Maura E. Sullivan

The Medical Mission and Modern Cultural Competency Training

BACKGROUND Culture has increasingly appreciated clinical consequences on the patient-physician relationship, and governing bodies of medical education are widely expanding educational programs to train providers in culturally competent care. A recent study demonstrated the value an international surgical mission in modern surgical training, while fulfilling the mandate of educational growth through six core competencies. This report further examines the impact of international volunteerism on surgical residents, and demonstrates that such experiences are particularly suited to education in cultural competency. METHODS Twenty-one resident physicians who participated in the inaugural Operation Smile Regan Fellowship were surveyed one year after their experiences. RESULTS One hundred percent strongly agreed that participation in an international surgical mission was a quality educational experience and 94.7% deemed the experience a valuable part of their residency training. In additional to education in each of the ACGME core competencies, results demonstrate valuable training in cultural competence. CONCLUSIONS A properly structured and proctored experience for surgical residents in international volunteerism is an effective instruction tool in the modern competency-based residency curriculum. These endeavors provide a unique understanding of the global burden of surgical disease, a deeper appreciation for global public health issues, and increased cultural sensitivity. A surgical mission experience should be widely available to surgery residents.

The impact of central line simulation before the ICU experience

BACKGROUND This study was designed to evaluate whether resident performance of placing central lines improved after simulation training on newly available partial-task simulators. METHODS This study was designed as a prospective, randomized controlled trial of standard training versus simulated training using CentralLine Man (SimuLab, Seattle, WA, USA). After receiving a lecture on central line placement, all junior residents on the trauma rotation were randomized on a monthly alternating schedule. Equivalency of groups was determined with a self-reported survey. All lines placed by the participants were monitored, and data were collected on performance and complications. RESULTS The 2 groups (n = 34; 21 standard and 13 simulated) were equivalent at baseline. The simulated training group had a significantly higher level of comfort and ability than the standard training group. The simulated group outperformed the standard group on 12 of the 15 specific variables monitored, although this did not reach statistical significance. There were significantly more complications in the standard group. CONCLUSIONS Simulation for central line placement using a partial-task simulator does positively impact resident performance.

Multi‐decadal drought and amplified moisture variability drove rapid forest community change in a humid region

Climate variability, particularly the frequency of extreme events, is likely to increase in the coming decades, with poorly understood consequences for terrestrial ecosystems. Hydroclimatic variations of the Medieval Climate Anomaly (MCA) provide a setting for studying ecological responses to recent climate variability at magnitudes and timescales comparable to expectations of coming centuries. We examined forest response to the MCA in the humid western Great Lakes region of North America, using proxy records of vegetation, fire, and hydroclimate. Multi-decadal moisture variability during the MCA was associated with a widespread, episodic decline in Fagus grandifolia (beech) populations. Spatial patterns of drought and forest changes were coherent, with beech declining only in areas where proxy-climate records indicate that severe MCA droughts occurred. The occurrence of widespread, drought-induced ecological changes in the Great Lakes region indicates that ecosystems in humid regions are vulnerable to rapid changes in drought magnitude and frequency.

The potential influence of short-term environmental variability on the composition of testate amoeba communities in "Sphagnum" peatlands

Testate amoebae are a group of moisture-sensitive, shell-producing protozoa that have been widely used as indicators of changes in mean water-table depth within oligotrophic peatlands. However, short-term environmental variability (i.e., sub-annual) also probably influences community composition. The objective of this study was to assess the potential influence of short-term environmental variability on the composition of testate amoeba communities in Sphagnum-dominated peatlands. Testate amoebae and environmental conditions, including hourly measurements of relative humidity within the upper centimeter of the peatland surface, were examined throughout the 2008 growing season at 72 microsites within 11 peatlands of Pennsylvania and Wisconsin, USA. Relationships among testate amoeba communities, vegetation, depth to water table, pH, and an index of short-term environmental variability (EVI), were examined using nonmetric multidimensional scaling and correlation analysis. Results suggest that EVI influences testate amoeba communities, with some taxa more abundant under highly variable conditions (e.g., Arcella discoides, Difflugia pulex, and Hyalosphenia subflava) and others more abundant when environmental conditions at the peatland surface were relatively stable (e.g., Archerella flavum and Bullinularia indica). The magnitude of environmental variability experienced at the peatland surface appears to be primarily controlled by vegetation composition and density. In particular, sites with dense Sphagnum cover had lower EVI values than sites with loose-growing Sphagnum or vegetation dominated by vascular plants and/or non-Sphagnum bryophytes. Our results suggest that more environmental information may be inferred from testate amoebae than previously recognized. Knowledge of relationships between testate amoebae and short-term environmental variability should lead to more detailed and refined environmental inferences.

Ecology of testate amoebae in a North Carolina pocosin and their potential use as environmental and paleoenvironmental indicators

ABSTRACT Testate amoebae inhabiting Sphagnum peatlands are sensitive indicators of substrate-moisture content. However, ecological data from a range of peatland types is needed to assess their indicator-value in other peatland systems. We examined testate amoeba communities and species–environment relationships at 40 locations within a pocosin of North Carolina. Primary objectives were to provide baseline data on the ecology of testate amoebae in pocosins, compare communities with those of northern peatlands, and assess the potential of using testate amoebae as environmental indicators in these systems. Results indicated that pH, substrate-moisture content, and conductivity were important controls on community composition. Communities that were relatively similar and dissimilar to those of northern peatlands were encountered, and the ecology of species with respect to water-table depth was similar in both peatland types. Cross validation of transfer functions for pH and water-table depth suggests that pocosin testate amoebae can be used as indicators for these variables. However, water-table depth was poorly inferred from communities at several dry sites characterized by high bulk density. These sites may experience large seasonal or interannual variability in moisture conditions because of differences in peat structure, suggesting that research is needed on the influence of short-term variability in shaping community structure. Nomenclature: Radford, Ahles & Bell, 1969; Charman, Hendon & Woodland, 2000.

The Effectiveness of a Cognitive Task Analysis Informed Curriculum to Increase Self-Efficacy and Improve Performance for an Open Cricothyrotomy

OBJECTIVE This study explored the effects of a cognitive task analysis (CTA)-informed curriculum to increase surgical skills performance and self-efficacy beliefs for medical students and postgraduate surgical residents learning how to perform an open cricothyrotomy. METHODS Third-year medical students and postgraduate year 2 and 3 surgery residents were assigned randomly to either the CTA group (n = 12) or the control group (n = 14). The CTA group learned the open cricothyrotomy procedure using the CTA curriculum. The control group received the traditional curriculum. RESULTS The CTA group outperformed the control group significantly based on a 19-point checklist score (CTA mean score: 17.75, standard deviation [SD] = 2.34; control mean score: 15.14, SD = 2.48; p = 0.006). The CTA group also reported significantly higher self-efficacy scores based on a 140-point self-appraisal inventory (CTA mean score: 126.10, SD = 16.90; control: 110.67, SD = 16.8; p = 0.029). CONCLUSIONS The CTA curriculum was effective in increasing the performance and self-efficacy scores for postgraduate surgical residents and medical students performing an open cricothyrotomy.

Development of a cardiac surgery simulation curriculum: From needs assessment results to practical implementation

OBJECTIVE A paradigm shift in surgical training has led to national efforts to incorporate simulation-based learning into cardiothoracic residency programs. Our goal was to determine the feasibility of developing a cardiac surgery simulation curriculum using the formal steps of curriculum development. METHODS Cardiothoracic surgery residents (n = 6) and faculty (n = 9) evaluated 54 common cardiac surgical procedures to determine their need for simulation. The highest scoring procedures were grouped into similarly themed monthly modules, each with specific learning objectives. Educational tools consisting of inanimate, animate, and cadaveric facilities and a newly created virtual operating room were used for curriculum implementation. Resident satisfaction was evaluated by way of a 5-point Likert scale. Perceived competency (scale of 1-10) and pre-/post-self-confidence (scale of 1-5) scores were collected and analyzed using cumulative mean values and a paired t-test. RESULTS Of the 23 highest scoring procedures (mean score, ≥ 4.0) on the needs assessment, 21 were used for curriculum development. These procedures were categorized into 12 monthly modules. The simulation curriculum was implemented using the optimal simulation tool available. Resident satisfaction (n = 57) showed an overwhelmingly positive response (mean score, ≥ 4.7). The perceived competency scores highlighted the procedures residents were uncomfortable performing independently. The pre-/post-self-confidence scores increased throughout the modules, and the differences were statistically significant (P < .001). CONCLUSIONS It is feasible to develop and implement a cardiac surgery simulation curriculum using a structured approach. High-fidelity, low-technology tools such as a fresh tissue cadaver laboratory and a virtual operating room could be important adjuncts.

The use of cognitive task analysis to reveal the instructional limitations of experts in the teaching of procedural skills.

Purpose Because of the automated nature of knowledge, experts tend to omit information when describing a task. A potential solution is cognitive task analysis (CTA). The authors investigated the percentage of knowledge experts omitted when teaching a cricothyrotomy to determine the percentage of additional knowledge gained during a CTA interview. Method Three experts were videotaped teaching a cricothyrotomy in 2010 at the University of Southern California. After transcription, they participated in CTA interviews for the same procedure. Three additional surgeons were recruited to perform a CTA for the procedure, and a “gold standard” task list was created. Transcriptions from the teaching sessions were compared with the task list to identify omitted steps (both “what” and “how” to do). Transcripts from the CTA interviews were compared against the task list to determine the percentage of knowledge articulated by each expert during the initial “free recall” (unprompted) phase of the CTA interview versus the amount of knowledge gained by using CTA elicitation techniques (prompted). Results Experts omitted an average of 71% (10/14) of clinical knowledge steps, 51% (14/27) of action steps, and 73% (3.6/5) of decision steps. For action steps, experts described “how to do it” only 13% (3.6/27) of the time. The average number of steps that were described increased from 44% (20/46) when unprompted to 66% (31/46) when prompted. Conclusions This study supports previous research that experts unintentionally omit knowledge when describing a procedure. CTA is a useful method to extract automated knowledge and augment expert knowledge recall during teaching.

Workplace bullying of general surgery residents by nurses

OBJECTIVE Workplace bullying is at the forefront of social behavior research, garnering significant media attention. Most of the medical research has addressed bullying of nurses by physicians and demonstrates that patient care and outcomes may suffer. The intent of this study was to determine if general surgery residents are bullied by nurses. DESIGN A survey instrument previously validated (Negative Acts Questionnaire-Revised) to evaluate for workplace bullying was modified to reflect the resident-nurse relationship. After institutional review board approval, the piloted online survey was sent to general surgery program directors to forward to general surgery residents. Demographic data are presented as percentages, and for negative acts, percentages of daily, weekly, and monthly frequencies are combined. SETTING Allopathic general surgery residencies in the United States. PARTICIPANTS General surgery residents. RESULTS The response rate was 22.1% (n = 452). Most respondents were men (55%) and had a mean age of 29 years (standard deviation = 7). Although 27.0% of the respondents were interns, the remaining classes were equally represented (12%-18% of responses/class). The respondents were primarily from medium-sized residency programs (45%), in the Midwest (28%), training in university programs (72%), and rotating primarily in a combined private and county hospital that serves both insured and indigent patients (59%). The residents had experienced each of the 22 negative acts (11.5%-82.5%). Work-related bullying occurs more than person-related bullying and physical intimidation. Ignoring of recommendations or orders by nurses occurs on a daily, weekly, or monthly basis for 30.2% of residents (work-related bullying). The most frequent person-related bullying act is ignoring the resident when they approach or reacting in a hostile manner (18.0%), followed by ignoring or excluding the resident (17.1%). CONCLUSIONS Workplace bullying of general surgery residents by nurses is prominent. Future research is needed to determine the toll on the residents well-being and patient outcomes.

Incorporation of Fresh Tissue Surgical Simulation into Plastic Surgery Education: Maximizing Extraclinical Surgical Experience

BACKGROUND As interest in surgical simulation grows, plastic surgical educators are pressed to provide realistic surgical experience outside of the operating suite. Simulation models of plastic surgery procedures have been developed, but they are incomparable to the dissection of fresh tissue. We evolved a fresh tissue dissection (FTD) and simulation program with emphasis on surgical technique and simulation of clinical surgery. We hypothesized that resident confidence could be improved by adding FTD to our resident curriculum. METHODS Over a 5-year period, FTD was incorporated into the curriculum. Participants included clinical medical students, postgraduate year 1 to 7 residents, and attending surgeons. Participants performed dissections and procedures with structured emphasis on anatomical detail, surgical technique, and rehearsal of operative sequence. Resident confidence was evaluated using retrospective pretest and posttest analysis with a 5-point scale, ranging from 1 (least confident) to 5 (most confident). Confidence was evaluated according to postgraduate year level, anatomical region, and procedure. RESULTS A total of 103 dissection days occurred, and a total of 192 dissections were reported, representing 73 different procedures. Overall, resident predissection confidence was 1.90±1.02 and postdissection confidence was 4.20±0.94 (p<0.001). The average increase in confidence correlated with training year, such that senior residents had greater gains. When compared by anatomical region, confidence was lowest for the head and neck region. When compared by procedure, confidence was lowest for rhinoplasty and face-lift, and highest for radial forearm and latissimus flaps. CONCLUSIONS A high-volume FTD experience was successfully incorporated into the residency program over 5 years. Training with FTD improves resident confidence, and this effect increases with seniority of training. Although initial data demonstrate that resident confidence is improved with FTD, additional evaluation is needed to establish objective evidence that patient outcomes and surgical quality can be improved with FTD.