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Year of Publication
1.  Erratum 
doi:10.4300/1949-8357-6.1.192
PMCID: PMC3963789
2.  Standardizing and Evaluating Transitions of Care in the Era of Duty Hour Reform: One Institution's Resident-Led Effort 
Background
Compliance with the Accreditation Council for Graduate Medical Education duty hour standards may necessitate more frequent transitions of patient responsibility.
Intervention
We created a multidisciplinary Patient Safety and Quality Council with a Task Force on Handoffs (TFH), engaging residents at a large, university-based institution.
Methods
The TFH identified core content of effective handoffs and patterned institutional content on the SIGNOUTT mnemonic. A web-based module highlighting core content was developed for institutional orientation of all trainees beginning summer 2011 to standardize handoff education. The TFH distributed handoff material and catalogued additional program initiatives in teaching and evaluating handoffs. A standard handoff evaluation tool, assessing content, culture, and communication, was developed and “preloaded” into the institution-wide electronic evaluation system to standardize evaluation. The TFH developed questions pertaining to handoffs for an annual institutional survey in 2011 and 2012. Acceptability of efforts was measured by program participation, and feasibility was measured by estimating time and financial costs.
Results
Programs found the TFH's efforts to improve handoffs acceptable; to date, 13 program-specific teaching initiatives have been implemented, and the evaluation tool is being used by 5 programs. Time requirements for TFH participants average 2 to 3 h/mo, and financial costs are minimal. More residents reported having education on handoffs (58% [388 of 668] versus 42% [263 of 625], P < .001) and receiving adequate signouts (69% [469 of 680] versus 61% [384 of 625], P  =  .004) in the 2012 survey, compared with 2011.
Conclusions
Use of a multispecialty resident leadership group to address content, education, and evaluation of handoffs was feasible and acceptable to most programs at a large, university-based institution.
doi:10.4300/JGME-D-12-00287
PMCID: PMC3886467  PMID: 24455017
4.  Analyzing and Interpreting Data From Likert-Type Scales 
doi:10.4300/JGME-5-4-18
PMCID: PMC3886444  PMID: 24454995
6.  In This Issue 
doi:10.4300/JGME-05-04-38
PMCID: PMC3886446
7.  The “Hateful Resident” 
doi:10.4300/JGME-D-12-00371.1
PMCID: PMC3886447  PMID: 24454997
8.  Medical Errors: Teachable Moments in Doing the Right Thing 
doi:10.4300/JGME-D-13-00110.1
PMCID: PMC3886448  PMID: 24454998
11.  Can We Make Grand Rounds “Grand” Again? 
doi:10.4300/JGME-D-12-00355.1
PMCID: PMC3886451  PMID: 24455001
12.  Resident Scholarship Expectations and Experiences: Sources of Uncertainty as Barriers to Success 
Background
Scholarly activity during residency is vital to resident learning and ultimately to patient care. Incorporating that activity into training is, however, a challenge for medical educators. Most research on medical student and resident attitudes toward scholarly activity to date has been quantitative and has focused on level of interest, desire to perform scholarship, and perceived importance of scholarship.
Objective
We explored attitudes, expectations, and barriers regarding participation in scholarly activity among current residents and graduates of a single family medicine residency program.
Methods
Using a phenomenologic approach, we systematically analyzed data from one-on-one, semistructured interviews with residents and graduates. Interviews included participant expectations and experiences with scholarly activity in residency.
Results
The 20 participants (residents, 15 [75%]; residency graduates, 5 [25%]) identified uncertainty in their attitudes toward, and expectations regarding, participation in scholarly activity as an overarching theme, which may present a barrier to participation. Themes included uncertainty regarding their personal identity as a clinician, time to complete scholarly activity, how to establish a mentor-mentee relationship, the social norms of scholarship, what counted toward the scholarship requirements, the protocol for completing projects, and the clinical relevance of scholarship.
Conclusions
Uncertainty about scholarly activity expectations can add to learner anxiety and make performing scholarly activity during residency seem like an insurmountable task. Programs should consider implementing a variety of strategies to foster scholarly activity during residency, including clarifying and codifying expectations and facilitating mentoring relationships with faculty.
doi:10.4300/JGME-D-12-00280.1
PMCID: PMC3886452  PMID: 24455002
13.  Development of the Objective, Structured Communication Assessment of Residents (OSCAR) Tool for Measuring Communication Skills With Patients 
Background
Although interpersonal and communication skills are essential to physician practice, there is a dearth of effective tools to meaningfully teach and assess communication skills.
Objective
The purpose of our study was to create a standardized tool for evaluation of communication skills for residents across specialties.
Methods
We designed an Objective, Structured Communication Assessment of Residents (OSCAR) tool, consisting of 4 clinical stations, to assess intern communication skills with relationship development, their establishment of case goals, and their organization and time management skills. Interns from 11 training programs completed the stations, with senior residents trained to function as standardized patients. The 4 stations' scenarios were a disruptive patient, handling a phone call for a narcotics refill, disclosing a medical mistake, and delivering bad news.
Results
Eighty-three interns completed OSCAR during orientation. The assessment took interns about 40 minutes to complete, and participants were given immediate feedback by the standardized patients. The total possible score for each station was 50. Resident performance was highest for disclosing a medical error (94%, 47 of 50), followed by handling a disruptive patient (90%, 45 of 50), disclosing bad news (86%, 43 of 50), and handling the phone call for the narcotics refill (62%, 31 of 50). Multivariate analysis of variance results indicated differences between residents from US and international medical schools, but there were no significant differences across specialties. Interrater reliability was excellent for each station (> 0.80).
Conclusions
OSCAR is a practical tool for assessing interns' communication skills to provide timely results to program directors.
doi:10.4300/JGME-D-12-00230.1
PMCID: PMC3886453  PMID: 24455003
14.  Understanding the Impact of Residents' Interpersonal Relationships During Emergency Department Referrals and Consultations 
Background
Communicating with colleagues is a key physician competency. Yet few studies have sought to uncover the complex nature of relationships between referring and consulting physicians, which may be affected by the inherent relationships between the participants.
Objective
Our study examines themes identified from discussions about communications and the role of relationships during the referral-consultation process.
Methods
From March to September 2010, 30 residents (10 emergency medicine, 10 general surgery, 10 internal medicine) were interviewed using a semistructured focus group protocol. Two investigators independently reviewed the transcripts using inductive methods and grounded theory to generate themes (using codes for ease of analysis) until saturation was reached. Disagreements were resolved by consensus, yielding an inventory of themes and subthemes. Measures for ensuring trustworthiness of the analysis included generating an audit trail and external auditing of the material by investigators not involved with the initial analysis.
Results
Two main relationship-related themes affected the referral-consultation process: familiarity and trust. Various subthemes were further delineated and studied in the context of pertinent literature.
Conclusions
Relationships between physicians have a powerful influence on the emergency department referral-consultation dynamic. The emergency department referral-consultation may be significantly altered by the familiarity and perceived trustworthiness of the referring and consulting physicians. Our proposed framework may further inform and improve instructional methods for teaching interpersonal communication. Most importantly, it may help junior learners understand inherent difficulties they may encounter during the referral process between emergency and consulting physicians.
doi:10.4300/JGME-D-12-00211.1
PMCID: PMC3886454  PMID: 24455004
15.  The Relationship Between Faculty Performance Assessment and Results on the In-Training Examination for Residents in an Emergency Medicine Training Program 
Background
Medical knowledge (MK) in residents is commonly assessed by the in-training examination (ITE) and faculty evaluations of resident performance.
Objective
We assessed the reliability of clinical evaluations of residents by faculty and the relationship between faculty assessments of resident performance and ITE scores.
Methods
We conducted a cross-sectional, observational study at an academic emergency department with a postgraduate year (PGY)-1 to PGY-3 emergency medicine residency program, comparing summative, quarterly, faculty evaluation data for MK and overall clinical competency (OC) with annual ITE scores, accounting for PGY level. We also assessed the reliability of faculty evaluations using a random effects, intraclass correlation analysis.
Results
We analyzed data for 59 emergency medicine residents during a 6-year period. Faculty evaluations of MK and OC were highly reliable (κ  =  0.99) and remained reliable after stratification by year of training (mean κ  =  0.68–0.84). Assessments of resident performance (MK and OC) and the ITE increased with PGY level. The MK and OC results had high correlations with PGY level, and ITE scores correlated moderately with PGY. The OC and MK results had a moderate correlation with ITE score. When residents were grouped by PGY level, there was no significant correlation between MK as assessed by the faculty and the ITE score.
Conclusions
Resident clinical performance and ITE scores both increase with resident PGY level, but ITE scores do not predict resident clinical performance compared with peers at their PGY level.
doi:10.4300/JGME-D-12-00240.1
PMCID: PMC3886455  PMID: 24455005
16.  The Learners' Perceptions Survey—Primary Care: Assessing Resident Perceptions of Internal Medicine Continuity Clinics and Patient-Centered Care 
Background
In 2010, the Department of Veterans Affairs (VA) implemented a national patient-centered care initiative that organized primary care into interdisciplinary teams of health care professionals to provide patient-centered, continuous, and coordinated care.
Objective
We assessed the discriminate validity of the Learners' Perceptions Survey—Primary Care (LPS-PC), a tool designed to measure residents' perceptions about their primary and patient-centered care experiences.
Methods
Between October 2010 and June 2011, the LPS-PC was administered to Loma Linda University Medical Center internal medicine residents assigned to continuity clinics at the VA Loma Linda Healthcare System (VALLHCS), a university setting, or the county hospital. Adjusted differences in satisfaction ratings across settings and over domains (patient- and family-centered care, faculty and preceptors, learning, clinical, work and physical environments, and personal experience) were computed using a generalized linear model.
Results
Our response rate was 86% (77 of 90). Residents were more satisfied with patient- and family-centered care at the VALLHCS than at either the university or county (P < .001). However, faculty and preceptors (odds ratio [OR]  =  1.53), physical (OR  =  1.29), and learning (OR  =  1.28) environments had more impact on overall resident satisfaction than patient- and family-centered care (OR  =  1.08).
Conclusions
The LPS-PC demonstrated discriminate validity to assess residents' perceptions of their patient-centered clinical training experience across outpatient primary care settings at an internal medicine residency program. The largest difference in scores was the patient- and family-centered care domain, in which residents rated the VALLHCS much higher than the university or county sites.
doi:10.4300/JGME-D-12-00233.1
PMCID: PMC3886456  PMID: 24455006
17.  Leading Educationally Effective Family-Centered Bedside Rounds 
Background
Family-centered bedside rounds (family-centered rounds) enable learning and clinical care to occur simultaneously and offer benefits to patients, health care providers, and multiple levels of learners.
Objective
We used a qualitative approach to understand the dimensions of successful (ie, educationally positive) family-centered rounds from the perspective of attending physicians and residents.
Methods
We studied rounds in a tertiary academic hospital affiliated with the University of Calgary. Data were collected from 7 focus groups of pediatrics residents and attendings and were analyzed using grounded theory.
Results
Attending pediatricians and residents described rounds along a spectrum from successful and highly educational to unsuccessful and of low educational value. Perceptions of residents and attendings were influenced by how well the environment, educational priorities, and competing priorities were managed. Effectiveness of the manager was the core variable for successful rounds led by persons who could develop predictable rounds and minimize learner vulnerability.
Conclusions
Success of family-centered rounds in teaching settings depended on making the education and patient care aims of rounds explicit to residents and attending faculty. The role of the manager in leading rounds also needs to be made explicit.
doi:10.4300/JGME-D-13-00036.1
PMCID: PMC3886457  PMID: 24455007
18.  Paperwork Versus Patient Care: A Nationwide Survey of Residents' Perceptions of Clinical Documentation Requirements and Patient Care 
Background
The current health care system requires a substantial amount of documentation by physicians, potentially limiting time spent on patient care.
Objective
We sought to explore trainees' perceptions of their clinical documentation requirements and the relationship between time spent on clinical documentation versus time available for patient care.
Methods
An anonymous, online survey was sent to trainees in all postgraduate years of training and specialties in Accreditation Council for Graduate Medical Education–accredited programs.
Results
Over a 2-month time frame, 1515 trainees in 24 specialties completed the survey. Most (92%) reported that documentation obligations are excessive, that time spent with patients has been compromised by this (90%), and that the amount of clinical documentation has had a negative effect on patient care (73%). Most residents and fellows reported feeling rushed and frustrated because of these documentation demands. They also reported that time spent on these tasks decreased their time available for teaching others and reduced the quality of their education. Respondents reported spending more time on clinical documentation than on direct patient care (P < .001).
Conclusions
Trainees' current clinical documentation workload may be a barrier to optimal patient care and to resident and fellow education. Residents and fellows report that clinical documentation duties are onerous, and there is a perceived negative effect on time spent with patients, overall quality of patient care, physician well-being, time available for teaching, and quality of resident education.
doi:10.4300/JGME-D-12-00377.1
PMCID: PMC3886458  PMID: 24455008
19.  Filling the Void: Defining Invasive Bedside Procedural Competency for Internal Medicine Residents 
Background
Residents perform invasive bedside procedures in most training programs. To date, there is no universal approach for determining competency and ensuring quality and safety of care.
Objective
We developed and implemented an assessment of central venous catheter insertion competency for internal medicine and internal medicine–pediatrics residents, using measurements for knowledge, skill, and attitude and linking them to procedural outcomes.
Methods
We conducted a cohort study of a 4-week, resident-run procedure service from July 2007 through June 2011 at a large academic medical center. Knowledge was assessed by using a written test, technical skill by using a checklist, and attitude by self- and supervisor assessments of residents' confidence and capability. Competence was defined as (1) a minimum written test score (70%); (2) a perfect checklist score; (3) a resident's self-assessed confidence and capability scores of 4 or 5 of 5; and (4) faculty rating of the resident's confidence and capability as 5 of 5. A composite success rate was based on procedural outcomes (eg, completed procedures, less than 3 forward needle passes, and complication rate) and was compared to the checklist scores.
Results
A total of 148 internal medicine and medicine–pediatrics residents inserted 639 catheters, and 53 (36%) achieved competence by the end of 4 weeks. Residents judged to be competent by checklist scores had a higher composite success rate than those deemed not competent.
Conclusions
Our multi-factorial criteria used to define central venous catheter insertion competency effectively discriminated between residents judged to be competent and those judged not competent, using data from procedural outcomes.
doi:10.4300/JGME-D-13-00030.1
PMCID: PMC3886459  PMID: 24455009
20.  Impact of Simulation Training on Time to Initiation of Cardiopulmonary Resuscitation for First-Year Pediatrics Residents 
Background
Pediatrics residents have few opportunities to perform cardiopulmonary resuscitation (CPR). Enhancing the quality of CPR is a key factor to improving outcomes for cardiopulmonary arrest in children and requires effective training strategies.
Objective
To evaluate the effectiveness of a simulation-based intervention to reduce first-year pediatrics residents' time for 3 critical actions in CPR: (1) call for help, (2) initiate bag-mask ventilation, and (3) initiate chest compressions.
Methods
A prospective study involving 31 first-year pediatrics residents at a children's hospital assigned to an early or late (control) intervention group. Residents underwent baseline assessment followed by repeat evaluations at 3 and 6 months. Time to critical actions was scored by video review. A 90-minute educational intervention focused on skill practice was conducted following baseline evaluation for the early-intervention group and following 3-month evaluation for the late-intervention group. Primary outcome was change in time to initiating the 3 critical actions. Change in time was analyzed by comparison of Kaplan-Meier curves, using the log-rank test. A 10% sample was timed by a second rater. Agreement was assessed using intraclass correlation (ICC).
Results
There was a statistically significant reduction in time for all 3 critical actions between baseline and 3-month evaluation in the early intervention group; this was not observed in the late (control) group. Rater agreement was excellent (ICC ≥ 0.99).
Conclusions
A simulation-based educational intervention significantly reduced time to initiation of CPR for first-year pediatrics residents. Simulation training facilitated acquisition of critical CPR skills that have the potential to impact patient outcome.
doi:10.4300/JGME-D-12-00343.1
PMCID: PMC3886460  PMID: 24455010
21.  Effect of Resident Evaluations of Obstetrics and Gynecology Faculty on Promotion 
Background
Promotion for academic faculty depends on a variety of factors, including their research, publications, national leadership, and quality of their teaching.
Objective
We sought to determine the importance of resident evaluations of faculty for promotion in obstetrics-gynecology programs.
Methods
A 28-item questionnaire was developed and distributed to 185 department chairs of US obstetrics-gynecology residency programs.
Results
Fifty percent (93 of 185) responded, with 40% (37 of 93) stating that teaching has become more important for promotion in the past 10 years. When faculty are being considered for promotion, teaching evaluations were deemed “very important” 60% of the time for clinician track faculty but were rated as mainly “not important” or “not applicable” for research faculty. Sixteen respondents (17%) stated a faculty member had failed to achieve promotion in the past 5 years because of poor teaching evaluations. Positive teaching evaluations outweighed low publication numbers for clinical faculty 24% of the time, compared with 5% for research faculty and 8% for tenured faculty being considered for promotion. The most common reason for rejection for promotion in all tracks was the number of publications. Awards for excellence in teaching improved chances of promotion.
Conclusions
Teaching quality is becoming more important in academic obstetrics-gynecology departments, especially for clinical faculty. Although in most institutions promotion is not achieved without adequate research and publications, the importance of teaching excellence is obvious, with 1 of 6 (17%) departments reporting a promotion had been denied due to poor teaching evaluations.
doi:10.4300/JGME-D-13-00002.1
PMCID: PMC3886461  PMID: 24455011
22.  The Surgical Residency Baby Boom: Changing Patterns of Childbearing During Residency Over a 30-Year Span 
Background
Birthrates during surgical residency appear to be rising. One assumption is that this is due to changes in the structure of surgical residencies.
Objective
The purpose of our study was to explore whether an increase in birthrates has occurred and the reasons for this.
Methods
We conducted an anonymous survey of current residents and alumni from 1976 to 2009 at a single university-based surgery training program.
Results
Alumni (46 of 116) and current residents (38 of 51) were surveyed, and our response rate was approximately 50% (84 of 167). Respondents were grouped into cohorts based on their residency start year. The early cohort consisted of residents starting residency between 1976 and 1999, and the late cohort consisted of residents starting residency between 2000 and 2009. The percentage of male residents with children during residency training was similar for the early and late cohorts (34% [10 of 29] versus 41% [9 of 22]). For female residents, there was a substantial increase in childbearing for the late cohort (7% [1 of 15] versus 35% [6 of 18]). Fifty-two percent (44 of 84) of the respondents who had children during residency reported that work hours and schedule had a negative effect on their decision to have children. Most respondents reported that availability or cost of child care, impact on residency, support from the program, increased length of training, or availability of family leave did not factor as concerns.
Conclusions
Childbearing during residency has increased in female residents in our study. Surgical residency programs may need to accommodate this change if they want to continue to recruit and retain talented residents.
doi:10.4300/JGME-D-12-00334.1
PMCID: PMC3886462  PMID: 24455012
23.  Accuracy of Residents' Retrospective Perceptions of 16-Hour Call Admitting Shift Compliance and Characteristics 
Background
The Accreditation Council for Graduate Medical Education Resident-Fellow Survey measurement of compliance with duty hours uses remote retrospective resident report, the accuracy of which has not been studied. We investigated residents' remote recall of 16-hour call-shift compliance and workload characteristics at 1 institution.
Methods
We sent daily surveys to second- and third-year internal medicine residents immediately after call shifts from July 2011 to June 2012 to assess compliance with 16-hour shift length and workload characteristics. In June 2012, we sent a survey with identical items to assess residents' retrospective perceptions of their call-shift compliance and workload characteristics over the preceding year. We used linear models to compare on-call data to residents' retrospective data.
Results
We received a survey response from residents after 497 of 648 call-shifts (77% response). The end-of-year perceptions survey was completed by 87 of 95 residents (92%). Compared with on-call data, the recollections of 5 (6%) residents were accurate; however, 48 (56%) underestimated and 33 (38%) overestimated compliance with the 16-hour shift length requirement. The average magnitude of under- and overestimation was 18% (95% confidence interval  =  13–23). Using a greater than 10% absolute difference to define under- and overestimation, 39 (45%) respondents were found to be accurate, 27 (31%) underestimated compliance, and 20 (23%) overestimated compliance. Residents overestimated census size, long call admissions, and admissions after 5 pm.
Conclusions
Internal medicine residents' remote retrospective reporting of compliance with the 16-hour limit on continuous duty and workload characteristics was inaccurate compared with their immediate recall and included errors of underestimation and overestimation.
doi:10.4300/JGME-D-12-00311.1
PMCID: PMC3886463  PMID: 24455013
24.  Napping on the Night Shift: A Study of Sleep, Performance, and Learning in Physicians-in-Training 
Background
Physicians in training experience fatigue from sleep loss, high workload, and working at an adverse phase of the circadian rhythm, which collectively degrades task performance and the ability to learn and remember. To minimize fatigue and sustain performance, learning, and memory, humans generally need 7 to 8 hours of sleep in every 24-hour period.
Methods
In a naturalistic, within-subjects design, we studied 17 first- and second-year internal medicine residents working in a tertiary care medical center, rotating between day shift and night float every 4 weeks. We studied each resident for 2 weeks while he/she worked the day shift and for 2 weeks while he/she worked the night float, objectively measuring sleep by wrist actigraphy, vigilance by the Psychomotor Vigilance Task test, and visual-spatial and verbal learning and memory by the Brief Visuospatial Memory Test-Revised and the Rey Auditory-Verbal Learning Test.
Results
Residents, whether working day shift or night float, slept approximately 7 hours in every 24-hour period. Residents, when working day shift, consolidated their sleep into 1 main sleep period at night. Residents working night float split their sleep, supplementing their truncated daytime sleep with nighttime on-duty naps. There was no difference in vigilance or learning and memory, whether residents worked day shift or night float.
Conclusions
Off-duty sleep supplemented with naps while on duty appears to be an effective strategy for sustaining vigilance, learning, and memory when working night float.
doi:10.4300/JGME-D-12-00324.1
PMCID: PMC3886464  PMID: 24455014
25.  A Longitudinal Career-Focused Block for Third-Year Pediatrics Residents 
Background
The traditional 1-month training blocks in pediatrics may fail to provide sufficient exposure to develop the knowledge, skills, and attitudes residents need for practice and may not be conducive to mentoring relationships with faculty and continuity with patients.
Intervention
We created a 4-month career-focused experience (CFE) for third-year residents. The CFE included block time and longitudinal experiences in different content areas related to residents' choice of urban and rural primary care, hospitalist medicine, or subspecialty care (prefellowship). Content was informed by graduate surveys, focus groups with primary care pediatricians and hospitalists, and interviews with fellowship directors. Outcomes were assessed via before and after surveys of residents' attitudes and skills, assessment of skills with an objective structured clinical examination (OSCE), and interviews with residents and mentors.
Results
Twenty-three of 49 third-year residents took part in the first 2 years of CFE. Two residents dropped out, leaving 21 who completed the 4-month experience (9 in primary care, 2 in hospitalist medicine, and 10 in a subspecialty). Residents reported improvement in their clinical skills, increased satisfaction with faculty mentoring and evaluation, and the ability to focus on what was important to their careers. OSCE performance did not differ between residents who completed the CFE and those who did not. Administrative burden was high.
Conclusions
Four-month career-focused training for pediatrics residents is feasible and may be effective in meeting part of the new requirement for 6 months of career-focused training during pediatrics residency.
doi:10.4300/JGME-D-12-00340.1
PMCID: PMC3886465  PMID: 24455015

Results 1-25 (633)