Mentorship is critical to the professional success of physicians, physicians-in-training, and junior faculty in academic practice. There are challenges to being a thoughtful and effective mentor and to being an engaged mentee. Many physicians and physicians-in-training cite difficulty finding professional time to dedicate to building their mentoring relationships, particularly given demanding clinical workloads and competing time commitments. Therefore, making the most out of the time in mentoring relationships is key to success. We present a collection of frustrations and good advice that have been passed between mentees and mentors on improving the mentor-mentee relationship. The information was compiled from actual interactions between mentors and mentees, and these “love letters” draw on complex associations, which like any “committed” relationship require constant reevaluation and discussion to bring them to their full potential.
We explore the history behind the current structure of graduate medical education funding and the problems with continuing along the current funding path. We then offer suggestions for change that could potentially manage this health care spill. Some of these changes include attracting more students into primary care, aligning federal graduate medical education spending with future workforce needs, and training physicians with skills they will require to practice in systems of the future.
The purpose of this study is to systematically review the literature on the prevalence of patient assaults against residents in all specialties, and to identify curricula that address this issue.
The authors searched published English-language literature using PubMed and Scopus databases using key terms including “patient,” “assaults,” “threats,” “violence,” “aggression,” and “residents.” A separate search to identify curricula used the same terms in combination with key words including “curriculum,” “didactics,” and “course.” Bibliographies of studies found by electronic searches were also searched manually.
Fifteen studies met the inclusion criteria. Of these, 7 were conducted on psychiatry residents alone, 6 assessed assaults on residents in nonpsychiatric specialties, and 2 reported cross-specialty data. The prevalence of assaults was defined as the percentage of residents who have experienced at least one assault. The prevalence of physical assaults on residents was 38% in surgery, 26% in emergency medicine, 16% to 40% in internal medicine, 5% to 9% in pediatrics, and 25% to 64% in psychiatry. All studies were cross-sectional; none collected data prospectively. Definitions of assault were heterogeneous or not specified. Few of the assaults were reported to clinical supervisors or training directors, and no programs had a formal reporting process. Approximately 21% to 79% of psychiatry residents and 30% of residents in other specialties had received some training on how to manage violent patients. We found no descriptions of formal curricula for managing the possibility of patient violence against residents or for preparing for the aftermath.
Although the data are limited, assaults by patients are commonly experienced by residents in training. There is a paucity of information and curricula that pertain to reducing the prevalence of these incidents and to addressing potential psychologic consequences, especially in nonpsychiatric specialties.
Global health is an expansive field, and global health careers are as diverse as the practice of medicine, with new paths being forged every year. Interest in global health among medical students, residents, and fellows has never been higher. As a result, a greater number of these physicians-in-training are participating in global health electives during their training. However, there is a gap between the level of trainee interest and the breadth and depth of educational opportunities that prepare them for a career in global health.
Global health experiences can complement and enhance each step of traditional physician training, from medical school through residency and fellowship. Global health experiences can expose trainees to patients with diverse pathologies, improve physical exam skills by decreasing reliance on laboratory tests and imaging, enhance awareness of costs and resource allocation in resource-poor settings, and foster cultural sensitivity. The aim of this article is to describe issues faced by physicians-in-training and the faculty who mentor them as trainees pursue careers in global health.
We conducted a narrative review that addresses opportunities and challenges, competing demands on learners' educational schedules, and the need for professional development for faculty mentors.
A widening gap between trainee interest and the available educational opportunities in global health may result in many medical students and residents participating in global health experiences without adequate preparation and mentorship. Without this essential support, global health training experiences may have detrimental consequences on both trainees and the communities hosting them. We discuss considerations at each training level, options for additional training, current career models in global health, and challenges and potential solutions during training and early career development.
The clinical work in academic internal medicine inpatient units is done by teaching teams. To date, few studies have investigated how team workload affects patient safety outcomes.
We examined the association between the number of patients seen by a teaching team, 30-day readmission, and 60-day mortality.
In this retrospective observational study we defined each team as “less busy” (total monthly admissions ≤49, the median for all teams) or “more busy” (total monthly admissions >49). We compared patients in both groups' demographic characteristics, comorbidities (Charlson score), severity of illness (the Laboratory-based Acute Physiology Score [LAPS]), and length of stay using t tests, χ2 tests, and rank sum tests, as appropriate. Logistic regression models were constructed to determine whether there was an association between assignment to a busy team and readmission and mortality.
Of 12 119 admissions examined, 6398 (52.8%) were assigned to the less busy teams and 5721 (47.2%) were assigned to busy teams. Mean length of stay was not statistically different between the groups (5.2 vs 5.3 days; P = .08). After adjustment for demographic and clinical characteristics (LAPS and Charlson score), care by a busy team was associated with greater 30-day readmission rate (odds ratio, 1.21; 95% confidence interval [CI], 1.10–1.34) but not with increased risk of mortality (odds ratio, 1.05; 95% CI, 0.88–1.27). There was a significant linear association between the number of monthly admissions to teams and the readmission rate.
Admission to a busier teaching team is associated with a 21% increase in the odds of 30-day readmission. Sixty-day mortality was not affected by the number of monthly admissions to the teaching team.
Real-time assessment of operator performance during procedural simulation is a common practice that requires undivided attention by 1 or more reviewers, potentially over many repetitions of the same case.
To determine whether reviewers display better interrater agreement of procedural competency when observing recorded, rather than live, performance; and to develop an assessment tool for pediatric rapid sequence intubation (pRSI).
A framework of a previously established Objective Structured Assessment of Technical Skills (OSATS) tool was modified for pRSI. Emergency medicine residents (postgraduate year 1–4) were prospectively enrolled in a pRSI simulation scenario and evaluated by 2 live raters using the modified tool. Sessions were videotaped and reviewed by the same raters at least 4 months later. Raters were blinded to their initial rating. Interrater agreement was determined by using the Krippendorff generalized concordance method.
Overall interrater agreement for live review was 0.75 (95% confidence interval [CI], 0.72–0.78) and for video was 0.79 (95% CI, 0.73–0.82). Live review was significantly superior to video review in only 1 of the OSATS domains (Preparation) and was equivalent in the other domains. Intrarater agreement between the live and video evaluation was very good, greater than 0.75 for all raters, with a mean of 0.81 (95% CI, 0.76–0.85).
The modified OSATS assessment tool demonstrated some evidence of validity in discriminating among levels of resident experience and high interreviewer reliability. With this tool, intrareviewer reliability was high between live and 4-months' delayed video review of the simulated procedure, which supports feasibility of delayed video review in resident assessment.
The Accreditation Council for Graduate Medical Education requirements recommend using outside measures to perform annual residency program evaluations to identify areas for program improvement.
The aim of the study was to identify areas for residency program improvement via an alumni survey.
An anonymous online survey was sent to the last 10 years of graduates from our obstetrics and gynecology residency program.
Response rate was 63% (34 of 54). All respondents reported being comfortable serving as gynecologic consultants. More than 75% (26 of 54) reported being comfortable performing abdominal hysterectomies, vaginal hysterectomies, basic and complex laparoscopies, and vaginal surgery. Regarding management of urologic injuries, the participants' responses varied, with 58% (20 of 34) reporting they felt prepared, 21% (7 of 34) with neutral responses, and 21% (7 of 34) reporting they felt unprepared. For total laparoscopic hysterectomy, 65% (22 of 34) reported feeling prepared, 29% (10 of 34) reported they felt unprepared, and 9% (3 of 34) reported they felt neutral. All respondents indicated that he or she would still choose the obstetrics and gynecology residency program at the University of Michigan.
An alumni survey can provide useful outside measures for training programs to assess their effectiveness in preparing their graduates for independent practice. Results of alumni surveys can provide a blueprint for program improvement.
Providing high-quality teaching to residents during attending rounds is challenging. Reasons include structural factors that affect rounds, which are beyond the attending's teaching style and control.
To develop a new evaluation tool to identify the structural components of ward rounds that most affect teaching quality in an internal medicine (IM) residency program.
The authors developed a 10-item Ecological Momentary Assessment (EMA) tool and collected daily evaluations for 18 months from IM residents rotating on inpatient services. Residents ranked the quality of teaching on rounds that day, and questions related to their service (general medicine, medical intensive care unit, and subspecialty services), patient census, absenteeism of team members, call status, and number of teaching methods used by the attending.
Residents completed 488 evaluation cards over 18 months. This found no association between perceived teaching quality and training level, team absenteeism, and call status. We observed differences by service (P < .001) and patient census (P = .009). After adjusting for type of service, census was no longer significant. Use of a larger variety of teaching methods was associated with higher perceived teaching quality, regardless of service or census (P for trend < .001).
The EMA tool successfully identified that higher patient census was associated with lower perceived teaching quality, but the results were also influenced by the type of teaching service. We found that, regardless of census or teaching service, attendings can improve their teaching by diversifying the number of methods used in daily rounds.
Development of surgical skills is an integral component of residency education in obstetrics and gynecology.
We report data from a supervised, deliberate, dry lab practice in hysteroscopy for junior obstetrics-gynecology residents, undertaken to evaluate whether simulation training improved hysteroscopy performance to a skill level similar to that of senior residents.
A prospective, comparative, multicenter trial compared Objective Structured Assessment Of Technical Skills (OSATS) performance of 2 groups: 19 postgraduate year (PGY)-1 and PGY-2 and 18 PGY-3 and PGY-4 Ob-Gyn residents. PGY-1 and PGY-2 participants underwent 4 sessions of brief, deliberate, focused training in hysteroscope assembly and operative hysteroscopic polypectomy using uterine models. Subsequently, all participants completed a simulated hysteroscopic polypectomy OSATS, and procedure times and structured assessment scores were compared among groups.
PGY-1 and PGY-2 residents who had completed OSATS training performed at or above the level of untrained PGY-3 and PGY-4 residents. Junior residents had better assembly times and scores, resection scores, and global skills scores (P < .05). Resection times did not differ between groups but differed among institutions.
Brief, hands-on training sessions, which were task-specific and repetitive facilitated short-term gains in learning operative hysteroscopy and increased the dry lab skill level of junior residents compared to that of senior residents. This curriculum was effectively implemented at 3 institutions and generated comparable results, suggesting generalizability.
Residency networks, comprising groups of residency programs organized as collaborative ventures or consortia, have existed in the United States for more than 30 years. At the same time, there have been no comparative assessments of their structures and functions.
We conducted a survey of residency networks to assess their organizational structures and activities.
We identified 9 residency networks and designed a survey to specifically assess their organizational structures and activities. This survey was sent electronically to network leadership and all respective program directors in each residency network. The survey contained 6 areas of focus: (1) network history and administration; (2) network funding; (3) resource sharing and communication within the network; (4) network activities; (5) research within the network; and (6) strengths and weaknesses of the network.
Of the 9 networks, 5 provided data, with 32 of a possible 51 residency programs (62.8%) responding. Respondents reported predominantly functioning as affiliated networks (76.3%) rather than collaborative ventures or consortia. The networks have a variety of funding streams and share resources.
A major function of residency networks is the sharing of resources, particularly in the area of faculty development, with 97.1% of respondents sharing faculty development resources. In addition, all residency networks were actively involved in research, and they participated in political advocacy and in enhancing the engagement of medical students. Networks have been successful at obtaining grants to support their infrastructure.
Discrepancies exist between what resident and attending physicians perceive as adequate supervision. We documented current practices in a university-based, categoric, internal medicine residency to characterize these discrepancies and the types of mixed messages that are communicated to residents, as well as to assess their potential effect on resident supervision and patient safety.
We surveyed residents and attending physicians separately about their current attitudes and behaviors regarding resident supervision. Both groups responded to 2 different measures of resident supervision: (1) 6 clinical vignettes that involved patient safety concerns, and (2) 9 frequently reported phrases communicated by attending physicians to residents before leaving the hospital during on-call admission days.
There were clear and substantial differences between the perceptions of resident and attending physicians about when the supervising attending physician should be notified in each of the 6 vignettes. For example, 85% of attending physicians reported they wanted to be notified of an unexpected pneumothorax that required chest tube placement, but only 31% of resident physicians said they would call their attending physician during those circumstances. Common phrases, such as “page me if you need me,” resulted in approximately 50% of residents reporting they would “rarely” or “never” call and another 41% reporting they would only “sometimes” call their attending physicians.
Our study found that attending physicians reported they would want more frequent communication and closer supervision than routinely perceived by resident physicians. Although this discrepancy exists, commonly used phrases, such as “page me if you need me,” rarely resulted in a change in resident behavior, and attending physicians appeared to be aware of the ineffectiveness of these statements. These mixed messages may increase the difficulty of balancing the dual goals of appropriate attending supervision and progressive independence during residency training.
Obstetrics and gynecology residents benefit from providing care to diverse patient populations and increasing their awareness of the social determinants of health.
To describe and evaluate an outpatient rotation for obstetrics and gynecology residents at a county jail.
A comprehensive curriculum incorporating Accreditation Council for Graduate Medical Education (ACGME) core competencies was designed for all first-year residents to rotate weekly at the local county jail during their 6-week ambulatory care block. Residents completed an anonymous online evaluation and wrote a reflective essay at the end of the rotation. Data for patient visits were tabulated.
All 9 first-year residents completed the rotation and the evaluation. Seventy-eight percent of patient visits were for gynecologic services, predominantly family planning. Residents reported that the rotation overall was a positive experience, emphasizing the unique intersection between psychosocial issues and health care in the jail setting. Rotation objectives that satisfied the 6 ACGME competencies were met.
Providing care to incarcerated women through a structured curriculum is a novel way to encourage obstetrics and gynecology residents to consider the social determinants of health and for residents to cultivate their counseling skills. The rotation also included a wide breadth and depth of clinical diagnoses and procedures. Obstetrics and gynecology residency programs should consider a curriculum in reproductive health for incarcerated women.
Preparing health care professionals for challenging communication tasks such as delivering bad news to patients and families is an area where a need for improved teaching has been identified.
We developed a simulation-based curriculum to enhance the skills of health care professionals, with an emphasis on the communication of difficult or bad news, which we termed relational crises.
Our approach was based on a review of existing simulation-based curricula, with the addition of unique features, including a learner-focused needs assessment to shape curriculum development, use of 360-degree evaluations, and provision of written feedback. Development and implementation of our curriculum occurred in 3 phases. Phase I involved a multidisciplinary needs assessment, creation of a clinical scenario based on needs assessment results, and training of standardized patients. In Phase II we implemented the curriculum with 36 pediatric and internal medicine-pediatrics residents, 20 nurses, and 1 chaplain. Phase III consisted of the provision of written feedback for learners, created from the 360-degree evaluations compiled from participants, observers, faculty, and standardized patients.
Participants felt the scenarios were realistic (average rating of 4.7 on a 5-point Likert scale) and improved their practice and preparedness for these situations (average rating, 4.75/5 and 4.18/5, respectively). Our curriculum produced a statistically significant change in participants' pre- and postcurriculum self-reported perceptions of skill (2.42/5 vs. 3.23/5, respectively, P < .001) and level of preparedness (2.91/5 vs. 3.72/5, respectively, P < .001).
A simulation-based curriculum using standardized patients, learner-identified needs, 360-degree evaluations, and written feedback demonstrated a statistically significant change in participants' self-perceived skills and preparedness for communicating difficult news in pediatrics.
Despite the importance of lifestyle change in disease management and the growing evidence supporting motivational interviewing (MI) as an effective counseling method to promote behavioral change, to date there are few published reports about MI training in graduate medical education.
The study aimed to pilot the feasibility and effectiveness of a brief MI training intervention for endocrinology fellows and other providers.
We used a pretest/posttest design to evaluate a brief MI training for 5 endocrinology fellows and 9 other providers. All participants completed subjective assessments of perceived confidence and beliefs about behavioral counseling at pretest and posttest. Objective assessment of MI was conducted using fellows' audiotaped patient encounters, which were coded using a validated tool for adherence to MI before and after the training. Paired t tests examined changes in objective and subjective assessments.
The training intervention was well received and feasible in the endocrinology setting. At posttest, participants reported increased endorsement of the MI spirit and improved confidence in MI skills. Objective assessment revealed relative improvements in MI skills across several domains. However, most domains, as assessed by a validated tool, did not reach competency level after the training intervention.
Although more intensive training may be needed to develop MI competence, the results of our pilot study suggest that brief, targeted MI training has short-term efficacy and is well received by endocrinology fellows and other providers.
Women in medicine report many gender-specific barriers to their career success and satisfaction, including a lack of mentors and role models. The literature calls for innovative strategies to enhance mentorship for women in medicine.
To describe the content, perceived value, and ongoing achievements of a mentoring program for women in emergency medicine.
The program offered mentoring for female faculty and residents in an academic emergency medicine department. Volunteers participated in group mentoring sessions using a mosaic of vertical and peer mentoring. Sessions focused on topics specific to women in medicine. An anonymous, electronic survey was sent to women who participated during 2004–2010 to assess the perceived value of the program and to collect qualitative feedback. Preliminary achievements fulfilling the program's goals were tracked.
A total of 46 women (64%) completed the survey. The results showed a positive perceived value of the program (average, 4.65 on a 5-point Likert scale) in providing mentors and role models (4.41), in offering a supportive environment (4.39), in providing discussions pertinent to both personal (4.22) and professional development (4.22), while expanding networking opportunities (4.07). Notable achievements included work on the creation of a family leave policy, establishing lactation space, collaboration on projects, awards, and academic advancement.
This innovative model for mentoring women is perceived as a valuable asset to the academic department and residency. It offers the unique combination of expanding a female mentor pool by recruiting alumni and using a mosaic of vertical and peer mentoring.
Postpartum hemorrhage is a major cause of maternal morbidity and mortality throughout the world and uterine atony is the leading cause of postpartum hemorrhage. The B-Lynch brace suture is a fertility-sparing approach to treating intractable uterine atony at the time of cesarean delivery. However, many obstetricians lack confidence to perform this procedure, which they may not have performed during residency. In order to train all residents to perform the B-Lynch brace suture, we developed a realistic model by using a flank steak to imitate a gravid uterus.
A convenience sample of obstetrics-gynecology faculty and residents at different levels of training at a single large hospital participated in this pilot project. Each physician reported self-perceived understanding of and confidence in performing the B-Lynch procedure before and immediately after practicing the technique using the flank-steak model, via a Likert-type survey (scale 1 = low, 5 = high). A Wilcoxon matched-pairs signed rank test was used to compare the before and after responses.
Thirty-four participants completed the flank-steak model training and pretraining/posttraining surveys. The median score (range) for self-perceived understanding was 4 (2–5) and increased to 5 (4–5) (P < .01) after exposure to the training model. The confidence scores rose from 3 (1–5) to 5 (4–5) (P < .01) after training.
The flank-steak model for teaching the B-Lynch suture significantly improved resident and faculty self-perceived understanding of and confidence in performing this procedure, which is otherwise rarely practiced in residency.
To date, no standardized presentation format is taught to emergency medicine (EM) residents during patient handoffs to consulting or admitting physicians. The Situation-Background-Assessment-Recommendation (SBAR) is a common format that provides a consistent framework to communicate pertinent information.
The objective of this study was to describe and evaluate the feasibility of using SBAR to teach interphysician communication skills to first-year EM residents to use during patient handoffs.
An educational study was designed as part of a pilot curriculum to teach first-year EM residents handoff communication skills. A standardized SBAR reporting format was taught during a 1-hour didactic intervention. All residents were evaluated using pretest/posttest simulated cases using a 17-item SBAR checklist initially, and then within 4 months to assess retention of the tool. A survey was distributed to determine resident perceptions of the training and potential clinical utility.
There was a statistically significant improvement from the resident scores on the pretest/posttest of the first case (P = .001), but there was no difference between posttest of the first case and pretest of the second case (P = .34), suggesting retention of the material. There was a statistically significant improvement from the pretest and posttest scores on the second case (P = .001). The survey yielded good reliability for both sessions (Cronbach alpha = 0.87 and 0.89, respectively), demonstrating statistically significant increases for the perceived quality of training, presentation comfort level, and the use of SBAR (P = .001).
SBAR was acceptable to first-year EM residents, with improvements in both the ability to apply SBAR to simulated case presentations and retention at a follow-up session. This format was feasible to use as a training method and was well received by our resident physicians. Future research will be useful in examining the general applicability of the SBAR model for interphysician communications in the clinical environment and residency training programs.
Residents provide a significant amount of bedside teaching to medical students and more junior colleagues, but often do not receive feedback that is tailored to this aspect of their professional performance.
To assess residents' self-reported improvement in teaching skills after feedback based on direct observation of work rounds.
The authors initiated a program of direct observation of residents' teaching during work rounds during the academic year 2007–2008. Eleven interested faculty volunteers, including chief residents, observed teaching on work rounds by 18 second-year residents in internal medicine during 35 total encounters. Within 24 hours, the faculty observers provided individualized feedback to the resident teachers regarding the quantity and quality of their teaching based on the data collected with the Teaching on Work Rounds observation form. At the end of the year, a survey was conducted to assess the residents' receptivity to this program.
Each observation averaged 92 minutes per observer, for 81.5 recorded hours of observations. Eighty percent of the residents felt that they were better teachers because of the feedback they received, and 87% subsequently reported having made conscious changes in their teaching during work rounds.
A direct observation program of residents' teaching on work rounds improved residents' interest in teaching while motivating them to make conscious changes in their teaching based on the individualized feedback they received.
The annual American Board of Emergency Medicine (ABEM) in-training examination is a tool to assess resident progress and knowledge. We implemented a course at the New York-Presbyterian Emergency Medicine Residency Program to improve ABEM scores and evaluate its effect. Previously, the examination was not emphasized and resident performance was lower than expected.
As an adjunct to required weekly residency conferences, an intensive 14-week in-training examination preparation program was developed that included lectures, pre-tests, high-yield study sheets, and a remediation program. We compared each residents in-training examination score to the postgraduate year-matched national mean. Scores before and after course implementation were evaluated by repeat measures regression modeling. Residency performance was evaluated by comparing residency average to the national average each year and by tracking ABEM national written examination pass rates.
Following the course's introduction, odds of a resident scoring higher than the national average increased by 3.9 (95% CI 1.9-7.3) and percentage of residents exceeding the national average increased by 37% (95% CI 23%-52%). In the time since the course was started the overall residency mean score has outperformed the national average and the first-time ABEM written examination board pass rate has been 100%.
A multifaceted residency-wide examination curriculum focused around an intensive 14-week course was associated with marked improvement on the in-training examination.