Characteristics of Hospitals by Graduate Medical Education Expense Category: Implications for Rural Residency Program Expansion

PURPOSE

To describe how the characteristics of the hospitals and communities they serve vary across the 4 hospital graduate medical education (GME) expense categories (according to Section 131 of the Consolidated Appropriations Act of 2021) and identify the rurally located never claimer hospitals that are most similar to teaching hospitals, signaling that they might be good candidates for new rural GME programs.

METHOD

Hospital categories and characteristics were gathered from the March 2022 Medicare Cost Reports; 2022 County Health Rankings & Roadmaps data were used for community characteristics. Each acute hospital was classified into 1 of the following 4 mutually exclusive hospital categories: category A, category B, established teaching hospital (ETH), and never claimer. Multinomial logistic regressions were conducted to estimate the adjusted associations of hospital characteristics with hospital categories and to identify the never claimer hospitals in rural locations that have characteristics similar to teaching hospitals (category A, category B, and ETHs).

RESULTS

Out of 3,590 hospitals, 2,075 (57.8%) were never claimer hospitals. After adjusting for multiple characteristics, rural hospitals had a similar probability of being in each hospital category to that of urban hospitals. Never claimer hospitals served an older population and were located in communities with more uninsured adults and children and less availability of primary care physicians, dentists, and mental health professionals.

CONCLUSIONS

This study demonstrated that most hospitals in every category, but especially teaching hospitals (i.e., category A hospitals, category B hospitals, and ETHs), were concentrated in urban areas. Larger hospitals (measured by net patient revenue) were more likely to report GME expenses (i.e., be a category A hospital, a category B hospital, or an ETH). The study suggests that there are roughly 145 rural never claimer hospitals that might be strong candidates for initiating new residency programs.

Variation in Oral Board Examination Accommodations Among Specialties

Importance

Board certification can have broad implications for candidates' career trajectories, and prior research has found sociodemographic disparities in pass rates. Barriers in the format and administration of the oral board examinations may disproportionately affect certain candidates.

Objective

To characterize oral certifying examination policies and practices of the 16 Accreditation Council for Graduate Medical Education (ACGME)-accredited specialties that require oral examinations.

Design, Setting, and Participants

This cross-sectional study was conducted from March 1 to April 15, 2023, using data on oral examination practices and policies (examination format, dates, and setting; lactation accommodations; and accommodations for military deployment, family emergency, or medical leave) as well as the gender composition of the specialties' boards of directors obtained from websites, telephone calls and email correspondence with certifying specialists. The percentages of female residents and residents of racial and ethnic backgrounds who are historically underrepresented in medicine (URM) in each specialty as of December 31, 2021, were obtained from the Graduate Medical Education 2021 to 2022 report.

Main Outcome and Measures

For each specialty, accommodation scores were measured by a modified objective scoring system (score range: 1-13, with higher scores indicating more accommodations). Poisson regression was used to assess the association between accommodation score and the diversity of residents in that specialty, as measured by the percentages of female and URM residents. Linear regression was used to assess whether gender diversity of a specialty's board of directors was associated with accommodation scores.

Results

Included in the analysis were 16 specialties with a total of 46 027 residents (26 533 males [57.6%]) and 233 members of boards of directors (152 males [65.2%]). The mean (SD) total accommodation score was 8.28 (3.79), and the median (IQR) score was 9.25 (5.00-12.00). No association was found between test accommodation score and the percentage of female or URM residents. However, for each 1-point increase in the test accommodation score, the relative risk that a resident was female was 1.05 (95% CI, 0.96-1.16), and the relative risk that an individual was a URM resident was 1.04 (95% CI, 1.00-1.07). An association was found between the percentage of female board members and the accommodation score: for each 10% increase in the percentage of board members who were female, the accommodation score increased by 1.20 points (95% CI, 0.23-2.16 points; P = .03).

Conclusions and Relevance

This cross-sectional study found considerable variability in oral board examination accommodations among ACGME-accredited specialties, highlighting opportunities for improvement and standardization. Promoting diversity in leadership bodies may lead to greater accommodations for examinees in extenuating circumstances.

Trends in Racial, Ethnic, and Gender Diversity in Orthopedic Surgery Spine Fellowships From 2007 to 2021

STUDY DESIGN

Descriptive.

OBJECTIVE

The objective of this study is to analyze trends in racial, ethnic, and gender diversity in orthopedic spine surgery fellowship trainees.

SUMMARY OF BACKGROUND DATA

Orthopedic surgery has consistently been labeled as one of the least diverse fields in Medicine. Although some effort has been made to combat this in recent years at the residency level, it is uncertain whether spine fellowships have had any changes in fellow demographics.

MATERIALS AND METHODS

Fellowship demographic data were collected through the Accreditation Council for Graduate Medical Education. Data collected included gender (male, female, and not reported) and race (White, Asian, Black, Hispanic, Native Hawaiians, American Indian or Alaskan Native, other, and unknown). Percentage equivalents were calculated for each group from 2007 to 2008 to 2020 to 2021. A χ 2 test for trend (Cochran-Armitage test) was done to determine whether there was a significant change in percentages of each race and gender during the study period. The results were considered statistically significant at P <0.05.

RESULTS

White, Non-Hispanic males represent the largest proportion of orthopedic spine fellowship positions each year. From 2007 to 2021, there were no significant changes in the representation of any race or gender of orthopedic spine fellows. Males ranged from 81% to 95%, Whites from 28% to 66%, Asians from 9% to 28%, Blacks from 3% to 16%, and Hispanics from 0% to 10%. Native Hawaiians and American Indians remained at 0% for all years included in the study. Females and all races, excluding Whites, continue to be under-represented in orthopedic spine fellowship.

CONCLUSIONS

Orthopedic spine surgery fellowship programs have not made substantial progress in diversifying its population. More attention is needed to increase diversity in residency programs through pipeline programs, increased mentorship and sponsorship, and early exposure to the field.

LEVEL OF EVIDENCE

1.

US Postgraduate Trainee Racial, Ethnic, and Gender Representation and Faculty Compensation By Specialty

This study compares postgraduate trainee racial, ethnic, and gender representation and faculty compensation for 21 clinical specialties using 2015-2022 data.

Dobbs Decision Threatens Full Breadth of Ob-Gyn Training

This Medical News article discusses how the overturning of Roe v Wade will change training for future obstetrician-gynecologists in states where abortion is banned or severely restricted.

What Behaviors Define a Good Physician? Assessing and Communicating About Noncognitive Skills

Once medical students attain a certain level of medical knowledge, success in residency often depends on noncognitive attributes, such as conscientiousness, empathy, and grit. These traits are significantly more difficult to assess than cognitive performance, creating a potential gap in measurement. Despite its promise, competency-based medical education (CBME) has yet to bridge this gap, partly due to a lack of well-defined noncognitive observable behaviors that assessors and educators can use in formative and summative assessment. As a result, typical undergraduate to graduate medical education handovers stress standardized test scores, and program directors trust little of the remaining information they receive, sometimes turning to third-party companies to better describe potential residency candidates. The authors have created a list of noncognitive attributes, with associated definitions and noncognitive skills-called observable practice activities (OPAs)-written for learners across the continuum to help educators collect assessment data that can be turned into valuable information. OPAs are discrete work-based assessment elements collected over time and mapped to larger structures, such as milestones, entrustable professional activities, or competencies, to create learning trajectories for formative and summative decisions. Medical schools and graduate medical education programs could adapt these OPAs or determine ways to create new ones specific to their own contexts. Once OPAs are created, programs will have to find effective ways to assess them, interpret the data, determine consequence validity, and communicate information to learners and institutions. The authors discuss the need for culture change surrounding assessment-even for the adoption of behavior-based tools such as OPAs-including grounding the work in a growth mindset and the broad underpinnings of CBME. Ultimately, improving assessment of noncognitive capacity should benefit learners, schools, programs, and most importantly, patients.

Representation of American Indian and Alaska Native Individuals in Academic Medical Training

IMPORTANCE

Identifying gaps in inclusivity of Indigenous individuals is key to diversifying academic medical programs, increasing American Indian and Alaska Native representation, and improving disparate morbidity and mortality outcomes in American Indian and Alaska Native populations.

OBJECTIVE

To examine representation of American Indian and Alaska Native individuals at different stages in the 2018-2019 academic medical training continuum and trends (2011-2020) of American Indian and Alaska Native representation in residency specialties.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional, population-based analysis was conducted using self-reported race and ethnicity data on trainees from the Association of American Medical Colleges (2018), the Accreditation Council for Graduate Medical Education (2011-2018), and the US Census (2018). Data were analyzed between February 18, 2020, and March 4, 2021.

EXPOSURES

Enrolled trainees at specific stages of medical training.

MAIN OUTCOMES AND MEASURES

The primary outcome was the odds of representation of American Indian and Alaska Native individuals at successive academic medical stages in 2018-2019 compared with White individuals. Secondary outcomes comprised specialty-specific proportions of American Indian and Alaska Native residents from 2011 to 2020 and medical specialty-specific proportions of American Indian and Alaska Native physicians in 2018. Fisher exact tests were performed to calculate the odds of American Indian and Alaska Native representation at successive stages of medical training. Simple linear regressions were performed to assess trends across residency specialties.

RESULTS

The study data contained a total of 238 974 607 White and American Indian and Alaska Native US citizens, 24 795 US medical school applicants, 11 242 US medical school acceptees, 10 822 US medical school matriculants, 10 917 US medical school graduates, 59 635 residents, 518 874 active physicians, and 113 168 US medical school faculty. American Indian and Alaska Native individuals had a 63% lower odds of applying to medical school (odds ratio [OR], 0.37; 95% CI, 0.31-0.45) and 48% lower odds of holding a full-time faculty position (OR, 0.52; 95% CI, 0.44-0.62) compared with their White counterparts, yet had 54% higher odds of working in a residency specialty deemed as a priority by the Indian Health Service (OR, 1.54; 95% CI, 1.09-2.16). Of the 33 physician specialties analyzed, family medicine (0.55%) and pain medicine (0.46%) had more than an average proportion (0.41%) of American Indian and Alaska Native physicians compared with their representation across all specialties.

CONCLUSIONS AND RELEVANCE

This cross-sectional study noted 2 distinct stages in medical training with significantly lower representation of American Indian and Alaska Native compared with White individuals. An actionable framework to guide academic medical institutions on their Indigenous diversification and inclusivity efforts is proposed.

Gender Differences in the Amount and Type of Student Participation During In-Person and Virtual Classes in Academic Medicine Learning Environments

This cohort study examines gender differences in the amount and type of student participation during in-person and virtual classes in graduate-level academic medicine learning environments.

Frontline Reporting from the Epicenter of a Global Pandemic: A Survey of the Impact of COVID-19 on Plastic Surgery Training in New York and New Jersey

BACKGROUND

Since the first documented case of coronavirus disease of 2019 (COVID-19), the greater New York City area quickly became the epicenter of the global pandemic, with over 500,000 cases and 50,000 deaths. This unprecedented crisis affected all aspects of health care, including plastic surgery residency training. The purpose of this study was to understand the specific impact of the COVID-19 pandemic on plastic surgery residencies.

METHODS

A survey of all plastic surgery residency training programs in the greater New York City area was conducted. The impact to training during the peak months of infection (March and April of 2020) was evaluated using resident education as measured by case numbers, need for redeployment, and staff wellness as primary outcome variables.

RESULTS

A total of 11 programs were identified in the region, and seven programs completed the survey, with a response rate 63.6 percent. When comparing productivity in March and April of 2019 to March and April of 2020, a total decrease in surgical volume of 64.8 percent (range, 19.7 to 84.8 percent) and an average of 940 (range, 50 to 1287) cancelled clinic visits per month were observed. These decreases directly correlated with the local county's COVID-19 incidence rates (p = 0.70). A total of 83 percent of programs required redeployment to areas of need, and correlation between local incidence of COVID-19 and the percentage of residents redeployed to non-plastic surgical clinical environments by a given program (ρ = 0.97) was observed.

CONCLUSION

As the first COVID-19 wave passes the greater New York area and spreads to the rest of the country, the authors hope their experience will shed light on the effects of the ongoing COVID-19 pandemic, and inform other programs on what to expect and how they can try and prepare for future public health crises.

Assessment of Discrimination, Bias, and Inclusion in a United States Hematology and Oncology Fellowship Program

IMPORTANCE

Medical trainees frequently experience discrimination. Understanding their experiences is essential to improving learning environments.

OBJECTIVE

To characterize trainee experiences of discrimination and inclusion to inform graduate medical education (GME) policies.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study used an anonymous telephone interview technique to gather data from hematology and oncology fellows. All current trainees and recent graduates were eligible. Interviews were conducted anonymously with interviewer and participant in separate locations and recorded and transcribed. Data were analyzed in an iterative process into major themes using a general inductive analysis approach. Demographic information was obtained via anonymous survey. Data collection and analysis were conducted from July 2018 to November 2019.

MAIN OUTCOMES AND MEASURES

Emergent themes illustrating bias and inclusion in a GME program.

RESULTS

Among 34 fellows and recent graduates who were approached for this study, 20 consented and 17 were interviewed. Of those interviewed, 10 were men, and the median (range) age was 32 (29-53) years. The racial and ethnic distribution included 6 Asian individuals, 2 Black individuals, 3 Hispanic individuals, 2 multiracial individuals, and 4 White individuals. All fellows reported having experienced and/or witnessed discriminatory behavior. The themes elucidated were (1) foreign fellows perceived as outsiders, (2) US citizens feeling alien at home, (3) gender role-typing, (4) perception of futility of reporting, (5) diversity and inclusion, and (6) coping strategies. The majority of reported biases were from patients. Only 1 trainee reported any incidents. Reasons for not reporting were difficulty characterizing discrimination and doubt action would occur. Participants reported that diversity of cotrainees, involvement in committees, and open discussions promoted inclusivity.

CONCLUSIONS AND RELEVANCE

In this study, reports of discriminatory behavior toward trainees were common. The anonymous hotline methodology cultivated a safe environment for candid discussions. These findings suggest that GME programs should assess their learning climate regarding bias and inclusivity anonymously and develop processes to support trainees.

Perspectives of Stakeholders About an Early Result Acceptance Program to Complement the Residency Match in Obstetrics and Gynecology

IMPORTANCE

The residency application process is flawed, costly, and distracts from the preparation for residency. Disruptive change is needed to improve the inefficiencies in current selection processes.

OBJECTIVE

To determine interest in an early result acceptance program (ERAP) among stakeholders in obstetrics and gynecology (OBGYN), and to estimate its outcome in future application cycles.

DESIGN, SETTING, AND PARTICIPANTS

Surveys of stakeholders in March 2021 queried interest in ERAP across the US. Respondents included OBGYN residency applicants, members of the Association of American Medical Colleges Group on Student Affairs, OBGYN clerkship directors, and residency program directors. Statistical analysis was performed from March to April 2021.

EXPOSURES

Respondents completed surveys sent by email from the Association of American Medical Colleges (to OBGYN applicants and members of the Group on Student Affairs), the Association of Professors of Gynecology and Obstetrics (to clerkship directors), and the Council on Resident Education in Obstetrics and Gynecology (to program directors).

MAIN OUTCOMES AND MEASURES

Applicants and program directors indicated their interest in participating in ERAP, and clerkship directors and members of the Group on Student Affairs indicated their likelihood of recommending ERAP using a 5-point Likert scale.

RESULTS

Respondents included 879 (34.0%) of 2579 applicants to OBGYN, 143 (50.3%) of 284 residency program directors, 94 (41.8%) of 225 clerkship directors, and 51 (32.9%) of 155 student affairs deans. The majority of respondents reported being either somewhat or extremely likely to participate in ERAP, including 622 applicants (70.7%) and 87 program directors (60.8%). Interest in ERAP was independent of an applicant's reported board scores, medical school type, race, number of applications submitted, or number of interviews completed. Among program directors, those at university programs were more likely to participate. Stakeholders supported a limit of 3 applications for ERAP, to fill 25% to 50% of residency positions. Estimating the outcome of ERAP using these data suggests 26 280 to 52 560 fewer applications could be submitted in the regular match cycle.

CONCLUSIONS AND RELEVANCE

Stakeholders in the OBGYN application process expressed broad support for the concept of ERAP. The majority of applicants and programs indicated that they would participate, with potentially substantial positive impact on the application process. Careful pilot testing and research regarding implementation are essential to avoid worsening an already dysfunctional application process.

Trends in Race and Ethnicity Among Matriculants to US Oncology Training Programs, 2015-2020

This cross-sectional study assesses underrepresented minority trends across oncology specialties from 2015 to 2020.

Exploring the Association Between USMLE Scores and ACGME Milestone Ratings: A Validity Study Using National Data From Emergency Medicine

PURPOSE

The United States Medical Licensing Examination (USMLE) sequence and the Accreditation Council for Graduate Medical Education (ACGME) milestones represent 2 major components along the continuum of assessment from undergraduate through graduate medical education. This study examines associations between USMLE Step 1 and Step 2 Clinical Knowledge (CK) scores and ACGME emergency medicine (EM) milestone ratings.

METHOD

In February 2019, subject matter experts (SMEs) provided judgments of expected associations for each combination of Step examination and EM subcompetency. The resulting sets of subcompetencies with expected strong and weak associations were selected for convergent and discriminant validity analysis, respectively. National-level data for 2013-2018 were provided; the final sample included 6,618 EM residents from 158 training programs. Empirical bivariate correlations between milestone ratings and Step scores were calculated, then those correlations were compared with the SMEs' judgments. Multilevel regression analyses were conducted on the selected subcompetencies, in which milestone ratings were the dependent variable, and Step 1 score, Step 2 CK score, and cohort year were independent variables.

RESULTS

Regression results showed small but statistically significant positive relationships between Step 2 CK score and the subcompetencies (regression coefficients ranged from 0.02 [95% confidence interval (CI), 0.01-0.03] to 0.12 [95% CI, 0.11-0.13]; all P < .05), with the degree of association matching the SMEs' judgments for 7 of the 9 selected subcompetencies. For example, a 1 standard deviation increase in Step 2 CK score predicted a 0.12 increase in MK-01 milestone rating, when controlling for Step 1. Step 1 score showed a small statistically significant effect with only the MK-01 subcompetency (regression coefficient = 0.06 [95% CI, 0.05-0.07], P < .05).

CONCLUSIONS

These results provide incremental validity evidence in support of Step 1 and Step 2 CK score and EM milestone rating uses.

Overall Impact of the COVID-19 Pandemic on Interventional Radiology Services: A Canadian Perspective

PURPOSE

The aim of this national survey was to assess the overall impact of the coronavirus disease 2019 (COVID-19) pandemic on the provision of interventional radiology (IR) services in Canada.

METHODS

An anonymous electronic survey was distributed via national and regional radiology societies, exploring (1) center information and staffing, (2) acute and on-call IR services, (3) elective IR services, (4) IR clinics, (5) multidisciplinary rounds, (6) IR training, (7) personal protection equipment (PPE), and departmental logistics.

RESULTS

Individual responses were received from 142 interventional radiologists across Canada (estimated 70% response rate). Nearly half of the participants (49.3%) reported an overall decrease in demand for acute IR services; on-call services were maintained at centers that routinely provide these services (99%). The majority of respondents (73.2%) were performing inpatient IR procedures at the bedside where possible. Most participants (88%) reported an overall decrease in elective IR services. Interventional radiology clinics and multidisciplinary rounds were predominately transitioned to virtual platforms. The vast majority of participants (93.7%) reported their center had disseminated an IR specific PPE policy; 73% reported a decrease in case volume for trainees by at least 25% and a proportion of trainees will either have a delay in starting their careers as IR attendings (24%) or fellowship training (35%).

CONCLUSION

The COVID-19 pandemic has had a profound impact on IR services in Canada, particularly for elective cases. Many centers have utilized virtual platforms to provide multidisciplinary meetings, IR clinics, and training. Guidelines should be followed to ensure patient and staff safety while resuming IR services.

The RCA ReCAst: A Root Cause Analysis Simulation for the Interprofessional Clinical Learning Environment

PROBLEM

The Accreditation Council for Graduate Medical Education calls for resident participation in real or simulated interprofessional analysis of a patient safety event. There are far more residents who must participate in these investigations than available institutional root cause analyses (RCAs) to accommodate them. To correct this imbalance, the authors developed an institutionally sponsored, interprofessional RCA simulation program and implemented it across all graduate medical education (GME) residency programs at the Hospital of the University of Pennsylvania.

APPROACH

The authors developed RCA simulations based upon authentic adverse events experienced at their institution. To provide relevance to all GME programs, RCA simulation cases varied widely and included examples of errors involving high-risk medications, communication, invasive procedures, and specimen labeling. Each simulation included residents and other health care professionals such as nurses or pharmacists whose disciplines were involved in the actual event. Participants adopted the role of RCA investigation team, and in small groups systematically progressed through the RCA process.

OUTCOMES

A total of 289 individuals from 18 residency programs participated in an RCA simulation in 2019-2020. This included 84 interns (29%), 123 residents (43%), 20 attending physicians (7%), and 62 (21%) other health care professionals. There was an increase in ability of GME trainees to correctly identify factors required for an RCA investigation (62% pre vs 80% post, P = .02) and an increase in intent to "always report" for each adverse event category (3% pre vs 37% post, P < .001) following the simulation.

NEXT STEPS

The authors plan to expand the RCA simulation program to other GME clinical sites while striving to involve all GME learners in this educational experience at least once during training. Additionally, by collaborating with health system patient safety leaders, they will annually review all new RCAs to identify cases suitable for simulation adaptation.

Medicare Support for Dental and Podiatry Graduate Medical Education Programs

IMPORTANCE

Oral health care faces ongoing workforce challenges that affect patient access and outcomes. While the Medicare program provides an estimated $14.6 billion annually in graduate medical education (GME) payments to teaching hospitals, including explicit support for dental and podiatry programs, little is known about the level or distribution of this public investment in the oral health and podiatry workforce.

OBJECTIVE

To examine Medicare GME payments to teaching hospitals for dental and podiatry residents from 1998 to 2018, as well as the distribution of federal support among states, territories, and the District of Columbia.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study was conducted using data from 1252 US teaching hospitals. Data were analyzed from May through August 2020.

EXPOSURES

Dental and podiatry residency training.

MAIN OUTCOMES AND MEASURES

Medicare dental and podiatry GME payments were examined.

RESULTS

Among 1252 teaching hospitals, Medicare provided nearly $730 million in dental and podiatry GME payments in 2018. From 1998 to 2018, the number of residents supported more than doubled, increasing from 2340 residents to 4856 residents, for a 2.1-fold increase, while Medicare payments for dental and podiatry GME increased from $279 950 531 to $729 277 090, for a 2.6-fold increase. In 2018, an estimated 3504 of 4856 supported positions (72.2%) were dental. Medicare GME payments varied widely among states, territories, and the District of Columbia, with per capita payments by state, territory, and district population ranging from $0.05 in Puerto Rico to $14.24 in New York, while 6 states received no support for dental or podiatry residency programs.

CONCLUSIONS AND RELEVANCE

These findings suggest that dental and podiatry GME represents a substantial public investment, and deliberate policy decisions are needed to target this nearly $730 million and growing investment to address the nation's priority oral and podiatry health needs.

MD-PhD Program Graduates' Engagement in Research: Results of a National Study

PURPOSE

To determine if specialty, among other professional development and demographic variables, predicted MD-PhD program graduates' research engagement.

METHOD

The authors merged the 2015 Association of American Medical Colleges (AAMC) National MD-PhD Program Outcomes Survey database with selected data from the AAMC Student Records System, Graduation Questionnaire, and Graduate Medical Education (GME) Track Resident Survey. At the person level, they tested variables of interest for independent associations with MD-PhD graduates' research engagement using chi-square, Pearson correlations, and analysis of variance tests and logistic and linear regressions.

RESULTS

Of 3,297 MD-PhD graduates from 1991-2010 who were no longer in GME training in 2015, 78.0% (2,572/3,297) reported research engagement. In models controlling for several variables, a neurology (vs internal medicine; adjusted odds ratio [AOR]: 2.48; 95% confidence interval [CI]: 1.60-3.86) or pathology (vs internal medicine; AOR: 1.89; 95% CI: 1.33-2.68) specialty, full-time faculty/research scientist career intention at graduation (vs all other career intentions; AOR: 3.04; 95% CI: 2.16-4.28), and ≥ 1 year of GME research (vs no GME research year[s]; AOR: 2.45; 95% CI: 1.96-3.06) predicted a greater likelihood of research engagement. Among graduates engaged in research, the mean percentage of research time was 49.9% (standard deviation 30.1%). Participation in ≥ 1 year of GME research (beta [β] coefficient: 7.99, P < .001) predicted a higher percentage of research time, whereas a radiation oncology (β: -28.70), diagnostic radiology (β: -32.92), or surgery (β: -29.61) specialty, among others, predicted a lower percentage of research time (each P < .001 vs internal medicine).

CONCLUSIONS

Most MD-PhD graduates were engaged in research, but the extent of their engagement varied substantially among specialties. Across specialties, participation in research during GME may be one factor that sustains MD-PhD graduates' subsequent early- to midcareer research engagement.

Breaking Tradition to Bridge Bench and Bedside: Accelerating the MD-PhD-Residency Pathway

PROBLEM

Physician-scientists are individuals trained in both clinical practice and scientific research. Often, the goal of physician-scientist training is to address pressing questions in biomedical research. The established pathways to formally train such individuals are mainly MD-PhD programs and physician-scientist track residencies. Although graduates of these pathways are well equipped to be physician-scientists, numerous factors, including funding and length of training, discourage application to such programs and impede success rates.

APPROACH

To address some of the pressing challenges in training and retaining burgeoning physician-scientists, New York University Grossman School of Medicine formed the Accelerated MD-PhD-Residency Pathway in 2016. This pathway builds on the previously established accelerated 3-year MD pathway to residency at the same institution. The Accelerated MD-PhD-Residency Pathway conditionally accepts MD-PhD trainees to a residency position at the same institution through the National Resident Matching Program.

OUTCOMES

Since its inception, 2 students have joined the Accelerated MD-PhD-Residency Pathway, which provides protected research time in their chosen residency. The pathway reduces the time to earn an MD and PhD by 1 year and reduces the MD training phase to 3 years, reducing the cost and lowering socioeconomic barriers. Remaining at the same institution for residency allows for the growth of strong research collaborations and mentoring opportunities, which foster success.

NEXT STEPS

The authors and institutional leaders plan to increase the number of trainees who are accepted into the Accelerated MD-PhD-Residency Pathway and track the success of these students through residency and into practice to determine if the pathway is meeting its goal of increasing the number of practicing physician-scientists. The authors hope this model can serve as an example to leaders at other institutions who may wish to adopt this pathway for the training of their MD-PhD students.

GENDER DIFFERENCES IN SELF-REPORTED PROCEDURAL VOLUME AMONG VITREORETINAL FELLOWS

PURPOSE

A prior study revealed discrepancies in self-reported surgical numbers between male and female ophthalmology residents. This study further investigates the gender differences in self-reported procedural volume among vitreoretinal surgery fellows and examines the differences for surgical, medical, and total self-reported procedural volume between male and female vitreoretinal fellows.

METHODS

A retrospective review of case logs submitted to the American Society of Retina Specialists by first-year and second-year vitreoretinal fellows from July 1, 2018, to June 30, 2019, was performed. Fellows who reported fewer than 100 pars plana vitrectomies were excluded. A total of 133 fellows were included.

RESULTS

Overall, 37 of 57 (65%) first-year fellows and 59 of 76 (78%) second-year fellows were male. An average of 1,120 procedures were self-reported among all vitreoretinal fellows. In the group of second-year fellows at the completion of fellowship, men reported more total procedures (1,171 [864-1,600] vs. 1,005 [719-1,257]; P = 0.072). Women reported statistically significant fewer endolaser (P = 0.018), internal limiting membrane peel (P = 0.042), and cryoretinopexy (P = 0.002) procedures compared with men. When splitting the data by total surgical versus medical procedures, men reported more procedures than women both surgically (1,077 [799-1,490] vs. 925 [622-1,208]; P = 0.085) and medically (72 [41-116] vs. 56 [20-94]; P = 0.141), although these differences were not statistically significant.

CONCLUSION

There is a trend for female vitreoretinal fellows to report fewer surgical procedures than their male counterparts, raising concerns for gender gaps in vitreoretinal surgical training. Further research is needed to verify this discrepancy and identify potential barriers that female vitreoretinal surgeons are facing in training.

Learner Handover: Who Is It Really For?

PURPOSE

Learner handover is the sharing of information about learners between faculty supervisors. Learner handover can support longitudinal assessment in rotation-based systems, but there are concerns that the practice could bias future assessments or stigmatize struggling learners. Because successful implementation relies on an understanding of existing practices and beliefs, the purpose of this study was to explore how faculty perceive and enact learner handover in the workplace.

METHOD

Using constructivist grounded theory, 23 semistructured interviews were conducted with faculty from 2 Canadian universities between August and December 2018. Participants were asked to describe their learner handover practices, including learner handover delivered or received about resident and student trainees either within or between clinical rotations. The authors probed to understand why faculty used learner handover and their perceptions of its benefits and risks.

RESULTS

Learner handover occurs both formally and informally and serves multiple purposes for learners and faculty. While participants reported that learner handover was motivated by both learner benefit and patient safety, they primarily described motivations focused on their own needs. Learner handover was used to improve faculty efficiency by focusing teaching and feedback and was perceived as a "self-defense mechanism" when faculty were uncertain about a learner's competence and trustworthiness. Informal learner handover also served social or therapeutic purposes when faculty used these conversations to gossip, vent, or manage insecurities about their assessment of learner performance. Because of its multiple, sometimes unsanctioned purposes, participants recommended being reflective about motivations behind learner handover conversations.

CONCLUSIONS

Learners are not the only potential beneficiaries of learner handover; faculty use learner handover to lessen insecurities surrounding entrustment and assessment of learners and to openly share their frustrations. The latter created tensions for faculty needing to share stresses but wanting to act professionally. Formal education policies regarding learner handover should consider faculty perspectives.

Burnout and engagement among PhD students in medicine: the BEeP study

INTRODUCTION

Using a self-determination theory framework, we investigated burnout and engagement among PhD students in medicine, and their association with motivation, work-life balance and satisfaction or frustration of their basic psychological needs.

METHOD

This cross-sectional study was conducted among PhD students at a university medical centre (n = 990) using an electronic survey on background characteristics and validated burnout, engagement, motivation and basic psychological needs questionnaires. Cluster analysis was performed on the burnout subscale scores to find subgroups within the sample which had similar profiles on burnout. Structural equation modelling was conducted on a hypothesized model of frustration of basic psychological needs and burnout.

RESULTS

The response rate was 47% (n = 464). We found three clusters/subgroups which were composed of PhD students with similar burnout profiles within the cluster and different profiles between the clusters. Cluster 1 (n = 199, 47%) had low scores on burnout. Clusters 2 (n = 168, 40%) and 3 (n = 55, 13%) had moderate and high burnout scores, respectively, and were associated with low engagement scores. Cluster 3, with the highest burnout scores, was associated with the lowest motivational, engagement, needs satisfaction and work-life balance scores. We found a good fit for the "basic psychological needs frustration associated with burnout" model.

DISCUSSION

The most important variables for burnout among PhD students in medicine were lack of sleep and frustration of the basic psychological needs of autonomy, competence and relatedness. These add to the factors found in the literature.

Evaluation of pediatric procedural sedation education in pediatric emergency medicine fellowships

ABSTRACT

Pediatric procedural sedation (PPS) is often performed outside of the operating room, and by various sub-specialty providers. There is no consistency in how pediatric emergency medicine (PEM) fellows are trained in PPS. The objective of this study was to survey PEM program directors (PDs) and PEM fellows about their current sedation teaching practices via a direct survey. While many fellowship programs train PEM fellows in PPS, we hypothesize that there is no consistent method of developing and measuring this skill.A 12-question survey was sent to PEM PDs directly via email. A separate 17-question survey was sent to current PEM fellows via their program coordinators by email. Each survey had multiple choice, yes-no and select-all program questions. Responses were collected in an online (REDCap) database and summarized as frequencies and percentages.Based on identifiable email, 67 programs were contacted, with a PD response rate of 46 (59%). Sixty-two program coordinators were contacted based on identifiable email with 78 fellow responses. We noted that 11/46 PD respondents offer a formal PPS rotation. Thirty programs report using propofol in the emergency department and 93% of PD respondents (28/30) actively train fellows in the use of propofol. Approximately 62% of PEM fellow respondents (48/78) report sedating without any attending oversight. Twenty-eight percent of PEM fellow respondents report using simulation as a component of their sedation training.PPS is a critical skill. However, there is a lack of consistency in both education and evaluation of competency in this area. An organized PPS rotation would improve PPS case exposure and PPS skills.

Postgraduate Assessment Approaches Across Surgical Specialties: A Systematic Review of the Published Evidence

PURPOSE

Ensuring competence for surgical trainees requires holistic assessment of the qualities and competencies necessary to practice safely and effectively. To determine the next steps toward achieving this aim, the authors conducted a systematic review to summarize and appraise the available evidence related to any assessment approach to postgraduate surgical training and to identify the dominant themes for assessment approaches across different specialties or countries.

METHOD

Medline and Embase were searched on January 10, 2019, without language or time restrictions. Any peer-reviewed study that described an assessment framework (in practice or novel) throughout postgraduate surgical training globally was included. An iterative review and thematic analysis were performed on full-text articles to determine assessment themes. Studies were then grouped by assessment themes. A tailored quality assessment of the studies included in the final analysis was conducted. Assessment themes and validity were compared across surgical specialties and countries.

RESULTS

From an initial 7,059 articles, 91 studies (evaluating 6,563 surgical trainees) were included in the final analysis. Ten defined assessment themes were extracted. Ten studies (11.0%) were deemed low risk of bias based on the quality assessment tool used and thus were determined to be high quality. Minor differences in assessment themes were observed between specialties and countries. Assessment themes neglected by individual surgical specialties and assessment themes that need validated assessment tools were identified.

CONCLUSIONS

This review highlights the low quality of evidence and fragmented efforts to develop and optimize surgical assessments. The minor differences observed demonstrate a common approach, globally and across specialties, related to surgical assessments. A paradigm shift in assessment approaches, which will require national and international collaboration, is required to optimize design and validation so that a comprehensive assessment of surgical competence can be implemented.

Evaluation of Factors Associated With Successful Matriculation to Colon and Rectal Surgery Fellowship

BACKGROUND

As an increasing number of general surgery residents apply for fellowship positions, it is important to identify factors associated with successful matriculation. For applicants to colon and rectal surgery, there are currently no objective data available to distinguish which applicant attributes lead to successful matriculation.

OBJECTIVE

The purpose of this study was to identify objective factors that differentiate colon and rectal surgery fellowship applicants who successfully matriculate with those who apply but do not matriculate.

DESIGN

This was a retrospective analysis of colon and rectal surgery applicant characteristics.

SETTINGS

Deidentified applicant data provided by the Association of American Medical Colleges from 2015 to 2017 were included.

MAIN OUTCOME MEASURES

Applicant demographics, medical school and residency factors, number of program applications, number of publications, and journal impact factors were analyzed to determine associations with successful matriculation.

RESULTS

Most applicants (n = 371) and subsequent matriculants (n = 248) were white (61%, 62%), male (65%, 63%), US citizens (80%, 88%) who graduated from US allopathic medical schools (66%, 75%). Statistically significant associations included graduation from US allopathic medical schools (p < 0.0001), US citizenship (p < 0.0001), and number of program applications (p = 0.0004). Other factors analyzed included American Osteopathic Association membership (p = 0.57), university-based residency (p = 0.51), and residency association with a colon and rectal surgery training program (p = 0.89). Number of publications and journal impact factors were not statistically different between cohorts (p = 0.067, p = 0.150).

LIMITATIONS

American Board of Surgery In-Training Examination scores, rank list, and subjective characteristics, such as strength of interview and letters of recommendation, were not available using our data source.

CONCLUSIONS

Successful matriculation to a colon and rectal surgery fellowship program was found to be associated with US citizenship, graduation from a US allopathic medical school, and greater number of program applications. The remaining objective metrics analyzed were not associated with successful matriculation. Subjective and objective factors that were unable to be measured by this study are likely to play a determining role. See Video Abstract at http://links.lww.com/DCR/B415.

EVALUACIN DE FACTORES VINCULADOS EN LA INMATRICULACIN EXITOSA PARA BECAS DE CIRUGA COLORRECTAL

ANTECEDENTES:A medida que un número cada vez mayor de residentes de Cirugía General solicitan una beca, es importante identificar los factores vinculados con una inmatriculación exitosa. Para los candidatos a una beca en Cirugía Colorrectal, hoy en día no existen datos objetivos disponibles para distinguir qué atributos del solicitante conducen a una inmatriculación exitosa.OBJETIVO:Identificar objetivamente los factores que diferencian un candidato a una beca en Cirugía Colorrectal que se inmatricula con éxito de aquel que aplica pero no llega a inmatricularse.DISEÑO:Análisis retrospectivo de las características de los solicitantes de beca para Cirugía Colorrecatl.AJUSTES:Datos de los solicitantes no identificados, proporcionados por la Asociación de Colegios Médicos Estadounidenses de 2015 a 2017.PRINCIPALES MEDIDAS DE RESULTADO:Se analizaron los factores demográficos del solicitante, las facultades de medicina y los factores de la residencia, el número de solicitudes de programas, el número y el factor de impacto de las publicaciones realizadas para determinar la asociación con una inmatriculación exitosa.RESULTADOS:La mayoría de los solicitantes (n = 371) que posteriormente fueron inmatriculados exitosamente (n = 248) eran blancos (61%, 62%, respectivamente), hombres (65%, 63%), ciudadanos estadounidenses (80%, 88%) que se graduaron de Facultades de medicina alopática en los EE. UU. (66%, 75%). Las asociaciones estadísticamente significativas incluyeron la graduación de las escuelas de medicina alopática de los EE. UU. (P <0,0001), la ciudadanía de los EE. UU. (P <0,0001) y el número de solicitudes de programas (p = 0,0004). Otros factores analizados incluyeron: membresía AOA (p = 0,57), la residencia universitaria (p = 0,51) y asociación de la residencia con un programa de formación en Cirugía Colorrectal (p = 0,89). El número de publicaciones y los factores de impacto de las revistas no fueron estadísticamente diferentes entre las cohortes (p = 0,067, p = 0,15, respectivamente).LIMITACIONES:El Score ABSITE, la posición en lista de clasificación y las características subjetivas como el de una buena entrevista y las cartas de recomendación no se encontraban disponibles en la fuente de datos.CONCLUSIONES:Se encontró que la inmatriculación exitosa a un programa de becas de Cirugía Colorreectal estaba asociada con la ciudadanía estadounidense, la graduación en una Facultad de medicina alopática en los EE. UU, y al mayor número de solicitudes de programas. El analisis de las medidas objetivas restantes no se asociaron con una inmatriculación exitosa. Es probable que los factores subjetivos y objetivos que no pudieron ser medidos por este estudio jueguen un papel determinante. Consulte Video Resumen en http://links.lww.com/DCR/B415. (Traducción-Dr Xavier Delgadillo).

Demographics and Career Intentions of Graduates of Combined Baccalaureate-MD Programs, 2010-2017: An Analysis of AAMC Graduation Questionnaire Data

PURPOSE

Combined baccalaureate-MD programs exist to fulfill a variety of educational missions, including to promote the development of physician-scientists, increase workforce diversity, promote primary care careers, and meet the needs of underserved patients. The authors sought to determine the demographics of combined program graduates, as well as their intention to practice in primary care (IPPC) and intention to work with the medically underserved (IWMU), as compared with graduates of traditional MD programs.

METHOD

Data from the 2010-2017 Association of American Medical Colleges Graduation Questionnaire, a national survey of graduating medical students, were recategorized (e.g., as combined program or traditional program) before analysis. Logistic regression models on the 2 primary outcomes (IPPC and IWMU) were conducted to estimate odds ratios for the effects of covariates and predictors (e.g., gender, underrepresented in medicine [URM] group member, type of medical degree program).

RESULTS

Data from a total of 109,028 respondents were included (3,182 from combined and 105,846 from traditional programs). Compared with students in traditional programs, those in combined programs were more likely to be younger (age at graduation ≤ 29: 3,143, 98.8% vs 89,688, 84.7%) and female (1,813, 57.0% vs 52,013, 49.1%) but less likely to identify as a URM group member (276, 8.7% vs 14,757, 13.9%). In an adjusted logistic regression model, graduating from a combined program, identifying as female, and IWMU predicted significantly greater odds of IPPC, while identifying as a URM, identifying as female, and having debt predicted significantly greater odds of IWMU. Graduating medical students who indicated family medicine as a career specialty were more likely to indicate an IWMU.

CONCLUSIONS

Medical students graduating from combined programs were more likely to indicate an IPPC but were no more likely to indicate an IWMU than traditional program graduates.

Early Effects of COVID-19 Pandemic on Neurosurgical Training in the United States: A Case Volume Analysis of 8 Programs

OBJECTIVE

To determine the impact of the 2019 novel coronavirus disease (COVID-19) pandemic on operative case volume in 8 U.S. neurosurgical residency training programs in early 2020 and to survey these programs regarding training activities during this period.

METHODS

A retrospective review was conducted of monthly operative case volumes and types for 8 residency programs for 2019 and January through April 2020. Cases were grouped as elective cranial, elective spine, and nonelective emergent cases. Programs were surveyed regarding residents' perceptions of the impact of COVID-19 on surgical training, didactics, and research participation. Data were analyzed for individual programs and pooled across programs.

RESULTS

Across programs, the 2019 monthly mean ± SD case volume was 211 ± 82; 2020 mean ± SD case volumes for January, February, March, and April were 228 ± 93, 214 ± 84, 180 ± 73, and 107 ± 45. Compared with 2019, March and April 2020 mean cases declined 15% (P = 0.003) and 49% (P = 0.002), respectively. COVID-19 affected surgical case volume for all programs; 75% reported didactics negatively affected, and 90% reported COVID-19 resulted in increased research time. Several neurosurgery residents required COVID-19 testing; however, to our knowledge, only 1 resident from the participating programs tested positive.

CONCLUSIONS

This study documents a significant reduction in operative volume in 8 neurosurgery residency training programs in early 2020. During this time, neurosurgery residents engaged in online didactics and research-related activities, reporting increased research productivity. Residency programs should collect data to determine the educational impact of the COVID-19 pandemic on residents' operative case volumes, identify deficiencies, and develop plans to mitigate any effects.

Identifying Entrustable Professional Activities for Shared Decision Making in Postgraduate Medical Education: A National Delphi Study

PURPOSE

Although shared decision making (SDM) is considered the preferred approach in medical decision making, it is currently not routinely used in clinical practice. To bridge the transfer gap between SDM training and application, the authors aimed to reach consensus on entrustable professional activities (EPAs) for SDM and associated behavioral indicators as a framework to support self-directed learning during postgraduate medical education.

METHOD

Using existing literature on SDM frameworks and competencies; input from an interview study with 17 Dutch experts in SDM, doctor-patient communication, and medical education; and a national SDM expert meeting as a starting point, in 2017, the authors conducted a modified online Delphi study with a multidisciplinary Dutch panel of 32 experts in SDM and medical education.

RESULTS

After 3 Delphi rounds, consensus was reached on 4 EPAs-(1) the resident discusses the desirability of SDM with the patient, (2) the resident discusses the options for management with the patient, (3) the resident explores the patient's preferences and deliberations, and (4) the resident takes a well-argued decision together with the patient. Consensus was also reached on 18 associated behavioral indicators. Of the 32 experts, 30 (94%) agreed on this list of SDM EPAs and behavioral indicators.

CONCLUSIONS

The authors succeeded in developing EPAs and associated behavioral indicators for SDM for postgraduate medical education to improve the quality of SDM training and the application of SDM in clinical practice. These EPAs are characterized as process EPAs for SDM in contrast with content EPAs related to diverse medical complaints. A next step is the implementation of the SDM EPAs in existing competency-based workplace curricula.

Does Educational Handover Influence Subsequent Assessment?

PURPOSE

Educational handover (i.e., providing information about learners' past performance) is controversial. Proponents argue handover could help tailor learning opportunities. Opponents fear it could bias subsequent assessments and lead to self-fulfilling prophecies. This study examined whether raters provided with reports describing learners' minor weaknesses would generate different assessment scores or narrative comments than those who did not receive such reports.

METHOD

In this 2018 mixed-methods, randomized, controlled, experimental study, clinical supervisors from 5 postgraduate (residency) programs were randomized into 3 groups receiving no educational handover (control), educational handover describing weaknesses in medical expertise, and educational handover describing weaknesses in communication. All participants watched the same videos of 2 simulated resident-patient encounters and assessed performance using a shortened mini-clinical evaluation exercise form. The authors compared mean scores, percentages of negative comments, comments focusing on medical expertise, and comments focusing on communication across experimental groups using analyses of variance. They examined potential moderating effects of supervisor experience, gender, and mindsets (fixed vs growth).

RESULTS

Seventy-two supervisors participated. There was no effect of handover report on assessment scores (F(2, 69) = 0.31, P = .74) or percentage of negative comments (F(2, 60) = 0.33, P = .72). Participants who received a report indicating weaknesses in communication generated a higher percentage of comments on communication than the control group (63% vs 50%, P = .03). Participants who received a report indicating weaknesses in medical expertise generated a similar percentage of comments on expertise compared to the controls (46% vs 47%, P = .98).

CONCLUSIONS

This study provides initial empirical data about the effects of educational handover and suggests it can-in some circumstances-lead to more targeted feedback without influencing scores. Further studies are required to examine the influence of reports for a variety of performance levels, areas of weakness, and learners.

Impact of COVID-19 on Neurosurgical Training in Southeast Asia

OBJECTIVE

Neurosurgery departments worldwide have been forced to restructure their training programs because of the coronavirus disease 2019 (COVID-19) pandemic. In this study, we describe the impact of COVID-19 on neurosurgical training in Southeast Asia.

METHODS

We conducted an online survey among neurosurgery residents in Indonesia, Malaysia, Philippines, Singapore, and Thailand from May 22 to 31, 2020 using Google Forms. The 33-item questionnaire collected data on elective and emergency neurosurgical operations, ongoing learning activities, and health worker safety.

RESULTS

A total of 298 of 470 neurosurgery residents completed the survey, equivalent to a 63% response rate. The decrease in elective neurosurgical operations in Indonesia and in the Philippines (median, 100% for both) was significantly greater compared with other countries (P < 0.001). For emergency operations, trainees in Indonesia and Malaysia had a significantly greater reduction in their caseload (median, 80% and 70%, respectively) compared with trainees in Singapore and Thailand (median, 20% and 50%, respectively; P < 0.001). Neurosurgery residents were most concerned about the decrease in their hands-on surgical experience, uncertainty in their career advancement, and occupational safety in the workplace. Most of the residents (n = 221, 74%) believed that the COVID-19 crisis will have a negative impact on their neurosurgical training overall.

CONCLUSIONS

An effective national strategy to control COVID-19 is crucial to sustain neurosurgical training and to provide essential neurosurgical services. Training programs in Southeast Asia should consider developing online learning modules and setting up simulation laboratories to allow trainees to systematically acquire knowledge and develop practical skills during these challenging times.

Critical Evaluation of Interventional Neuroradiology Fellowship Program Websites in North America

OBJECTIVE

To investigate the accessibility and content of interventional neuroradiology (INR) fellowship program websites in North America.

METHODS

We obtained a list of INR/endovascular surgical neuroradiology (ESN) fellowship programs from the Accreditation Council for Graduate Medical Education, the Committee on Advanced Subspecialty Training, the Society of NeuroInterventional Surgery, and the Neurosurgical Fellowship Training Program Directory websites. Individual program websites were evaluated for 27 different fellow recruitment and education criteria. U.S. programs were grouped based on census region and national ranking, and differences between these groups with regard to fellow recruitment and education characteristics were analyzed using nonparametric statistics.

RESULTS

A total of 79 INR/ESN fellowship websites were evaluated for presence of fellow recruitment and education features. Approximately one third of all features pertinent to recruitment (32.11%) and approximately 1 in 5 features regarding education (19.11%) were described in these websites. Program description (69.6%), program coordinator/administrator contact e-mail (59.5%), program director's name (59.5%), program eligibility requirements (51.9%), research opportunities (40.5%), and faculty listing (39.2%) were among the most frequently described features, whereas details about parking (1.3%), interview day itinerary (1.3%), meal allowance (2.5%), retirement and benefits (3.8%), and call schedule (5.1%) were the least frequently described features. There was no significant difference between surveyed features and programs when stratified by U.S. census region, neurosurgery/neurology hospital rankings, or accreditation status.

CONCLUSIONS

INR/ESN fellowship website content is variable across North America and there is room for improvement to develop and enhance comprehensiveness of program website content.

Fellowship Match Outcomes in the U.S. From 2010 to 2017: Analysis of San Francisco Match

PURPOSE

To describe applicant characteristics and outcomes associated with the ophthalmology fellowship match.

DESIGN

Retrospective case-control study.

METHODS

This study took place in San Francisco and matched data for ophthalmology fellowship applicants in the USA. The study population was registrants for the 2010-2017 ophthalmology fellowship match cycles. The match rate took place during the 8-year study period. Applicant characteristics were stratified by match status and factors associated with matching to ophthalmology fellowship positions.

RESULTS

Between 2010 and 2017, most applicants (2,558/3,471; 73.7%) were matched into ophthalmology fellowship programs. No difference over time in the proportion of applicants that matched for fellowship was identified (P = .41). On average, ophthalmology residents who were matched into fellowships had higher step 1 (difference: 9; 99% confidence interval [CI]: 6.8-10.9; P < .001), step 2 (difference: 9.5; 99% CI: 7-12; P < .001), and step 3 (difference: 7.4; 99% CI: 5-9.7; P <.001) scores than those who did not match. Applicants who matched also had a greater number of application distributions (difference: 9.6; 99% CI: 7.9-11.2; P < .001), and ranked programs on the match list (difference: 6.2; 99% CI: 5.8-6.7; P < .001). Among applicants who matched, 15% matched at the same institute, 29% matched in the same state, and 45% matched in the same region. On multivariable analysis, factors associated with an increased likelihood of matching into an ophthalmology fellowship program included graduates from the US versus graduates from non-US residency programs (odds ratio [OR]: 2.09; 99% CI: 1.27-3.44; P <.001), increasing percentage of applications ranked (number of ranked programs and/or number of applications distributed) (OR: 1.02; 99% CI: 1.02-1.03; P < .001) as well as having ranked more programs (OR: 1.24; 99% CI: 1.17-1.31; P < .001). Medical graduate status outside of the US (OR: 0.58; 99% CI: 0.36-0.93; P < .001) was associated with decreased odds of matching for fellowship.

CONCLUSIONS

From 2010 to 2017, approximately three-quarters of residents applying for an ophthalmology fellowship position matched. Factors associated with increased likelihood of matching included the applicant's graduating from a U.S. residency, graduating from a U.S. medical school, ranking more programs, and having a higher percentage of applications ranked (number of programs ranked by applicant and/or number of applications distributed). The information gained from this study may help applicants as they consider applying to fellowship programs.

Telemedicine in Radiation Oncology: Is It Here to Stay? Impacts on Patient Care and Resident Education

PURPOSE

Telemedicine was rapidly and ubiquitously adopted during the COVID-19 pandemic. However, there are growing discussions as to its role postpandemic.

METHODS AND MATERIALS

We surveyed patients, radiation oncology (RO) attendings, and RO residents to assess their experience with telemedicine. Surveys addressed quality of patient care and utility of telemedicine for teaching and learning core competencies. Satisfaction was rated on a 6-point Likert-type scale. The quality of teaching and learning was graded on a 5-point Likert-type scale, with overall scores calculated by the average rating of each core competency required by the Accreditation Council for Graduate Medical Education (range, 1-5).

RESULTS

Responses were collected from 56 patients, 12 RO attendings, and 13 RO residents. Patient feedback was collected at 17 new-patient, 22 on-treatment, and 17 follow-up video visits. Overall, 88% of patients were satisfied with virtual visits. A lower proportion of on-treatment patients rated their virtual visit as "very satisfactory" (68.2% vs 76.5% for new patients and 82.4% for follow-ups). Only 5.9% of the new patients and none of the follow-up patients were dissatisfied, and 27% of on-treatment patients were dissatisfied. The large majority of patients (88%) indicated that they would continue to use virtual visits as long as a physical examination was not needed. Overall scores for medical training were 4.1 out of 5 (range, 2.8-5.0) by RO residents and 3.2 (range, 2.0-4.0) by RO attendings. All residents and 92% of attendings indicated they would use telemedicine again; however, most indicated that telemedicine is best for follow-up visits.

CONCLUSIONS

Telemedicine is a convenient means of delivering care to patients, with some limitations demonstrated for on-treatment patients. The majority of both patients and providers are interested in using telemedicine again, and it will likely continue to supplement patient care.

Learner handover: Perspectives and recommendations from the front-line

INTRODUCTION

Current medical education models increasingly rely on longitudinal assessments to document learner progress over time. This longitudinal focus has re-kindled discussion regarding learner handover-where assessments are shared across supervisors, rotations, and educational phases, to support learner growth and ease transitions. The authors explored the opinions of, experiences with, and recommendations for successful implementation of learner handover among clinical supervisors.

METHODS

Clinical supervisors from five postgraduate medical education programs at one institution completed an online questionnaire exploring their views regarding learner handover, specifically: potential benefits, risks, and suggestions for implementation. Survey items included open-ended and numerical responses. The authors used an inductive content analysis approach to analyze the open-ended questionnaire responses, and descriptive and correlational analyses for numerical data.

RESULTS

Seventy-two participants completed the questionnaire. Their perspectives varied widely. Suggested benefits of learner handover included tailored learning, improved assessments, and enhanced patient safety. The main reported risk was the potential for learner handover to bias supervisors' perceptions of learners, thereby affecting the validity of future assessments and influencing the learner's educational opportunities and well-being. Participants' suggestions for implementation focused on who should be involved, when and for whom it should occur, and the content that should be shared.

DISCUSSION

The diverse opinions of, and recommendations for, learner handover highlight the necessity for handover to maximize learning potential while minimizing potential harms. Supervisors' suggestions for handover implementation reveal tensions between assessment-of and for-learning.

Postgraduate education among family and community physicians in Brazil: the Trajetórias MFC project

OBJECTIVE

Our objective was to describe the postgraduate education trajectories of family and community physicians in Brazil, where neither primary healthcare nor family and community medicine is recognised as a knowledge area for the purpose of research and postgraduate education (master's and PhD degrees).

DESIGN

An observational, exploratory study, using administrative data. A nationwide list of family and community physicians as of late November 2018 was compiled from multiple sources. Data on the mode of specialisation was obtained from the same sources and were correlated with data on master's and PhD degrees, obtained from the curricula vitae on the Lattes Platform.

SETTING

This study was set in Brazil.

PARTICIPANTS

6238 family and community physicians (58.3% female), of whom 2795 had earned a specialist certificate (identified from the list of physicians certified by Sociedade Brasileira de Medicina de Família e Comunidade) and 3957 had completed medical residency (identified from SisCNRM, the national information system for medical residency).

RESULTS

A master's degree was held by 747 (12.0%) family and community physicians, and a PhD by 170 (2.7%); most degrees were in collective health (47.0% and 42%, respectively). Men were more likely than women to hold a master's degree (adjusted odds ratio (aOR) 1.24, 95% uncertainty interval (UI) 1.07-1.45) and even more likely to a hold PhD (aOR 1.86, 95% UI 1.35-2.59). Family and community physicians were also less likely to hold a PhD degree if their master's degree was professional (oriented towards jobs outside academia) instead of academic (aOR 0.15, 95% UI 0.05-0.39) or in some area other than collective health or medicine (aOR 0.41, 95% UI 0.21-0.78, compared with a master's degree in collective health). The postgraduate degree was more likely to precede specialisation for family and community physicians specialising through certification (master's degree 39.9%, PhD 33%) than through medical residency (master's degree 9.1%, PhD 6%).

CONCLUSION

Family and community physicians in Brazil increasingly earn academic and professional master's and PhD degrees, with an emphasis on collective health, even though women seemingly face barriers to advance their education. The consequences of different postgraduate trajectories should be critically examined.

Assessment of Training in Health Disparities in US Internal Medicine Residency Programs

IMPORTANCE

Health disparities continue to exist despite the call to increase education of health care practitioners. An assessment of health disparities education has not been previously studied in a national cohort.

OBJECTIVE

To describe and compare the curriculum on health disparities from the perspective of program directors and perceptions of training among internal medicine residents.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional survey study used a survey of US internal medicine program directors, the 2015 Association of Program Directors in Internal Medicine annual survey, which included questions about health disparities curriculum, and a 1-time survey of US internal medicine residents that asked questions related to their training in health disparities on the American College of Physicians 2015 Internal Medicine In-Training Examination. All internal medicine program directors who were members of Association of Program Directors in Internal Medicine (368 of 396 accredited programs), and internal medicine residents who took the Internal Medicine In-Training Examination were eligible. Final analysis of the merged data set was completed in 2018.

EXPOSURES

Questions were included on the annual Association of Program Directors in Internal Medicine survey and the Internal Medicine In-Training Examination.

MAIN OUTCOMES AND MEASURES

Program directors reported on presence of health disparities curriculum, educational methods, quality, barriers and challenges to curriculum, and Clinical Learning Environment Review. Residents reported whether they received training and quality of the training in health disparities.

RESULTS

A total of 227 program directors (response rate, 61.7%) and 22 723 residents (response rate, 87.2%) responded to the surveys. A total of 90 program directors (39.6%) reported a curriculum in health disparities, but among these, only 16 program directors (17.8%) felt quality of their education was very good or excellent. In more than half of the programs (52 programs [55.9%]), outcomes of the curriculum were not measured. After merging, the combined data set included 18 883 residents from 366 APDIM member programs with 225 program director responses. Among these, 13 251 residents (70.2%) reported some training in caring for patients at risk for health disparities. Of residents who reported receiving training, 10 494 (79.2%) rated the quality as very good or excellent.

CONCLUSIONS AND RELEVANCE

These findings suggest that that despite the Clinical Learning Environment Review mandate and Accreditation Council for Graduate Medical Education required competencies for training in health disparities, relatively few internal medicine programs in the US provided educational curriculum. Additionally, the existence of health disparities curricula in internal medicine training programs was not associated with resident's perception of training or its quality.

Characteristics of ACGME Residency Programs That Select Osteopathic Medical Graduates

BACKGROUND

The transition from American Osteopathic Association (AOA) and Accreditation Council for Graduate Medical Education (ACGME) residency matches to a single graduate medical education accreditation system culminated in a single match in 2020. Without AOA-accredited residency programs, which were open only to osteopathic medical (DO) graduates, it is not clear how desirable DO candidates will be in the unified match. To avoid increased costs and inefficiencies from overapplying to programs, DO applicants could benefit from knowing which specialties and ACGME-accredited programs have historically trained DO graduates.

OBJECTIVE

This study explores the characteristics of residency programs that report accepting DO students.

METHODS

Data from the American Medical Association's Fellowship and Residency Electronic Interactive Database Access were analyzed for percentage of DO residents in each program. Descriptive statistics and a logit link generalized linear model for a gamma distribution were performed.

RESULTS

Characteristics associated with graduate medical education programs that reported a lower percentage of DO graduates as residents were surgical subspecialties, longer training, and higher US Medical Licensing Examination Step 1 scores of their residents compared with specialty average. Characteristics associated with a higher percentage of DO graduates included interviewing more candidates for first-year positions and reporting a higher percentage of female residents.

CONCLUSIONS

Wide variation exists in the percentage of DO graduates accepted as residents among specialties and programs. This study provides valuable information about the single Match for DO graduates and their advisers and outlines education opportunities for the osteopathic profession among the specialties with low percentages of DO students as residents.

Are we generating more assessments without added value? Surgical trainees' perceptions of and receptiveness to cross-specialty assessment

INTRODUCTION

Competency-based medical education (CBME) hinges on robust assessment. However, integrating regular workplace-based assessment within demanding and sometimes chaotic clinical environments remains challenging. Many faculty lack assessment expertise, and some programs lack the infrastructure and faculty numbers to fulfill CBME's mandate. Recognizing this, we designed and implemented an assessment innovation that trains and deploys a cadre of faculty to assess in specialties outside their own. Specifically, we explored trainees' perceptions of and receptiveness to this novel assessment approach.

METHODS

Within Western University's Surgical Foundations program, 27 PGY‑1 trainees were formatively assessed by trained non-surgeons on a basic laparoscopic surgical skill. These assessments did not impact trainees' progression. Four focus groups were conducted to gauge residents' sentiments about the experience of cross-specialty assessment. Data were then analyzed using a thematic analysis approach.

RESULTS

While a few trainees found the experience motivating, more often trainees questioned the feedback they received and the practicality of this assessment approach to advance their procedural skill acquisition. What trainees wanted were strategies for improvement, not merely an assessment of performance.

DISCUSSION

Trainees' trepidation at the idea of using outside assessors to meet increased assessment demands appeared grounded in their expectations for assessment. What trainees appeared to desire was a coach-someone who could break their performance into its critical individual components-as opposed to an assessor whose role was limited to scoring their performance. Understanding trainees' receptivity to new assessment approaches is crucial; otherwise training programs run the risk of generating more assessments without added value.

I Can't Breathe: The Continued Disproportionate Exclusion of Black Physicians in the United States Radiation Oncology Workforce

Purpose

Black physicians remain disproportionately underrepresented in certain medical specialties, yet comprehensive assessments in radiation oncology (RO) are lacking. Our purpose was to report current and historical representation trends for Black physicians in the US RO workforce.

Methods and Materials

Public registries were used to assess significant differences in 2016 representation for US vs RO Black academic full-time faculty, residents, and applicants. Historical changes from 1970 to 2016 were reported descriptively. Linear regression was used to assess significant changes for Black residents and faculty from 1995 to 2016.

Results

In 2016, Black people represented 3.2% vs 1.5% (P < .001), 5.6% vs 3.2% (P = .005), and 6.5% vs 5.4% (P = .352) of US vs RO faculty, residents, and applicants, respectively. Although RO residents nearly doubled from 374 (1974) to 720 (2016), Black residents peaked at 31 in 1984 (5.9%; 31 of 522) and fell to 23 (3.2%; 23 of 720) in 2016 across 91 accredited programs; Black US graduate medical education trainees nearly doubled over the same period: 3506 (1984) to 6905 (2016). From 1995 to 2016, Black US resident representation significantly increased by 0.03%/y, but decreased significantly in RO by –0.20%/y before 2006 and did not change significantly thereafter. Over the same period, Black US faculty representation significantly increased by 0.02%/y, whereas Black RO faculty significantly increased by 0.07%/y before 2006, then decreased significantly by –0.16%/y thereafter. The number of Black RO faculty peaked at 37 in 2006 (3.1%; 37 of 1203) and was 27 (1.5%; 27 of 1769) in 2016, despite the nearly 1.5-fold increase in the number of both RO faculty and Black US faculty overall (4169 in 2006 and 6047 in 2016) during that period.

Conclusions

Black physicians remain disproportionately underrepresented in RO despite an increasing available pipeline in the US physician workforce. Deliberate efforts to understand barriers to specialty training and inclusion, along with evidence-based targeted interventions to overcome them, are needed to ensure diversification of the RO physician workforce.

Association of Gender With Learner Assessment in Graduate Medical Education

IMPORTANCE

Gender bias may affect assessment in competency-based medical education.

OBJECTIVE

To evaluate the association of gender with assessment of internal medicine residents.

DESIGN, SETTING, AND PARTICIPANTS

This multisite, retrospective, cross-sectional study included 6 internal medicine residency programs in the United States. Data were collected from July 1, 2016, to June 30, 2017, and analyzed from June 7 to November 6, 2019.

EXPOSURES

Faculty assessments of resident performance during general medicine inpatient rotations.

MAIN OUTCOMES AND MEASURES

Standardized scores were calculated based on rating distributions for the Accreditation Council for Graduate Medical Education's core competencies and internal medicine Milestones at each site. Standardized scores are expressed as SDs from the mean. The interaction of gender and postgraduate year (PGY) with standardized scores was assessed, adjusting for site, time of year, resident In-Training Examination percentile rank, and faculty rank and specialty.

RESULTS

Data included 3600 evaluations for 703 residents (387 male [55.0%]) by 605 faculty (318 male [52.6%]). Interaction between resident gender and PGY was significant in 6 core competencies. In PGY2, female residents scored significantly higher than male residents in 4 of 6 competencies, including patient care (mean standardized score [SE], 0.10 [0.04] vs 0.22 [0.05]; P = .04), systems-based practice (mean standardized score [SE], -0.06 [0.05] vs 0.13 [0.05]; P = .003), professionalism (mean standardized score [SE], -0.04 [0.06] vs 0.21 [0.06]; P = .001), and interpersonal and communication skills (mean standardized score [SE], 0.06 [0.05] vs 0.32 [0.06]; P < .001). In PGY3, male residents scored significantly higher than female patients in 5 of 6 competencies, including patient care (mean standardized score [SE], 0.47 [0.05] vs 0.32 [0.05]; P = .03), medical knowledge (mean standardized score [SE], 0.47 [0.05] vs 0.24 [0.06]; P = .003), systems-based practice (mean standardized score [SE], 0.30 [0.05] vs 0.12 [0.06]; P = .02), practice-based learning (mean standardized score [SE], 0.39 [0.05] vs 0.16 [0.06]; P = .004), and professionalism (mean standardized score [SE], 0.35 [0.05] vs 0.18 [0.06]; P = .03). There was a significant increase in male residents' competency scores between PGY2 and PGY3 (range of difference in mean adjusted standardized scores between PGY2 and PGY3, 0.208-0.391; P ≤ .002) that was not seen in female residents' scores (range of difference in mean adjusted standardized scores between PGY2 and PGY3, -0.117 to 0.101; P ≥ .14). There was a significant increase in male residents' scores between PGY2 and PGY3 cohorts in 6 competencies with female faculty and in 4 competencies with male faculty. There was no significant change in female residents' competency scores between PGY2 to PGY3 cohorts with male or female faculty. Interaction between faculty-resident gender dyad and PGY was significant in the patient care competency (β estimate [SE] for female vs male dyad in PGY1 vs PGY3, 0.184 [0.158]; β estimate [SE] for female vs male dyad in PGY2 vs PGY3, 0.457 [0.181]; P = .04).

CONCLUSIONS AND RELEVANCE

In this study, resident gender was associated with differences in faculty assessments of resident performance, and differences were linked to PGY. In contrast to male residents' scores, female residents' scores displayed a peak-and-plateau pattern whereby assessment scores peaked in PGY2. Notably, the peak-and-plateau pattern was seen in assessments by male and female faculty. Further study of factors that influence gender-based differences in assessment is needed.

H-1B Visa Sponsorship and Physician Trainee Retention: A Single Institution Experience

BACKGROUND

International medical graduates (IMGs) form a significant portion of the physician workforce in the United States and are vital in filling training slots due to a shortage of American medical graduates. Most often, IMGs require visa sponsorship, which must be solidified before applying for a residency or fellowship.

OBJECTIVE

We examined the association of H-1B visa sponsorship on retention of physician trainees within the state of Ohio.

METHODS

This was a single institutional study that examined all visa-sponsored residency and fellowship graduates who entered fully licensed clinical practice between 2006 and 2015. Practice location was ascertained immediately upon completion of training and at follow-up to determine which visa group (H-1B or J-1) were more likely to initially practice in Ohio after graduation and remain within the state.

RESULTS

Of 103 visa-sponsored residency and fellowship graduates, 42 were H-1B sponsored and 61 were J-1-sponsored. Fifty-two percent (22) of H-1B visa-sponsored trainees and 31% (19) of J-1 visa-sponsored trainees were retained in Ohio after graduation. At follow-up, 40% (17) of H-1B and 26% (16) of J-1 visa holders remained in the state.

CONCLUSIONS

H-1B visa-sponsored trainees were more likely than those with J-1 visas to practice in the state of Ohio after graduation. Regardless of visa status, graduates tended not to change their geographical location over time.

Compliance with the Accreditation Council for Graduate Medical Education duty hours in a general surgery residency program: Challenges and solutions in a teaching hospital

BACKGROUND

The inception of work hour restrictions for resident physicians in 2003 created controversial changes within surgery training programs. On a recent Accreditation Council for Graduate Medical Education survey at our institution, we noted a discrepancy between low recorded violations of the duty hour restrictions and the surgery resident's perception of poor duty hour compliance. We sought to identify factors that lead to duty hour violations and to encourage accurate reporting among surgery trainees.

METHODS

The A3/Lean methodology, an industry-derived, systematic, problem-solving approach, was used to investigate barriers to accurate reporting of duty hours by residents within the Department of Surgery at our academic institution. In partnership with our office of Graduate Medical Education, we encouraged a 6-month period where residents were asked to record duty hour accurately and to provide honest, descriptive explanations of violations without punitive effects on residents or the program. We performed a 6-month before-and-after analysis of duty hours violations after the A3/Lean implementation. Quantitative analysis was used to elucidate trends in violations by post graduate year and rotation. Qualitative evaluation by key thematic areas revealed resident attitudes and opinions about duty hour violations.

RESULTS

Residents reported concern for personal and programmatic, punitive measures, desire to retain control of their education, and frustration with the administrative burden after violations as deterrents to honest duty hour reporting. The intervention was successful in changing logging behavior with 10 total violations prior to A3 meeting and 179 violations afterward (P = .003). This change was driven largely from an increase in short break violations (4 vs 134, P = .021). Analysis of violations revealed trends by post-graduate year, rotation, and weekend cross-coverage. Key findings including less than anticipated violations of the 80-hour work week despite high rates of short break violations. The ability to participate in procedures voluntarily and a sense of professional responsibility emerged as the prevailing themes among surgery residents describing violations.

CONCLUSION

Systematic evaluation of duty hour reporting within a surgery training program can identify structural and cultural barriers to accurate reporting of duty hours. Accurate reporting can identify program-specific trends in duty hour violations that can be addressed though programmatic intervention.

A Novel, Web-Based Quality Improvement Platform to Address ACGME CLER Requirements

BACKGROUND

In 2014, the Accreditation Council for Graduate Medical Education (ACGME) formally mandated trainee (resident and fellow) participation in health care quality improvement (QI) projects as one of the Clinical Learning Environment Review (CLER) Pathways to Excellence. Subsequent national reviews showed large variations in how QI education is conducted, as well as a significant mismatch between educational and organizational goals.

OBJECTIVE

We developed a web-based platform to engage trainees in QI that better aligned with best practice methodology and matched identified institutional priorities.

METHODS

A needs assessment survey was distributed to trainees to understand the obstacles to compliance with ACGME QI requirements. Based on the results, a web-based clearinghouse, called the QI Platform, was developed and launched in July 2016, and utilization was analyzed in February 2019.

RESULTS

A total of 196 of 440 needs assessment surveys (45%) were completed. Themes extracted from surveys to identify barriers in QI participation included difficulties designing projects, lack of mentorship or expert support, and difficulty engaging an interprofessional team. Over 2.5 years, 151 projects were registered on the platform. Of these, 17 (11%) were collaborative entries. At the time of analysis, 166 of 437 trainees (38%) were listed as participants in active QI projects. A total of 22 projects were archived as complete, and 68 incomplete projects were reassigned to the "Ideas" section as works in progress after lead trainee graduation.

CONCLUSIONS

An institutional QI Platform clearinghouse for GME QI projects was feasible to develop and maintain, and it appeared acceptable to most GME programs and trainees for recording and tracking QI projects, and linking these to hospital QI priorities.

Rate of Programs Affected by Resident Attrition and Program Factors Associated With Attrition in Emergency Medicine

BACKGROUND

Resident attrition negatively affects residents and programs. The incidence of attrition in emergency medicine (EM) and program-specific factors associated with attrition remain unclear.

OBJECTIVE

We quantified the percentage of EM residencies affected by attrition between 2007 and 2016 and identified program-specific factors associated with attrition.

METHODS

We performed a retrospective analysis of data derived from the American Medical Association National Graduate Medical Education Census. We defined attrition as any postgraduate who left their residency training program prior to completion. We calculated the percentage of residency programs that experienced attrition and the overall incidence of attrition. We used Fisher's exact tests, Wilcoxon rank sum tests, and t tests, as well as multivariable logistic regression, to identify program-specific factors associated with attrition.

RESULTS

Between 2007 and 2016, 139 EM residency programs (82%) experienced attrition of at least 1 resident. An average of 23% of EM training programs experienced attrition annually. The incidence of EM resident attrition averaged 0.85% per year. Program-specific factors associated with attrition include 4-year residencies (P = .031), programs with medium class size (P = .0003), more female residents (P = .002), and more female faculty (P = .003). After analysis, only medium class size (compared to small) was associated with attrition (odds ratio = 4.96, 95% confidence interval 1.65-14.91).

CONCLUSIONS

Between 2007 and 2016, while the incidence of resident attrition in EM was low (< 1%), the majority of programs experienced resident attrition. Medium class size (7 to 12 residents) was the only program-specific factor associated with increased attrition.

Factors that predict for representation of women in physician graduate medical education

Background/Objective: To identify factors associated with underrepresentation of women in the largest medical specialties. Methods: The authors obtained specialty-specific data from the Association of American Medical Colleges, National Residency Match Program and Journal of the American Medical Association Graduate Medical Education Supplement from 2014 on the gender of trainees and faculty members, residency program director (PD)-rated importance of interview selection and rank list formation criteria, and characteristics of matched NRMP participants. They used linear regression to evaluate whether factors were associated with representation of female trainees in the 18 largest specialties that participated in the NRMP. They hypothesized that factors representing lower student exposure or higher research requirements would be associated with lower representation of women. Results: In 2014, representation of women as trainees ranged from 13.7% in Orthopedic Surgery to 82.5% in OB/Gyn. On multivariable analysis, the factors associated with specialties having lower percentages of female trainees were: not being part of the third year core (slope = 0.141, p = 0.002), having lower specialty mean step 1 scores (slope = 0.007, p = 0.017), and having lower percentages of female faculty members. For each 1% increase in female faculty, the percentage of female trainees increased by 1.45% (p < 0.001). Conclusions: Two exposure-related factors, percentage of female faculty members and being part of the third year core, were associated with underrepresentation of women as trainees. Future research could help examine whether these are causal associations. Medical schools and training specialties should investigate whether strategies to enhance mentorship and increase exposure to non-core specialties will increase the proportion of women in fields in which they are underrepresented.

Diversity in the Last Decade of the Association of Program Directors in Surgery: A Descriptive Analysis of Leadership and Future Directions

OBJECTIVE

The Association of Program Directors in Surgery Diversity and Inclusion Taskforce (APDS-DIT) was created in 2017 after the Executive Committee recognized low diversity in its membership. The DIT was charged to address gaps in diversity and inclusion at various phases of training and development from medical student to surgical leader. The aim of this study was to examine APDS demographics and determine the status of inclusion of women, racial and ethnic minorities, and nonuniversity surgeons.

DESIGN

Eleven years (2008-2018) of APDS annual-meeting programs, web directory, 2018-membership lists, and 2017-AAMC data were analyzed. Leadership positions were examined by officer (program chair/vice chair, executive committee, and board of directors. Internet searches identified gender, race, and institutional affiliation. Representative members to other organizations, resident liaisons, and historian members were excluded. APDS "Member," "Associate," and "Resident" lists and AAMC data were divided by gender.

RESULTS

Fifty-one individuals fulfilled 223 leadership positions over 11 years; 13 (25%) were women and 5 (10%) were non-Caucasian. Since 2013, the percentage of nonuniversity surgeons in APDS leadership has declined while, over the last 2 years, the percentage of women and ethnic/racial minority has increased. In 2018, the percentage of women in leadership (38%) was higher than the percentage of women in membership (combined total of program directors and associate program directors [26%]) and nonuniversity-affiliated surgeons comprised 35% of the APDS membership but only 14% of leadership roles.

CONCLUSIONS

Over the last 11 years, representation of women, non-Caucasians, and nonuniversity surgeons has been at or less than 1/3 of their counterparts. As an organization that is tasked with creating future generations of the surgical workforce, it is imperative to recognize an under-representation of those members with diverse backgrounds that would add to the creative growth of the organization. The creation of the APDS-DIT emphasizes the organization's commitment to diversity and inclusion and an effort to create a pipeline of diverse leaders in the APDS and surgical training in general.