Gurjit Sandhu

Progressive Entrustment to Achieve Resident Autonomy in the Operating Room: A National Qualitative Study With General Surgery Faculty and Residents.

Objective: The purpose of this study was to identify behaviors that faculty and residents exhibit during intraoperative interactions, which support or inhibit progressive entrustment leading to operative autonomy. Background: In the operating room, a critical balance is sought between direct faculty supervision and appropriate increase in resident autonomy with indirect faculty supervision. Little is known regarding perspectives of faculty and residents about how attendings increasingly step back and safely delegate autonomy to trainees. Understanding the context in which these decisions are made is critical to achieving a safe strategy for imparting progressive responsibility. Methods: A qualitative study was undertaken from January 2014 to February 2015. Semistructured interviews were conducted with 37 faculty and 59 residents from 14 and 41 institutions, respectively. Participants were selected using stratified random sampling from general surgery residency programs across the United States to represent a range of university, university-affiliated, and community programs, and geographic regions. Audio recordings of interviews were transcribed, iteratively analyzed, and emergent themes identified. Results: Six themes were identified as influencing progressive entrustment in the operating room: optimizing faculty intraoperative feedback; policies and regulations affecting role of resident in the operating room; flexible faculty teaching strategies; context-specific variables; leadership opportunities for resident in the case; and safe struggle for resident when appropriate. Conclusions: Perspectives of faculty and residents while overlapping were different in emphasis. Better understanding faculty–resident interactions, individual behaviors, contextual influences, and national regulations that influence intraoperative education have the potential to significantly affect progressive entrustment in training paradigms.

Training autonomous surgeons: more time or faculty development?

I t is of growing concern that residents are not prepared for independent practice upon completion of General Surgery training.1–6 Changes in duty hours and marked increased stringency in supervision standards has correlated with an increased failure rate on the certifying examination administered by the American Board of Surgery.7 When considering this current climate, Dr Frank R. Lewis, executive director of the American Board of Surgery, recently espoused a personal opinion that all residents should complete a fellowship following General Surgery residency to ensure that they are prepared for autonomous practice.6 Dr Lewis points to resident duty-hour restrictions as a major factor that has carved away approximately 2400 to 4800 hours of residency experiences, which equates to a loss of 6 to 12 months of training.6 In recognition of the issues of lost opportunities for graduated responsibility for surgical residents, the American Board of Surgery also recently added a requirement for a minimum of 25 teaching cases by graduating surgical residents as a proxy for some level of autonomy during training. At the present time, greater than 80% of graduating residents already complete a subspecialty fellowship program,8 but fellowship directors have also expressed frustration with the lack of readiness on arrival to fellowship to focus on the subspecialty content of the fellowship.1 The American College of Surgeons recently developed a postgraduate apprenticeship model of additional training for General Surgeons; however, it is too soon to determine if these “finishing programs” will gain traction with the 15% to 20% of General Surgery residents not currently pursuing subspecialty training. Although fellowships and additional time in training are likely an essential consideration, as we work toward a solution to this critical problem, we need to be cautious that we do not assume that simply adding additional time to training will address this emerging deficiency, and we must carefully examine the true root causes that have led to a lack of preparation for independent practice. It is certainly easy to point to the reduction of duty hours as a reason for the reduced experience and confidence of General Surgery residents upon graduation; however, we believe the problem is much more complex. Specifically, the degree of autonomy surgical residents experience in the operating room has significantly decreased over time due to many factors. These include, but are not limited to, duty-hour restrictions; increasing regulations that mandate more attending surgeon involvement and greater direct observation of residents; increased pressure on faculty surgeons to do more operations in less time; and more defined specialties within General Surgery— resulting in residents having exposure to numerous disciplines, but with little time to develop or demonstrate depth of ability with any

OpTrust: Validity of a Tool Assessing Intraoperative Entrustment Behaviors

Objective: The aim of this study is to establish evidence to support the validity of a novel faculty-resident intraoperative assessment tool for entrustment known as OpTrust. Background: Recently, the landscape of surgical training has been altered, in part, because of resident work-hour changes and increased supervision requirements. To address these concerns, a new model for assessment of teaching and learning in surgical residencies must be anchored on progression through milestones and entrustment. Methods: OpTrust was designed to assess the faculty-resident dyad in the operating room and measure the entrustment exhibited during intraoperative interactions across 5 domains: (i) types of questions asked, (ii) operative plan, (iii) instruction, (iv) problem solving, and (v) leadership by the surgical resident. After initial pilot testing and refinement of OpTrust, 5 individual raters underwent rater training sessions; 49 individual operating room observations were completed based on 28 cases. Results: OpTrust, as a tool for assessing intraoperative entrustment, is supported by strong validity evidence. In part, it demonstrates strong interrater reliability across all faculty domains as measured by intraclass correlation 1 (ICC1) (0.81–0.93). For resident domains the results were similar with ICC1 (0.84–0.94). Cronbach alpha was 0.89 and 0.87 for faculty and resident entrustment respectively, signifying the 5 domains could be combined into a single construct of entrustment. A high correlation existed between faculty and resident scores (Pearson r = 0.94, P < 0.001) indicating a strong positive linear relationship between faculty and resident mean entrustment scores across all scale domains. Conclusions: OpTrust successfully assesses behaviors associated with entrustment during intraoperative faculty-resident interactions, and has the potential to be adopted across other procedural-based specialties to promote autonomous training progression.

AIDER: A model for social accountability in medical education and practice

Background: Social accountability in healthcare requires physicians and medical institutions to direct their research, services and education activities to adequately address health inequities. The need for greater social accountability has been addressed in numerous national and international healthcare reviews of health disparities and medical education. Aim: The aim of this work is to better understand how to identify underserved populations and address their specific needs and also to provide physicians and medical institutions with a means by which to cultivate social accountability. Methods: The authors reviewed existing literature and prominent models focusing on social accountability, as well as medical education frameworks, and identified the need to engage underserved stakeholders and incorporate education that includes knowledge translation and reciprocity. The AIDER model was developed to satisfy the need in medical education and practice that is not explicitly addressed in previous models. Results: The AIDER model (Assess, Inquire, Deliver, Educate, Respond) is a continuous monitoring process that explicitly incorporates reciprocal education and continuous collaboration with underserved stakeholders. Conclusion: This model is an incremental step forward in helping physicians and medical institutions foster a culture of social accountability both in individual practice and throughout the continuum of medical education.

Using the ACMGE Milestones as a Handover Tool From Medical School to Surgery Residency

OBJECTIVE To map current medical school assessments for graduating students to the Accreditation Council for Graduate Medical Education (ACGME) milestones in general surgery, and to pass forward individual performance metrics on level 1 milestones to receiving residency programs. DESIGN The study included 20 senior medical students who were accepted into surgery internship positions. Data from medical school performance assessments from the third-year surgery clerkship, fourth-year surgery rotations, fourth-year surgery boot camp, Clinical Competency Assessment Examination, and United States Medical Licensing Examination (USMLE) Step 1 and 2 examinations were used to map each students competency assessments to the General Surgery Milestones based on a scoring system created and validated by independent assessors. This Milestones Assessment was then provided to each students receiving program director. SETTING The study was conducted at the University of Michigan Medical School, in Ann Arbor, Michigan. PARTICIPANTS Fourth-year medical students entering into surgical internship. RESULTS Of 16 Accreditation Council for Graduate Medical Education (ACGME) General Surgery Milestones subcompetencies, 12 were able to be evaluated with current medical school assessments. Of the 20 students, 11 met criteria for all the level 1 milestones and 9 needed improvement in at least 1 domain. CONCLUSIONS It was feasible to use medical school assessments to feed forward information about senior medical students on 12 of the 16 General Surgery Milestones subcompetency domains.

Association of Faculty Entrustment With Resident Autonomy in the Operating Room

Importance A critical balance is sought between faculty supervision, appropriate resident autonomy, and patient safety in the operating room. Variability in the release of supervision during surgery represents a potential safety hazard to patients. A better understanding of intraoperative faculty-resident interactions is needed to determine what factors influence entrustment. Objective To assess faculty and resident intraoperative entrustment behaviors and to determine whether faculty behaviors drive resident entrustability in the operating room. Design, Setting, and Participants This observational study was conducted from September 1, 2015, to August 31, 2016, at Michigan Medicine, the University of Michigan’s health care system. Two surgical residents, 1 medical student, 2 behavioral research scientists, and 1 surgical faculty member observed surgical intraoperative interactions between faculty and residents in 117 cases involving 28 faculty and 35 residents and rated entrustment behaviors. Without intervening in the interaction, 1 or 2 researchers observed each case and noted behaviors, verbal and nonverbal communication, and interaction processes. Immediately after the case, observers completed an assessment using OpTrust, a validated tool designed to assess progressive entrustment in the operating room. Purposeful sampling was used to generate variation in type of operation, case difficulty, faculty-resident pairings, faculty experience, and resident training level. Main Outcomes and Measures Observer results in the form of entrustability scores (range, 1-4, with 4 indicating full entrustability) were compared with resident- and faculty-reported measures. Difficulty of operation was rated on a scale of 1 to 3 (higher scores indicate greater difficulty). Path analysis was used to explore direct and indirect effects of the predictors. Associations between resident entrustability and observation duration, observation month, and faculty entrustment scores were assessed by pairwise Pearson correlation coefficients. Results Twenty-eight faculty and 35 residents were observed across 117 surgical cases from 4 surgical specialties. Cases observed by postgraduate year (PGY) of residents were distributed as follows: PGY-1, 21 (18%); 2, 15 (13%); 3, 17 (15%); 4, 27 (23%); 5, 28 (24%); and 6, 9 (8%). Case difficulty was evenly distributed: 36 (33%) were rated easy/straightforward; 43 (40%), moderately difficult; and 29 (27%), very difficult by attending physicians. Path analysis showed that the association of PGY with resident entrustability was mediated by faculty entrustment (0.23 [.03]; P < .001). At the univariate level, case difficulty (mean [SD] resident entrustability score range, 1.97 [0.75] for easy/straightforward cases to 2.59 [0.82] for very difficult cases; F = 6.69; P = .01), PGY (range, 1.31 [0.28] for PGY-1 to 3.16 [0.54] for PGY-6; F = 22.85; P < .001), and faculty entrustment (2.27 [0.79]; R2 = 0.91; P < .001) were significantly associated with resident entrustability. Mean (SD) resident entrustability scores were highest for very difficult cases (2.59 [0.82]) and PGY-6 (3.16 [0.54]). Conclusions and Relevance Faculty entrustment behaviors may be the primary drivers of resident entrustability. Faculty entrustment is a feature of faculty surgeons’ teaching style and could be amenable to faculty development efforts.

Strategic questioning in surgical education

In the complex and nuanced world of surgical education, oneway teaching – often in the form of directives from the attending physician to the resident (i.e. from specialist to trainee) – is insuffi cient for understanding the needs of trainees and developing safe opportunities for learner advancement. We propose a novel learnercentred approach to intraoperative teaching using questioning that integrates: (1) Socratic questioning and (2) Bloom ’ s Taxonomy, which respectively incorporates wait time and progressively complex questioning to stimulate higherorder thinking. 1–4 As surgical faculty members, surgical residents and medical educators, we collaborate on this actionoriented initiative to enhance trainee education. The need for this multidimensional team approach has become particularly important in the context of educational time constraints, as a side effect of trainee workhour restrictions and the exponential growth in surgical innovations, interventions and technologies.

Assessment of clinical feedback given to medical students via an electronic feedback system

BACKGROUND The feedback medical students receive during clinical rotations, traditionally verbal and not formally captured, plays a critical role in student development. This study evaluates written daily feedback given to students through a novel web-based feedback system. METHODS A Minute Feedback System was used to collect feedback given to medical students during their surgery clerkship from May 2015-April 2016. Using qualitative content analysis, feedback comments were categorized as: encouraging, corrective, specific, and nonspecific. Effective feedback was a combination of specific and either corrective or encouraging feedback; ineffective feedback contained only nonspecific comments; mediocre feedback contained elements of both effective and ineffective comments. RESULTS 3191 feedback requests were sent by medical students and 2029 faculty/resident feedback responses were received. The overall response rate was 62%. Nonspecific feedback comprised 80% of faculty, 83% of senior resident, and 78% of junior resident comments. Specific feedback was given by only 35% of faculty, 17% of senior residents, and 26% of junior residents. Faculty provided Effective feedback in only 16% of comments, senior residents 8%, and junior residents 17%. Mediocre feedback comprised 13% of faculty, 9% of senior resident, and 7% of junior resident comments. Ineffective feedback comprised 67% of all feedback: 60% of faculty, 72% of senior resident, and 68% of junior resident feedback. CONCLUSIONS The majority of resident and faculty feedback to medical students using an electronic, email-based application during their surgery clerkship was nonspecific and encouraging and therefore of limited effectiveness. This presents an opportunity for resident/faculty development and education regarding optimal feedback techniques.

Intraoperative questioning to advance higher-order thinking

BACKGROUND The type of question asked elicits a particular response. The purpose of this study was to determine what types and levels of questions were asked in the operating room. These insights are important for understanding how questions are used to advance learners. METHODS 12 laparoscopic cholecystectomy operations were observed and recorded at a single institution. Intraoperative questions asked by faculty were transcribed for all cases. Using revised Blooms taxonomy, questions were classified into one of 5 levels: (1) remembering, (2) understanding, (3) applying, (4) analyzing, (5) evaluating. RESULTS 141 questions were asked by faculty and ranged from 0 to 34 questions per case. Classification of questions showed there were 43 remembering, 29 understanding, 47 applying, 13 analyzing, and 8 evaluating questions asked. CONCLUSIONS Questioning was predominately classified at lower-order and mid-level thinking skills (120/141). Integrating intraoperative questions at higher-order levels has the potential to guide trainees into progressively complex thinking and decision making.

Doctors of tomorrow: An innovative curriculum connecting underrepresented minority high school students to medical school

Background: Racial minorities continue to be underrepresented in medicine (URiM). Increasing provider diversity is an essential component of addressing disparity in health delivery and outcomes. The pool of students URiM that are competitive applicants to medical school is often limited early on by educational inequalities in primary and secondary schooling. A growing body of evidence recognizing the importance of diversifying health professions advances the need for medical schools to develop outreach collaborations with primary and secondary schools to attract URiMs. The goal of this paper is to describe and evaluate a program that seeks to create a pipeline for URiMs early in secondary schooling by connecting these students with support and resources in the medical community that may be transformative in empowering these students to be stronger university and medical school applicants. Methods: The authors described a medical student-led, action-oriented pipeline program, Doctors of Tomorrow, which connects faculty and medical students at the University of Michigan Medical School with 9th grade students at Cass Technical High School (Cass Tech) in Detroit, Michigan. The program includes a core curriculum of hands-on experiential learning, development, and presentation of a capstone project, and mentoring of 9th grade students by medical students. Cass Tech student feedback was collected using focus groups, critical incident written narratives, and individual interviews. Medical student feedback was collected reviewing monthly meeting minutes from the Doctors of Tomorrow medical student leadership. Data were analyzed using thematic analysis. Results: Two strong themes emerged from the Cass Tech student feedback: (i) Personal identity and its perceived effect on goal achievement and (ii) positive affect of direct mentorship and engagement with current healthcare providers through Doctors of Tomorrow. A challenge noted by the medical students was the lack of structured curriculum beyond the 1st year of the program; however, this was complemented by their commitment to the program for continued longitudinal development. Discussion: The authors propose that development of outreach pipeline programs that are context specific, culturally relevant, and established in collaboration with community partners have the potential to provide underrepresented students with opportunities and skills early in their formative education to be competitive applicants to college and ultimately to medical school.