum in a Pathology Informatics fellowship has significant impacts on both fellowship training and the general field of Pathology Informatics itself. For a fellowship, a core curriculum defines a basic, common scope of knowledge that the fellowship expects all of its graduates will know, while at the same time enhancing and broadening the traditional fellowship experience of research and operational rotations. For the field of Pathology Informatics itself, a core curriculum defines to the outside world, including departments, companies, and health systems considering hiring a pathology informatician, the core knowledge set expected of a person trained in the field and, more fundamentally, it helps to define the scope of the field within Pathology and healthcare in general.
Clinical informatics curriculum; clinical informatics teaching; informatics core content; informatics curriculum; pathology informatics core content; pathology informatics curriculum; pathology informatics definition; pathology informatics fellowship; pathology informatics teaching; pathology informatics
To quantify the prevalence, outcomes, and cost of surgical resident research.
Summary Background Data
General surgery is unique among graduate medical education programs because a large percentage of residents interrupt their clinical training to spend 1-3 years performing full-time research. No comprehensive data exists on the scope of this practice.
Survey sent to all 239 program directors of general surgery residencies participating in the National Resident Matching Program.
Response rate was 200/239 (84%). A total of 381 out of 1052 trainees (36%) interrupt residency to pursue full-time research. The mean research fellowship length is 1.7 years, with 72% of trainees performing basic science research. A significant association was found between fellowship length and post-residency activity, with a 14.7% increase in clinical fellowship training and a 15.2% decrease in private practice positions for each year of full-time research (p<0.0001). Program directors at 31% of programs reported increased clinical duties for research fellows as a result of ACGME work hour regulations for clinical residents, while a further 10% of programs are currently considering such changes. It costs $41.5 million to pay the 634 trainees who perform research fellowships each year, the majority of which is paid for by departmental funds (40%) and institutional training grants (24%).
Interrupting residency to perform a research fellowship is a common and costly practice among general surgery residents. While performing a research fellowship is associated with clinical fellowship training after residency, it is unclear to what extent this practice leads to the development of surgical investigators after post-graduate training.
It is suggested that this study may provide benchmark baseline data for assessing the impact of fellowship training on the morbidity, oncologic efficacy, continence results, and potency outcomes of new surgeons performing robotic-assisted laparoscopic prostatectomy.
Background and Objectives:
We examined 1-year functional and oncologic outcomes for robotic-assisted laparoscopic prostatectomy (RALP) from a single surgeon entering practice directly from fellowship training.
We prospectively analyzed the first 100 RALPs performed by one fellowship-trained robotic surgeon. Data included resident involvement during the procedure, perioperative data, and surgical complications (scored using the Clavien grading system). Health-related quality of life (HRQOL) data were captured using the EPIC questionnaire at baseline (prior to surgery) and at 1-year follow-up.
Eighty-two patients (82%) had hospital stays of 2 days or less without any postoperative complications, urethral catheter removal was within 14 days of surgery, and none required readmission to the hospital. The overall positive margin rate was 21% (19% for patients with T2 disease). Clavien grades 1 through 4 complication rates, respectively, were 4%, 10%, 1%, and 1%. There were no deaths, reoperations, or bladder neck contractures. One patient (1%) required a blood transfusion within the 90-day perioperative period. At 1-year follow-up, 78% of patients reported wearing no pads; 41.3% of patients with baseline and 1-year follow-up data reported having intercourse.
We provide baseline data pertaining to the morbidity, oncologic efficacy, continence results, and potency outcomes of new surgeons performing RALP.
Robotics; Prostatectomy; Training; Prostatic neoplasms
Training residents in medical procedures is an area of growing interest. Studies demonstrate that internal medicine residents are inadequately trained to perform common medical procedures, and program directors report residents do not master these essential skills. The American Board of Internal Medicine requires substantiation of competence in procedure skills for all internal medicine residents; however, for most procedures, standards of competence do not exist.
1) Create a new and standardized approach to teaching, performing, and evaluating inpatient medical procedures; 2) Determine the number of procedures required until trainees develop competence, by assessing both clinical knowledge and psychomotor skills; 3) Improve patient safety.
A Medical Procedure Service (MPS), consisting of select faculty who are experts at common inpatient procedures, was established to supervise residents performing medical procedures. Faculty monitor residents’ psychomotor performance, while clinical knowledge is taught through a complementary, comprehensive curriculum. After the completion of each procedure, the trainee and supervising faculty member independently complete online questionnaires.
During this pilot program, 246 procedures were supervised, with a pooled major complication rate of 3.7%. 123 thoracenteses were supervised, with a pneumothorax rate of 3.3%; this compares favorably with a pooled analysis of the literature. 87% of surveyed house staff felt the procedure service helped in their education of medical procedures.
The “see one, do one, teach one” model of procedure education is dangerously inadequate. Through the development of a Medical Procedure Service, and an associated procedure curriculum and a mechanism of evaluation, we hope to reduce the rate of complications and errors related to medical procedures and to determine at what point competency is achieved for these procedures.
procedures; education; competence; complications
The Program Requirements for Fellowship Education identify the knowledge and skills that physicians must master through the course of a training program to be certified in the subspecialty of clinical informatics. They also specify accreditation requirements for clinical informatics training programs. The AMIA Board of Directors approved this document in November 2008.
Limited information is available on personal digital assistant (PDA) use patterns in medical settings. Recognizing that use patterns may be important considerations for development of handheld-based information systems, the authors characterized PDA use at their institution. A survey was mailed to all internal medicine physicians at the Mayo Clinic, Rochester, Minnesota, in May 2002. PDA use prevalence, user demographics, hardware preferences, and work setting and application use frequencies were assessed for respondents reporting current PDA use. Use patterns of trainees (residents and subspecialty fellows) and attending physicians were compared. Trainees reported more frequent PDA use in the hospital setting and for direct patient care. Attending physicians reported more frequent PDA use in administrative settings and for calendar functions. These findings may reflect differences in the information needs and work roles of learners and experienced physicians. Such factors may be important considerations for the development and implementation of institutional PDA resources.