Pro-Con Debate: Electroencephalography-Guided Anesthesia for Reducing Postoperative Delirium

Postoperative delirium (POD) has significant implications on morbidity, mortality, and health care expenditures. Monitoring electroencephalography (EEG) to adjust anesthetic management has gained interest as a strategy to mitigate POD. In this Pro-Con commentary article, the pro side supports the use of EEG to reduce POD, citing an empiric reduction in POD with processed EEG (pEEG)-guided general anesthesia found in several studies and recent meta-analysis. The Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES) trial is the exception to this, and issues with methods and achieved depths are discussed. Meanwhile, the Con side advocates that the use of EEG to reduce POD is not yet certain, citing that there is a lack of evidence that associations between anesthetic depth and POD represent causal relationships. The Con side also contends that the ideal EEG signatures to guide anesthetic titration are currently unknown, and the potential benefits of reduced anesthesia levels may be outweighed by the risks of potentially insufficient anesthetic administration. As the public health burden of POD increases, anesthesia clinicians will be tasked to consider interventions to mitigate risk such as EEG. This Pro-Con debate will provide 2 perspectives on the evidence and rationales for using EEG to mitigate POD.

Mental Health Questions on State Medical License Applications and Evaluation of Updates

This cross-sectional study evaluates the consistency of US medical license renewal applications with the Federation of State Medical Boards recommendations for questions regarding physician mental health.

Left-Sided Double-Lumen Tube vs EZ-Blocker for One-Lung Ventilation in Thoracic Surgery: A Systematic Review and Meta-Analysis

Background. The EZ-Blocker is the newest generation of bronchial blocker and offers a potential alternative to left-sided double lumen tubes for lung isolation and one-lung ventilation during thoracic surgery. Methods. Databases were searched for randomized controlled trials comparing left-sided double lumen tube to the EZ-Blocker for one-lung ventilation during thoracic surgery. The time for placement, incidence of intraoperative displacement, and surgeons' rating of lung collapse quality were designated as coprimary outcomes. The safety profiles of the two devices, including the incidence of airway trauma and post-extubation discomfort were also examined. Results. Six randomized controlled trials (495 patients) were analyzed. Compared to the EZ-Blocker, the left-sided double lumen tube was faster to place by a weighted mean difference of [95% CI] of -61.24 seconds [-102.48, -20.00] (P = .004) and was much less likely to become displaced during lung isolation with an odds ratio [95% CI] of .56 [.34, .91] (P = .02). The left-sided double lumen tube and the EZ-Blocker provided similar surgeon-rated quality of lung isolation. Although the left-sided double lumen tube caused a greater degree of post-extubation sore throat, there was a similar incidence of carinal trauma and post-extubation hoarseness compared to the EZ-Blocker. Conclusion. Our analysis suggests that the left-sided double lumen tube can be placed more quickly and is less prone to intraoperative displacement compared to the EZ-Blocker; the quality of lung collapse is similar. Thus, evidence appears to support the continued utilization of the left-sided double lumen tube for routine thoracic surgery requiring one-lung ventilation.

Measuring deliberate reflection in residents: validation and psychometric properties of a measurement tool

PURPOSE

Reflective capacity is "the ability to understand critical analysis of knowledge and experience to achieve deeper meaning." In medicine, there is little provision for post-graduate medical education to teach deliberate reflection. The feasibility, scoring characteristics, reliability, validation, and adaptability of a modified previously validated instrument was examined for its usefulness assessing reflective capacity in residents as a step toward developing interventions for improvement.

METHODS

Third-year residents and fellows from four anesthesia training programs were administered a slightly modified version of the Reflection Evaluation for Learners' Enhanced Competencies Tool (REFLECT) in a prospective, observational study at the end of the 2019 academic year. Six written vignettes of imperfect anesthesia situations were created. Subjects recorded their perspectives on two randomly assigned vignettes. Responses were scored using a 5-element rubric; average scores were analyzed for psychometric properties. An independent self-report assessment method, the Cognitive Behavior Survey: Residency Level (rCBS) was used to examine construct validity. Internal consistency (ICR, Cronbach's alpha) and interrater reliability (weighted kappa) were examined. Pearson correlations were used between the two measures of reflective capacity.

RESULTS

46/136 invited subjects completed 2/6 randomly assigned vignettes. Interrater agreement was high (k = 0.85). The overall average REFLECT score was 1.8 (1-4 scale) with good distribution across the range of scores. ICR for both the REFLECT score (mean 1.8, sd 0.5; α = 0.92) and the reflection scale of the rCBS (mean 4.5, sd 1.1; α = 0.94) were excellent. There was a significant correlation between REFLECT score and the rCBS reflection scale (r = .44, p < 0.01).

CONCLUSIONS

This study demonstrates feasibility, reliability, and sufficiently robust psychometric properties of a modified REFLECT rubric to assess graduate medical trainees' reflective capacity and established construct/convergent validity to an independent measure. The instrument has the potential to assess the effectiveness of interventions intended to improve reflective capacity.

Doing More With Written Feedback: Improving Learner Satisfaction and Reflection With the LEAF (Learner-Engaged Analysis of Feedback) Method

PROBLEM

Written feedback is often overly positive, nonspecific, and difficult to interpret. Learner satisfaction with written feedback is low and obtaining written feedback that encourages self-reflection is challenging. Improving feedback quality is laborious and only modestly effective.

APPROACH

The authors developed the LEAF (Learner-Engaged Analysis of Feedback) method to improve learner satisfaction with, and reflection on, existing written feedback. The method pairs a learner and coach to methodically identify themes in the learner's written feedback. Themes occurring more frequently or less frequently than typical offer areas for reflection, as they may identify learners' relative strengths or weaknesses. The method was introduced at the Massachusetts General Hospital in 2017 during program director (PD) meetings with anesthesiology residents. In 2018, resident satisfaction was measured (1 to 5 Likert-type questions, 1 = "not at all satisfied," 5 = "extremely satisfied") for 4 feedback sources, 2 related to the LEAF method (PD meetings, written feedback) and 2 unrelated (verbal feedback, mentor feedback). Residents' comments were qualitatively assessed to explore the impact on self-reflection.

OUTCOMES

Residents who had participated in a LEAF session (n = 54), compared with those who had not (n = 11), reported higher satisfaction with written feedback (mean 3.1 versus 2.5, d = 0.53, P = .03) and PD meeting feedback (mean 3.8 versus 2.8, d = 0.80, P = .03). There were no significant differences between groups for satisfaction with feedback unrelated to the LEAF method. Qualitative analysis of comments suggested that residents found the method useful for providing holistic self-assessment, facilitating goal setting, uncovering blind spots, and improving feedback interpretation.

NEXT STEPS

Next steps should include studies determining if the association between increased learner satisfaction with written feedback and the LEAF method is causal, and whether this feedback process changes learners' subsequent behaviors.

Consistency Between State Medical License Applications and Recommendations Regarding Physician Mental Health

This study examines the consistency of medical license applications with recommendations from the Federation of State Medical Boards on physician wellness and burnout.

Faculty Underestimate Resident Desire for Constructive Feedback and Overestimate Retaliation

BACKGROUND

Constructive feedback from faculty to trainees is essential to promoting trainees' learning yet is rarely provided. Resident physicians want more feedback than they receive but it is unclear whether faculty know this. We explored faculty and resident impressions of constructive feedback and the barriers to giving more. We hypothesized that residents want more constructive feedback; however, faculty believe that residents do not want constructive feedback and would retaliate against faculty who give it.

METHODS

Between January and March 2019, we performed a cross-sectional survey study of anesthesiology residents and teaching faculty at two large academic centers. All residents and faculty were eligible to participate. The survey assessed satisfaction with written and in-person feedback and predicted responses to specific examples, in addition to perceived barriers.

RESULTS

The survey was distributed to 156 residents and 260 faculty across the two institutions: 116 residents (74% response rate) and 127 faculty (49% response rate) responded. Eighty-eight percent of residents would want to receive feedback similar to the examples, whereas only 60% of faculty responded that they thought residents would want feedback. Ninety-eight percent of residents said they would not retaliate. Barriers to providing feedback included time constraints, insufficient confidence/training, fear of retaliation, and feelings of futility.

CONCLUSIONS

Residents were significantly more likely to want to receive constructive feedback than the faculty members had predicted. Further, residents are unlikely to retaliate against faculty who provide feedback. Addressing barriers may help increase the amount of constructive feedback that faculty provide and resident satisfaction with feedback received.

Establishing Psychological Safety to Obtain Feedback for Training Programs: A Novel Cross-Specialty Focus Group Exchange

BACKGROUND

Formative feedback from residents is essential to improve residency programs, and focus groups may provide rich information. However, residents may withhold information due to fear of retaliation or speak less candidly to please focus group moderators.

OBJECTIVE

We assessed participant perceptions and utility of feedback obtained from a confidential focus group exchange between 2 residency programs.

METHODS

Anesthesiology and pediatric programs at the same institution participated in 2017. Residents voluntarily provided program feedback during 1 of 2 confidential focus groups for each program. Each focus group was moderated by the program director (PD) of the other specialty. The PDs used thematic analysis to identify themes for use by the respective programs in improvement efforts. An anonymous survey was distributed after the focus groups to collect participant perceptions (quantitative and narrative) on this approach.

RESULTS

Thirteen residents of 140 (9.3%) participated (7 anesthesiology, 6 pediatrics). Thematic feedback from focus groups was largely consistent with known issues, although novel information was also obtained (eg, pediatric interns wanted earlier one-on-one meetings with their PD). Survey data suggest that residents were able to share more meaningful feedback than they would otherwise, and they did not feel that having an external moderator (a PD who may have been unfamiliar with the specialty) was a barrier to discussion. The approach required 6 hours of time for each PD and approximately $200 for dinners.

CONCLUSIONS

The focus group exchange required modest resources, was perceived as safe by residents, and generated robust, actionable feedback for the programs.

Changing Resident Physician Studying Behaviors: A Randomized, Comparative Effectiveness Trial of Goal Setting Versus Use of WOOP

BACKGROUND

Following through on one's goals to study is essential for effective, self-regulated learning. This can be difficult for residents because of clinical demands and limited personal time. WOOP (Wish, Outcome, Obstacle, Plan) is a self-regulation strategy, also known as mental contrasting with implementation intentions. WOOP increases follow-through on goals in many domains, although it has not, to our knowledge, been evaluated in medical education.

OBJECTIVE

We compared the effect of WOOP versus goal setting on time residents spent studying.

METHODS

Through a prospective, randomized, comparative effectiveness study, during a 1-month, intensive care unit rotation, we clustered anesthesiology residents in single-blind fashion to WOOP versus goal setting. Both groups received organized study materials. The intervention group performed WOOP to study more; the comparison group set goals to study more. Residents tracked studying with daily diaries. The primary outcome was total time spent studying toward stated goals. Time spent studying "non-goal" medical material was a secondary outcome.

RESULTS

Of 34 eligible residents, 100% participated. Sixteen residents were randomized to the WOOP group and 18 to the goal-setting group. The WOOP group spent significantly more time studying toward their goals compared with the goal-setting group (median = 4.3 hours versus 1.5 hours; P = .021; g = 0.66). There was no significant difference in time spent studying non-goal medical material between groups (median = 5.5 hours versus 5.0 hours, P = .99).

CONCLUSIONS

WOOP increased the time residents spent studying toward their goals as compared with setting goals alone.

Changing Physician Behavior With Implementation Intentions: Closing the Gap Between Intentions and Actions

In medical education, even well-intentioned learners struggle to change their practice. This intention-action gap is a well-described phenomenon. Strong commitment to changing behaviors is important, but by itself it is only a modest predictor of goal attainment.Implementation intentions are an extensively studied strategy from cognitive psychology that have been shown to close the intention-action gap and increase goal attainment across myriad domains. Implementation intentions are "if-then" plans that specify an anticipated future situation and a planned response-"If I encounter situation X, then I will respond with action Y." They differ from simple goals, which specify only a desired behavior or outcome-"I intend to perform action Z." Despite this subtle difference, they have shown substantial effectiveness over goals alone in increasing goal attainment.In this article, the authors first describe implementation intentions, review the substantial body of evidence demonstrating their effectiveness, and explain the underlying psychological mechanisms. They then illustrate the connections between implementation intentions and established learning theory. The final section focuses on forming effective implementation intentions in medical education. The authors provide concrete examples across the continuum of learners (from medical students to attending physicians) and competencies, and make recommendations for when and how to employ implementation intentions.

Optimizing Mask Ventilation: Literature Review and Development of a Conceptual Framework

Mask ventilation is lifesaving, especially in cases of difficult intubation. Many publications have offered distinct techniques for optimizing mask ventilation. This article reviews currently available difficult mask ventilation literature and theory. We divide difficult mask ventilation into 3 broad categories based on etiology: inadequate mask seal, increased airway resistance, and decreased respiratory compliance. Published strategies for overcoming difficulty are presented and organized by etiology.

A decision analysis of amputation versus reconstruction for severe open tibial fracture from the physician and patient perspectives

Although reconstruction is often the primary choice of surgeons after an open tibial fracture, there is no evidence to support the long-term effectiveness of flap reconstruction over below-knee amputation. The aim of this study was to perform a decision analysis to evaluate treatment preferences for type IIIB and IIIC tibial fractures. Reconstructive microsurgeons, physical medicine physicians, and patients with lower extremity trauma completed a Web-based standard gamble utility survey to generate quality-adjusted life years (QALYs). Physicians assigned quite high utility values, and there was a slight preference for reconstruction over amputation, with a gain of only 0.55 QALY. Patients assigned significantly lower utility values and also favored reconstruction over amputation, but with a larger gain of 5.54 QALYs. The disparate utilities assigned by the physicians and the patients highlight the necessity of realistic discussion of outcomes, regardless of the management methods.

An economic analysis of hand transplantation in the United States

BACKGROUND

Hand transplantation has received international attention in recent years; however, the economic impact of this innovative treatment is uncertain. The aim of this study was to assess the utility and estimate the costs of hand transplantation and the use of hand prostheses for forearm amputations.

METHODS

One hundred medical students completed a time trade-off survey to assess the utilities of single and double hand transplantation and the use of hand prostheses. Quality-adjusted life years (QALYs) were calculated for each outcome to create decision trees. Cost data for medical care were estimated based on Medicare fee schedules using the Current Procedural Terminology code for forearm replantation. The cost of immunosuppressive therapy was estimated based on the wholesale price of drugs. The incremental cost-utility ratio was calculated from the differences in costs and utilities between transplantation and prosthesis. Sensitivity analyses were performed to assess the robustness of the results.

RESULTS

For unilateral hand amputation, prosthetic use was favored over hand transplantation (30.00 QALYs versus 28.81 QALYs; p = 0.03). Double hand transplantation was favored over the use of prostheses (26.73 QALYs versus 25.20 QALYs; p = 0.01). The incremental cost-utility ratio of double transplantation when compared with prostheses was $381,961/QALY, exceeding the traditionally accepted cost-effectiveness threshold of $50,000/QALY.

CONCLUSIONS

Prosthetic adaption is the dominant strategy for unilateral hand amputation. For bilateral hand amputation, double hand transplantation exceeds the societally acceptable threshold for general adoption. Improvements in immunosuppressive strategies may change the incremental cost-utility ratio for hand transplantation.

A cost-utility analysis of amputation versus salvage for Gustilo type IIIB and IIIC open tibial fractures

BACKGROUND

Lower extremity trauma is common. Despite an abundance of literature on severe injuries that can be treated with salvage or amputation, the appropriate management of these injuries remains uncertain. In this situation, a cost-utility analysis is an important tool in providing an evidence-based practice approach to guide treatment decisions.

METHODS

Costs following amputation and salvage were derived from data presented in a study that emerged from the Lower Extremity Assessment Project. The authors extracted relevant data on projected lifetime costs and analyzed them to include discounting and sensitivity analysis by considering patient age. The utilities for the various health states (amputation or salvage, including possible complications) were measured previously using the standard gamble method and a decision tree simulation to determine quality-adjusted life-years.

RESULTS

Amputation is more expensive than salvage, independently of varied ongoing prosthesis needs, discount rate, and patient age at presentation. Moreover, amputation yields fewer quality-adjusted life-years than salvage. Salvage is deemed the dominant, cost-saving strategy.

CONCLUSION

Unless the injury is so severe that salvage is not a possibility, based on this economic model, surgeons should consider limb salvage, which will yield lower costs and higher utility when compared with amputation.

A systematic review of outcomes and complications of reconstruction and amputation for type IIIB and IIIC fractures of the tibia

BACKGROUND

The question of whether to recommend amputation or salvage after type IIIB and IIIC tibial fractures remains unanswered. The purpose of this study was to conduct a systematic review to derive evidence-based recommendations concerning primary amputation versus limb salvage for type IIIB and IIIC open tibial fractures.

METHODS

Articles from Medline, Cinahl, and Embase that met predetermined criteria were included. Outcomes of interest included length of hospital stay, complications, rehabilitation time, quality of life, limb function, pain, and return to work data. Pooling of statistical data was performed when possible.

RESULTS

The authors reviewed 1947 articles, and 28 observational studies were included. Length of hospital stay was 56.9 days for salvage patients and 63.7 days for amputees. The most common complications after salvage attempt were osteomyelitis (17.9 percent), nonunion (15.5 percent), secondary amputation (7.3 percent), and flap failure (5.8 percent). Rehabilitation time for salvaged patients was reported as time to union (10.2 months) and time to full weight-bearing (8.1 months). Pain, quality of life, and limb function outcomes were assessed differently among studies and could not be combined. The proportion of patients who returned to work was 63.5 percent for salvage patients and 73 percent for amputees.

CONCLUSIONS

The current literature offers no evidence to support superior outcomes of either limb salvage or primary amputation for type IIIB and IIIC tibial fractures. When outcomes are similar between two treatment strategies, economic analysis that incorporates cost and preference (utility) may define an optimal treatment strategy to guide physicians and patients.

The impact of interactive, computerized educational modules on preclinical medical education

Interactive computerized modules have been linked to improved retention of material in clinical medicine. This study examined the effects of a new series of interactive learning modules for preclinical medical education, specifically in the areas of quiz performance, perceived difficulty of concepts, study time, and perceived stress level. We randomly allocated 102 medical student volunteers into control and experimental groups. All participants studied selected anatomical and physiologic concepts using existing material (lecture notes, textbooks, etc.), while those in the experimental groups used the new interactive modules as well. All participants completed a quiz to test their knowledge of the assigned concepts and a survey to assess their subjective experiences in studying with the modules. We found a trend toward higher quiz scores in the experimental group relative to the control group, though it did not reach statistical significance (P = 0.31). Perceived concept difficulty was significantly reduced among those who studied with the modules (P < 0.001), and the number of hours spent studying the concepts was significantly increased (P = 0.028). Of those who used the modules, 83% rated them as "very helpful" or "extremely helpful." No significant differences existed between participants' reported stress levels during the course of the study (P = 0.44). Our data suggest that medical students may learn more effectively and feel less intimidated by difficult concepts when interactive modules supplement traditional instruction.