Apprenticeships ease the transition to independent call: an evaluation of anxiety and confidence among junior radiology residents

The Diagnostic Accuracy of First-Year Ophthalmology Residents on Call: Considerations for Postgraduate Year 2 (PGY-2) Standardizations of Call Structure

Background Ophthalmology is a unique specialty with limited exposure during medical school. To improve the transition to ophthalmology residency, the Accreditation Council for Graduate Medical Education (ACGME) announced in 2017 that all ophthalmology residency programs would move to a combined post-graduate year (PGY) 1 year with mandatory integration by 2023. Currently, there are no standardized guidelines from the American Board of Ophthalmology (ABO) or the Accreditation Council for Graduate Medical Education (ACGME) to address ophthalmology resident competence prior to becoming the primary contact for inpatient and emergency room (ER) consultations as a PGY-2. Novice residents may not be equipped to accurately diagnose vision or life-threatening ocular conditions. A balance between resident autonomy and supervision is required for proper training without increasing patient morbidity and mortality. Objective This study's objective is to examine the diagnostic accuracy of PGY-2 ophthalmology non-integrated residents on call to standardize supervision requirements (through buddy-call) prior to initiating indirectly supervised calls. Methods All inpatient and ER ophthalmology consults for the first seven weeks of the year evaluated by PGY-2 (junior) residents were supervised and graded as "correct" or "incorrect" by PGY-4 (senior) residents. Results One hundred forty-eight consults were seen over 30 call days over a period of seven weeks (4.93 consults per call). The percentage of correct diagnoses increased with each successive week (R2 = 0.9581; correlation = 0.979). The greatest percent increase of correctly diagnosed encounters was between weeks 2 and 3 (19.14%) correlating to call numbers 10-16 and 45-68 patient encounters. The mean percent accuracy surpassed 70% during weeks 3-4, and improvement continued to week 7. High-acuity diagnoses were identified consistently 100% of the time from week 5 onward. Conclusion Our analysis indicated that diagnostic accuracy was greater than 70% between weeks 3 and 4 with high-acuity diagnostic accuracy reaching 100% at week 5. It can be postulated that optimal direct senior resident supervision is needed for at least 3-5 weeks before transitioning to indirectly supervised calls by PGY-2 residents. This standardization would allow junior residents to acquire sufficient clinical experience to accurately make a diagnosis and prevent patient morbidity. Further research nationally is necessary prior to creating a standardized call structure for PGY-2 residents especially with the newly mandatory integrated ophthalmology residency programs.

Performance Anxiety in Radiology Education and Clinical Practice

Performance anxiety is fear, anxiety, or avoidance of performative tasks, due to possible evaluation or criticism by others. Performance anxiety is well described in public speakers, musicians, and even surgeons. Its impact on radiologists and especially radiology trainees has not been explored. This article details performance anxiety, framing radiologists as performers, and highlights its potential impact on trainees and practicing radiologists. We offer strategies to manage and enhance the effects of performance anxiety that can be implemented in a training environment.

Supporting the transition to senior pediatric resident: an interactive online resource

Transitions to roles with increasing clinical responsibility and independence can be anxiety provoking for many trainees. To support our pediatric residents preparing to transition from the role of junior to senior resident, we developed a novel asynchronous online interactive case-based resource. Our experience suggests that this resource was voluntarily utilized and can effectively increase trainee confidence and reduce anxiety about this key transitional stage. We suggest that interactive case-based resources can be utilized as supplemental support for residents preparing for residency transitions in other programs and settings.

Optimizing the Orthopaedic Consult

Providing orthopaedic call coverage is a core requirement for orthopaedic surgery residents. Developing proper call habits and routines during residency is critical to becoming an attending surgeon who provides high-quality call coverage and consultations without difficulty. Although patient acuity and call duration and frequency may vary among rotations and hospitals, the fundamentals remain the same. Because personal health and content knowledge are critical for success, physical and mental preparation is done in advance. Using a stepwise approach for answering calls, taking a history, performing a physical examination, interpreting studies, and performing procedures can improve the quality and efficiency of patient care. Standard practices can be used to improve the process of scheduling urgent and emergent surgery or establishing outpatient follow-up. When the complexity or volume of patient care exceeds one's capabilities, it is critical to know when and how to ask for help. Clear communication is essential for safe and effective transitions of care and when presenting patients to attending surgeons. A call shift can also serve as a learning experience by reading on topics as each consult is completed, teaching others, and following up on patient outcomes after the call shift.

The Time Has Come: a Paradigm Shift in Diagnostic Radiology Education via Simulation Training

Current radiology training for medical students and residents predominantly consists of reviewing teaching files, attending lectures, reading textbooks and online sources, as well as one-on-one teaching at the workstation. In the case of medical schools, radiology training is quite passive. In addition, the variety of important and high-yield cases that trainees are exposed to may be limited in scope. We utilized an open-source dcm4chee-based Picture Archiving and Communication System (PACS) named "Weasis" in order to simulate a radiologist's practice in the real world, using anonymized report-free complete cases that could easily be uploaded live during read-outs for training purposes. MySQL was used for database management and JBOSS as application server. In addition, we integrated Weasis into a web-based reporting system through Java programming language using the MyEclipse development environment. A freeware, platform-independent, image database was established to simulate a real-world PACS. The sever was implemented on a dedicated non-workstation PC connected to the hospital secure network. As the client access is through a webpage, the cases can be viewed from any computer connected to the hospital network. The reporting system allows for evaluation purposes and providing feedback to the trainees. Brief survey results are available. Implementation of such a low-cost, versatile, and customizable tool provides a new opportunity for training programs in offering medical students with an active and more realistic radiology experience, junior radiology residents with potentially better preparation for independent call, and senior resident and fellows with the ability to fine-tune high-level specialty-level knowledge.

Cognitive Apprenticeship in Orthopaedic Surgery: Updating a Classic Educational Model

OBJECTIVE

To define cognitive apprenticeship and describe how it can be applied to orthopedic education.

DESIGN

Traditional apprenticeships have been used through history as a teaching model for wide variety of skills. These apprenticeships are characterized by practical, on-the-job training in which the apprentice observes and assists a master in the completion of a task, and thereby learns the skills needed to complete that task on his or her own.

RESULTS

Cognitive apprenticeship is differentiated from the traditional apprenticeship model primarily by its educational goals. Cognitive apprenticeships are used to teach skills which require internal though processes which cannot be readily observed externally by the teacher or the student.

CONCLUSION

Here, we review the history of the cognitive apprenticeship concept, its basic principles, its applications to a wide variety of educational circumstances, and its potential use a framework for developing orthopedic curricula.

Working in the dead of night: exploring the transition to after-hours duty

CONTEXT

Transitions, although often difficult, represent integral components of medical training. New postgraduate trainees (first-year residents) find themselves in an especially challenging transition as they are expected to fulfil both learning and service expectations concurrently. Workplace learning theory has been suggested as a lens through which to understand this unique educational, yet service-oriented, role. This tension may be further amplified overnight when residents are on-call with little to no support.

OBJECTIVES

The aims of this study were to explore the transition from medical student to resident with respect to the on-call experience, and to provide theory-based suggestions to enhance learning during this unique transition.

METHODS

We conducted an interpretivist qualitative study by interviewing eight medical students and 10 first-year residents from six different specialty training programmes across four academic sites. Each semi-structured interview was transcribed verbatim and anonymised. Resident interview transcripts were initially coded for major themes, after which medical student interview transcripts were coded for consistencies and discrepancies.

RESULTS

Four interrelated themes were identified in students' and residents' descriptions of on-call experiences: (i) shift in responsibility; (ii) supervisory support; (iii) contextual conditions, and (iv) clarity of expectations. Generally, students were not able to anticipate the challenges they would face as residents on-call, and residents perceived the transition as sudden with little emphasis placed on learning.

CONCLUSIONS

First-year residents face multiple challenges during on-call, which may prevent optimal learning in this setting. These challenges are amplified by the large gap between the respective roles of medical students and residents. We identified promoters of and barriers to effective learning in this environment and, by using workplace learning theory, provide recommendations for how we might be able to enhance medical students' preparation for and first-year residents' learning during experiences of being on-call.

Implementation of a Longitudinal Introduction to Radiology Course During Internship Year Improves Diagnostic Radiology Residents' Academic and Clinical Skills: A Canadian Experience

RATIONALE AND OBJECTIVES

In order to ease the transition from internship to diagnostic radiology residency, a year-long didactic introduction to radiology course was offered to post-graduate year one (PGY-1) diagnostic radiology residents during their internship, which consisted of 27 hours of lecture over 9 months. The purpose of this study was to determine the quantitative and qualitative educational value of this course and its effect with respect to on-call preparedness.

MATERIALS AND METHODS

Two consecutive cohorts of Diagnostic Radiology residents were included: the first cohort (PGY-1s in 2011-2012) did not participate in the new course (Old Curriculum Residents) and the second cohort (PGY-1s in 2012-2013) completed the new course (New Curriculum Residents). These two cohorts were compared both qualitatively and quantitatively. Scores were compared from the standardized Canadian National Pre-Call Observed Standardized Clinical Examination and American College of Radiology Diagnostic Radiology In-Training examination, which are taken in the PGY-2 year, at months 5 and 7, respectively. In addition, staff observation of on-call resident performance and resident self-reported preparedness were considered. Cohorts were compared using Mann-Whitney U test with significance defined as P value <0.05. P values from 0.05 to 0.10 were noted as possibly significant and further analyzed using a Cohen d test where the difference was determined to be small (0.2), medium (0.5), or large (0.8).

RESULTS

New Curriculum Residents reported that the content of the PGY1 curriculum was more appropriate than the old curriculum to prepare them for call in PGY2 (P = 0.013). New Curriculum Residents scored better than the Old Curriculum Residents on the Diagnostic Radiology In-Training examination (P = 0.039) and on the emergency cases of the Canadian National Pre-Call Observed Standardized Clinical Examination (P = 0.035). Staff radiologists, who were not blinded, reported that the New Curriculum Residents were better prepared for daytime (P = 0.006) and overnight (P = 0.008) independent call were better prepared to perform common ultrasound examinations alone (P = 0.049), and required less guidance while on call for nine competency areas. There was, however, no statistical difference between the residents' self-reported preparedness for independent call.

CONCLUSIONS

Participation in a lecture-based introductory radiology curriculum during the PGY-1 internship year improved both radiology residents' preparedness for call and their performance in PGY-2.

Preserving the educational value of call in a diagnostic radiology residency program

PURPOSE

Our study was designed to determine residents' opinions of the advantages, disadvantages and educational value of a traditional "Tandem Call" (TC) model as compared to night float (NF). Because TC is more representative of adult learning principles and constructivist theory, we hypothesized that resident satisfaction and educational outcomes would demonstrate a preference for, and the educational efficacy of, the TC model.

METHODS

We surveyed all residents in a university-based radiology residency on their opinions of TC and its educational value. Aggregate data from annual Graduate Medical Education Committee institutional surveys (2008-2012) and annual radiology alumni surveys (2009-2012) were reviewed as measures of satisfaction with TC. Performance on the ABR oral exam was a proxy for educational outcome. Quality data for the year of study and prior years in which TC was in effect were reviewed as a measure of patient safety.

RESULTS

The great majority of respondents attributed confidence/competence on call and added value to their education directly to TC. A majority believed that teamwork required for TC facilitated more positive relationships among residents and more peer teaching. Most said that they would not prefer NF. Almost all believed indirect supervision with attending backup aided in developing confidence in performance. Quality data confirmed a low number of discrepancies between preliminary resident and final attending reads.

CONCLUSIONS

TC provides a more consistent call experience throughout residency than NF. TC is valued by residents, facilitates retrieval-based learning and development of independence and efficiency, and parallels essential elements of team-based learning. Quality data suggests that lack of 24-hour attending supervision is not detrimental to patient safety.

Introductory lecture series for first-year radiology residents: implementation, investment and assessment

RATIONALE AND OBJECTIVES

A lecture series aimed at providing new radiology residents a rapid course on the fundamental concepts of professionalism, safety, and interpretation of diagnostic imaging was established. Evaluation of the course's educational value was attempted through surveys.

MATERIALS AND METHODS

Twenty-six live 45-minute lectures presented by 16 or 17 faculty members were organized exclusively for the first class of radiology residents, held over a 2-month period at the beginning of certain weekdays. Online surveys were conducted after the course to gather feedback from residents. Average resident rotation evaluation scores were measured over the first semester for the two classes before and after this new course implementation.

RESULTS

The lecture series was successfully organized and implemented. A total of 33 residents sat through the course over three summers. Faculty reported a reasonable number of preparation hours, and 100% of residents indicated they valued the course. Comparison of class average evaluation scores before and after the existence of this 2-month course did not significantly change.

CONCLUSIONS

This collection of introductory lectures on professionalism, safety, and diagnostic imaging, delivered early in the first year of the radiology residency, requires a reasonable number of invested preparation hours by the faculty but results in a universal increase in resident confidence. However, we were unable to demonstrate an objective improvement in resident performance on clinical rotations.

Cross-specialty integrated resident conferences: an educational approach to bridging the gap

RATIONALE AND OBJECTIVES

Radiologists play a pivotal role in patient management, primarily through interacting with referring clinicians. Despite this extensive cross-specialty interaction, radiology resident education rarely involves direct education from clinicians outside the department. We surveyed resident attitudes toward integrated conferences with subspecialty referring physicians both before and after a pilot lecture series at our institution.

MATERIALS AND METHODS

Three thoracic-themed multidisciplinary conferences were organized, which involved a variety of clinicians lecturing during normal resident conference times. Resident surveys were administered before and after the complete lectures series as well as immediately after each individual lecture.

RESULTS

The prelecture series survey indicated residents felt neutral about their confidence in knowing what clinicians want from radiology reports and the current level of "clinician-focus" in the curriculum. Residents indicated a desire for more clinician involvement in lectures. After completion of the series, residents expressed that the integrated conferences were useful and that they had greater confidence in understanding the clinicians' expectation of reports. Resident interest in clinician participation in lectures was higher after series completion. Most residents indicated that prespecified, self-identified learning objectives were met by the lectures. After the completion of the series, most residents indicated that they wanted the series to continue, with the most commonly indicated desired frequency being once or twice a month.

CONCLUSION

Subspecialty clinician participation in a cross-specialty integrated resident lecture series was highly favored and well received. An "Integrated Clinical Lecture Series" may be a beneficial addition to radiology residency curriculums.