Trainee Autonomy and Supervision in the Modern Clinical Learning Environment: A Mixed-Methods Study of Faculty and Trainee Perspectives

Background

Balancing autonomy and supervision during medical residency is important for trainee development while ensuring patient safety. In the modern clinical learning environment, tension exists when this balance is skewed. This study aimed to understand the current and ideal states of autonomy and supervision, then describe the factors that contribute to imbalance from both trainee and attending perspectives.

Methods

A mixed-methods design included surveys and focus groups of trainees and attendings at three institutionally affiliated hospitals between May 2019-June 2020. Survey responses were compared using chi-square tests or Fisher's exact tests. Open-ended survey and focus group questions were analyzed using thematic analysis.

Results

Surveys were sent to 182 trainees and 208 attendings; 76 trainees (42%) and 101 attendings (49%) completed the survey. Fourteen trainees (8%) and 32 attendings (32%) participated in focus groups. Trainees perceived the current culture to be significantly more autonomous than attendings; both groups described an "ideal" culture as more autonomous than the current state. Focus group analysis revealed five core contributors to the balance of autonomy and supervision: attending-, trainee-, patient-, interpersonal-, and institutional-related factors. These factors were found to be dynamic and interactive with each other. Additionally, we identified a cultural shift in how the modern inpatient environment is impacted by increased hospitalist attending supervision and emphasis on patient safety and health system improvement initiatives.

Conclusions

Trainees and attendings agree that the clinical learning environment should favor resident autonomy and that the current environment does not achieve the ideal balance. There are several factors contributing to autonomy and supervision, including attending-, resident-, patient-, interpersonal-, and institutional-related. These factors are complex, multifaceted, and dynamic. Cultural shifts towards supervision by primarily hospitalist attendings and increased attending accountability for patient safety and systems improvement outcomes further impacts trainee autonomy.

A clinical reasoning curriculum for medical students: an interim analysis

OBJECTIVES

Diagnostic error is a critical patient safety issue that can be addressed in part through teaching clinical reasoning. Medical schools with clinical reasoning curricula tend to emphasize general reasoning concepts (e.g., differential diagnosis generation). Few published curricula go beyond teaching the steps in the diagnostic process to address how students should structure their knowledge to optimize diagnostic performance in future clinical encounters or to discuss elements outside of individual cognition that are essential to diagnosis.

METHODS

In 2016, the University of California, San Francisco School of Medicine launched a clinical reasoning curriculum that simultaneously emphasizes reasoning concepts and intentional knowledge construction; the roles of patients, families, interprofessional colleagues; and communication in diagnosis. The curriculum features a longitudinal thread beginning in first year, with an immersive three week diagnostic reasoning (DR) course in the second year. Students evaluated the DR course. Additionally, we conducted an audit of the multiyear clinical reasoning curriculum using the Society to Improve Diagnosis in Medicine-Macy Foundation interprofessional diagnostic education competencies.

RESULTS

Students rated DR highly (range 4.13-4.18/5 between 2018 and 2020) and reported high self-efficacy with applying clinical reasoning concepts and communicating reasoning to supervisors. A course audit demonstrated a disproportionate emphasis on individual (cognitive) competencies with inadequate attention to systems and team factors in diagnosis.

CONCLUSIONS

Our clinical reasoning curriculum led to high student self-efficacy. However, we stressed cognitive aspects of reasoning with limited instruction on teams and systems. Diagnosis education should expand beyond the cognitive- and physician-centric focus of most published reasoning courses.

Decisions in the Dark: An Educational Intervention to Promote Reflection and Feedback on Night Float Rotations

BACKGROUND

Night float rotations, where residents admit patients to the hospital, are opportunities for practice-based learning. However, night float residents receive little feedback on their diagnostic and management reasoning, which limits learning.

AIM

Improve night float residents' practice-based learning skills through feedback solicitation and chart review with guided reflection.

SETTING/PARTICIPANTS

Second- and third-year internal medicine residents on a 1-month night float rotation between January and August 2017.

PROGRAM DESCRIPTION

Residents performed chart review of a subset of patients they admitted during a night float rotation and completed reflection worksheets detailing patients' clinical courses. Residents solicited feedback regarding their initial management from day team attending physicians and senior residents.

PROGRAM EVALUATION

Sixty-eight of 82 (83%) eligible residents participated in this intervention. We evaluated 248 reflection worksheets using content analysis. Major themes that emerged from chart review included residents' identification of future clinical practice changes, evolution of differential diagnoses, recognition of clinical reasoning gaps, and evaluation of resident-provider interactions.

DISCUSSION

Structured reflection and feedback during night float rotations is an opportunity to improve practice-based learning through lessons on disease progression, clinical reasoning, and communication.

Consensus-based perioperative protocols during the COVID-19 pandemic

OBJECTIVE

During the COVID-19 pandemic, quaternary-care facilities continue to provide care for patients in need of urgent and emergent invasive procedures. Perioperative protocols are needed to streamline care for these patients notwithstanding capacity and resource constraints.

METHODS

A multidisciplinary panel was assembled at the University of California, San Francisco, with 26 leaders across 10 academic departments, including 7 department chairpersons, the chief medical officer, the chief operating officer, infection control officers, nursing leaders, and resident house staff champions. An epidemiologist, an ethicist, and a statistician were also consulted. A modified two-round, blinded Delphi method based on 18 agree/disagree statements was used to build consensus. Significant disagreement for each statement was tested using a one-sided exact binomial test against an expected outcome of 95% consensus using a significance threshold of p < 0.05. Final triage protocols were developed with unblinded group-level discussion.

RESULTS

Overall, 15 of 18 statements achieved consensus in the first round of the Delphi method; the 3 statements with significant disagreement (p < 0.01) were modified and iteratively resubmitted to the expert panel to achieve consensus. Consensus-based protocols were developed using unblinded multidisciplinary panel discussions. The final algorithms 1) quantified outbreak level, 2) triaged patients based on acuity, 3) provided a checklist for urgent/emergent invasive procedures, and 4) created a novel scoring system for the allocation of personal protective equipment. In particular, the authors modified the American College of Surgeons three-tiered triage system to incorporate more urgent cases, as are often encountered in neurosurgery and spine surgery.

CONCLUSIONS

Urgent and emergent invasive procedures need to be performed during the COVID-19 pandemic. The consensus-based protocols in this study may assist healthcare providers to optimize perioperative care during the pandemic.

What Happened to My Patient? An Educational Intervention to Facilitate Postdischarge Patient Follow-Up

BACKGROUND

Following up on patients' clinical courses after hospital discharge may enhance physicians' learning and care of future patients. Barriers to this practice for residents include time constraints, discontinuous training environments, and difficulty accessing patient information.

OBJECTIVE

We designed an educational intervention facilitating informed self-assessment and reflection through structured postdischarge follow-up of patients' longitudinal clinical courses. We then examined the experience of interns who received this intervention in a mixed methods study.

METHODS

Internal medicine interns on a 4-week patient safety rotation received lists of hospitalized patients they had cared for earlier in the year. They selected patients for chart review and completed a guided reflection worksheet for each patient reviewed. Interns then discussed lessons learned in a faculty-led group debrief session.

RESULTS

Of 62 eligible interns, 62 (100%) participated in this intervention and completed 293 reflection worksheets. We analyzed worksheets and transcripts from 6 debrief sessions. Interns reported that postdischarge patient follow-up was valuable for their professional development, and helped them understand the natural history of disease and patients' illness experiences. After reviewing their patients' clinical courses, interns stated that they would advocate for earlier end-of-life counseling, improve care transitions, and adjust their clinical decision-making for similar patients in the future.

CONCLUSIONS

Our educational intervention created the time, space, and structure for postdischarge patient follow-up. It was well received by participants, and is an opportunity for experiential learning.

Office-based screening of common psychiatric conditions

Depression and anxiety disorders are common conditions with significant morbidity. Many screening tools of varying length have been well validated for these conditions in the office-based setting. Novel instruments, including Internet-based and computerized adaptive testing, may be promising tools in the future. The best evidence for cost-effectiveness currently is for screening of major depression linked with the collaborative care model for treatment. Data are not conclusive regarding comparative cost-effectiveness of screening for multiple conditions at once or for other conditions. This article reviews screening tools for depression and anxiety disorders in the ambulatory setting.

Identification of naturally occurring fatty acids of the myelin sheath that resolve neuroinflammation

Lipids constitute 70% of the myelin sheath, and autoantibodies against lipids may contribute to the demyelination that characterizes multiple sclerosis (MS). We used lipid antigen microarrays and lipid mass spectrometry to identify bona fide lipid targets of the autoimmune response in MS brain, and an animal model of MS to explore the role of the identified lipids in autoimmune demyelination. We found that autoantibodies in MS target a phosphate group in phosphatidylserine and oxidized phosphatidylcholine derivatives. Administration of these lipids ameliorated experimental autoimmune encephalomyelitis by suppressing activation and inducing apoptosis of autoreactive T cells, effects mediated by the lipids' saturated fatty acid side chains. Thus, phospholipids represent a natural anti-inflammatory class of compounds that have potential as therapeutics for MS.

Anatomical variations of the thyroid gland: possible surgical implications

INTRODUCTION

The organogenesis of the thyroid gland in humans is often disturbed, leading to a variety of morphological variations of the gland, such as hypoplasia, ectopy, hemiagenesis and agenesis. As the morphological variations are usually diagnosed incidentally during examination for other thyroid gland diseases, the true incidence is therefore uncertain.

METHODS

This study was structured to investigate the gross anatomical features of the thyroid gland in 105 (88 male and 17 female) cadavers from the coastal belt of southern India, an endemic goitre region.

RESULTS

The pyramidal lobe was present in 61 (58 percent) male cadavers, and 52 (49.5 percent) cadavers showed the presence of the levator glandulae thyroideae. 33 percent of the specimens studied showed agenesis of the isthmus. However, the accessory thyroid tissue was found in only one cadaver.

CONCLUSION

This study highlights the various developmental anomalies of the thyroid gland, which forms a cornerstone to safe and effective surgery.

Lipid microarrays identify key mediators of autoimmune brain inflammation

Recent studies suggest that increased T-cell and autoantibody reactivity to lipids may be present in the autoimmune demyelinating disease multiple sclerosis. To perform large-scale multiplex analysis of antibody responses to lipids in multiple sclerosis, we developed microarrays composed of lipids present in the myelin sheath, including ganglioside, sulfatide, cerebroside, sphingomyelin and total brain lipid fractions. Lipid-array analysis showed lipid-specific antibodies against sulfatide, sphingomyelin and oxidized lipids in cerebrospinal fluid (CSF) derived from individuals with multiple sclerosis. Sulfatide-specific antibodies were also detected in SJL/J mice with acute experimental autoimmune encephalomyelitis (EAE). Immunization of mice with sulfatide plus myelin peptide resulted in a more severe disease course of EAE, and administration of sulfatide-specific antibody exacerbated EAE. Thus, autoimmune responses to sulfatide and other lipids are present in individuals with multiple sclerosis and in EAE, and may contribute to the pathogenesis of autoimmune demyelination.

Construction of a whole body blood flow model for use in positron emission tomography imaging with [15O]water

A whole body blood flow model (WBBFM) was developed and tested using STELLA II, an icon-driven mathematical simulation software package. The WBBFM uses parallel chambers to represent gray and white areas of the brain, body organs such as lungs, heart (right and left halves), injection site, and blood sampling sites. Input values to the WBBFM include organ blood flows, organ volumes, tissue:blood partition coefficients, injected activity, and data acquisition times for a positron emission tomography (PET) camera. Input variables included an injection function (e.g., bolus), and a blood flow function (e.g., transient variations in flow). The kinetic behavior of [15O]water, a freely diffusible radiotracer employed in PET to characterize blood flow was examined by the WBBFM. The physiologic behavior of water in the human body was emulated using the WBBFM and the model's predictive value was verified by comparing calculated results with the following properties of water: diffusibility, tissue:blood partition coefficient of [15O]water, and the mixing of [15O]water with total body water. The WBBFM simulated Kety's autoradiographic method used in the estimation of regional cerebral blood flow by PET using [15O]water. The application of the model to a cognitive activation study paradigm based on Kety's method is presented and its results compared to published literature data. With appropriate modification in the half-life, tissue:blood partition coefficient, and the amount of administered radioactivity, the WBBFM should prove useful as a tool to examine kinetics of other freely diffusible radiotracers used in PET.

Dosimetry of [15O]water: a physiologic approach

Earlier dosimetry estimates for [15O]water assumed its instantaneous equilibrium with total body water. This assumption leads to an underestimation of the absorbed doses to organs with high blood flows, since the biodistribution of this short-lived radiopharmaceutical is dependent upon blood flow to organs. We have developed a physiologically based whole body blood flow model (WBBFM) using a commercially available icon-driven mathematical simulation software package and applied it to the reevaluation of [15O]water dosimetry in humans. The WBBFM uses multiple parallel compartments to represent organs, heart chambers, the injection site for [15O]water, and blood sampling sites (arterial and venous). Input values to the WBBFM include organ blood flows, organ masses, organ water volumes, organ:blood partition coefficients, injected activity and S-values of [15O]. The WBBFM is based on the same assumptions that are used in calculating regional blood flow using [15O]water and simulates the human body closely in its physiologic response. The activity in each organ is derived from the simulation and is used to calculate absorbed doses. The WBBFM calculated absorbed doses in microGy/MBq (mrad/mCi) to various organs are as follows: heart--2.66 (9.84), kidneys--2.20 (8.15), thyroid--1.83 (6.78), brain--1.66 (6.13), ovaries--1.25 (4.61), breast--1.24 (4.59), and small intestine--1.03 (3.83). These values are approximately two- to threefold higher than the earlier estimates of Kearfott [J. Nucl. Med. 23, 1031-1037 (1982)] and similar to the recent findings of Herscovitch et al. [J. Nucl. Med. 34, 155P (1983)]. We believe this approach yields more realistic dosimetry estimates for [15O]water. Accordingly, we have revised the amount of [15O]water administered during regional blood flow studies at our institution. The relative ease and accuracy of this approach suggests its usefulness in dosimetry estimation for other freely diffusible radiopharmaceuticals.

Effects of timing and duration of cognitive activation in [15O]water PET studies

The multiple injection [15O]water method offers unique opportunities for studying cognitive processing by the human brain. The influence of the duration and temporal placement of an activation task, in relation to the arrival of the radiotracer in the brain, is a fundamental methodologic question for cognitive activation studies. A quantitative positron emission tomography (PET) study of five normal volunteers was performed in which the stimulation consisted of a visual activation task (alternating checkerboard pattern) superimposed on an auditory baseline task (syllable monitoring). Ten injection conditions, with varying duration and timing of the visual activation, were used. Regional CBF (rCBF) in visual cortex was measured quantitatively using the autoradiographic method. A 20-s stimulation, centered on the bolus arrival in the brain, produced significant changes in rCBF. Because varying the duration and timing of the activation task technically violates the temporal homogeneity assumption of the autoradiographic model, a mathematical simulation was formulated to evaluate the potential influence of these variations. Results of the simulation are consistent with the PET data and suggest that activation can be limited to a narrow temporal window centered on the radiotracer uptake. The ability to observe significant changes in rCBF with short stimulation intervals is of particular interest in the use of [15O]water PET for studies of cognitive processes with a short time course.