Accuracy of Heart Auscultation Examination by General Practitioners From Various Levels of Competency in Detection of Heart Abnormality in Basic School Children

Background. Most of heart defects in children do not show typical clinical symptoms. Ten percent of the cases are late detected. Echocardiography is an examination with high sensitivity and specificity in detecting heart defects in children, but it cannot be performed by all health workers, expensive and not always available in hospitals. Auscultation is an important part of a physical examination that inexpensive, easy examination, and becomes a competency of all doctors. The aim of this study to determine the accuracy of the screening method by listening to murmurs on heart auscultation by various levels of physician competence. Methods. This is a diagnostic test of 250 elementary school children held in the pediatric ward of dr. Mohammad Hoesin Palembang from September to November 2019. The auscultation examination was performed by three pediatrics resident from three stages (i.e. junior, middle and senior), followed by echocardiography examinations by a pediatric cardiologist. Results. The highest sensitivity of auscultation was found in senior resident, 42.4%, while the lowest was found in junior resident, 12.1%. The results of the kappa analysis of the cardiac auscultation examination on the three examiners showed a poor level of agreement on junior stage compared to senior resident (k = 0.189; CI = 0.033-0.346) and the level of agreement was sufficient in junior stage compared to middle stage resident (k = 0.297; CI = 0.134 -0.461) and middle stage compared to senior resident (k = 0.301; CI = 0.147-0.456). Conclusion. Experience and length of learning will affect the accuracy of the auscultation examination in detecting heart defects in children.

Quality of Life among Varanasi based Ayurveda Junior Resident Doctors Engaged in Covid-19 Care using WHO-BREF - A Cross-Sectional Survey

During the Coronavirus Pandemic, the Varanasi based Ayurveda junior resident doctors experiencing challenges in their quality of life following the covid19 related challenges. The challenges include; loss of many patients, deaths and illnesses of colleagues, fear of transmission to family members, personal risk of infection, inability to cope, personal isolation, population restrictions, and long shifts of work which affect their QOL and have received less attention from scholars. The study aimed at evaluating the quality of life of Ayurvedic medicine practitioners during COVID-19 pandemic. Methods and Material: Varanasi based Ayurveda junior residents from both urban and rural settings were approached for the cross-sectional survey. An online cross-sectional survey was conducted to collect the data and WHOQOL-BREF questionnaire was made available online on Google forms to the junior residents. The study population involved individuals within the range of 24-80 years. A sample size of 100 was selected from the target population using a convenience sampling procedure. The study identified two or more categories for each variable in the dataset; therefore, the chi-square test was used to examine the relationship between two or more unconditional variables. SAS 9.4 (Statistical Analysis System, Carry, NC, USA) tool was used to analyse the relationship between the categorical variables. P values were obtained for each variable.

Ultra-widefield retinal imaging for adjunctive resident training in retinal break detection

We evaluated the clinical utility of ultra-widefield imaging as an adjunctive tool for training resident ophthalmologists in the detection of retinal breaks. This was a prospective study conducted at a secondary health care center (Tri-Service General Hospital) in Taiwan. Participants were 44 patients (53 eyes) who were referred to our hospital after being diagnosed with retinal breaks. Patients first underwent an indirect ophthalmoscopy examination of the total fundus without scleral depression by our junior (first and second year) or senior (third and fourth year) resident ophthalmologist and then underwent an ultra-widefield imaging examination with a central image and four gaze-steered (up, down, nasal, and temporal) images to determine the number of retinal breaks in the total fundus and the four quadrants. Of the total 53 eyes, 31 were examined by junior residents and 22 were examined by senior residents. In the group of junior residents, ultra-widefield imaging was significantly better at detecting retinal breaks of the total fundus (49 vs. 33 retinal breaks, p < 0.001) and the temporal quadrant (17 vs. 10 retinal breaks, p = 0.018) than indirect ophthalmoscopy. In the group of senior residents, there was no significant difference in the ability to detect retinal breaks in the total fundus or each of the four quadrants with ultra-widefield imaging or indirect ophthalmoscopy. Our results indicate that, compared to indirect ophthalmoscopy, ultra-widefield imaging with a central image and four gaze-steered images has a better performance and is a useful adjunct tool for the detection of retinal breaks in junior resident training. Additionally, it could be a useful method for teaching indirect ophthalmoscopy examination to junior residents.

KAP survey of practicing doctors on antimicrobial stewardship based on openWHO course

SynopsisBackgroundThe overwhelming, irrational behaviour of using antimicrobial (AM) has added to the amplification and spread of antimicrobial resistance (AMR) burden. Healthcare professionals can curtail the AMR by practicing antimicrobial stewardship (AMS). Keeping this in view WHO has laid down a global action plan to combat AMR including free online availability of openWHO course. So, our study aimed at accessing the knowledge, attitude, and practice (KAP) of practicing doctors towards AMS based on this course in a tertiary care hospital.MethodsThe study was conducted among practitioners (faculty, senior residents, junior residents) in different clinical departments. The study was designed as a KAP survey. A validated self-administered questionnaire consisting of 29 questions was designed and shared among 200 participants through the mail and physically. Apart from observing knowledge/attitude/practice gaps, the difference in response to questions was evaluated among various groups (surgeon vs physician, faculty vs senior resident vs junior resident, openWHO course participant vs openWHO course aware non-participant vs openWHO course unaware non-participants.ResultsResponse rate was 62.5% (n=200). Knowledge on AMS was observed among doctors’ with >50% near correct responses in each question except for the question asking on IV route of AM administration. A significant knowledge gap was found when a comparison was made between faculty members, senior residents, and junior residents (p <0.001) in the spectrum of activity of AM. Almost all the participants agreed that ASP is a necessity in the hospital and believed that ASP reduces healthcare costs and adverse effects of inappropriate AM prescription. A significant difference between the various groups’ aspects was also observed.ConclusionKnowledge gap on ASP is observed among all HCPs but significant differences among faculty, senior residents, and junior residents, among openWHO course vs unaware openWHO course participant. This shows faculty has to take the lead including more and more practice and education in ASP. The openWHO course may help in achieving this.

Operable, Low-Cost, High-Resolution, Patient-Specific 3D Printed Temporal Bones for Surgical Simulation and Evaluation

Objectives: Three-dimensional printed models created on a consumer level printer can be used to practice mastoidectomy and to discern mastoidectomy experience level. Current models in the literature for mastoidectomy are limited by expense or operability. The aims of this study were (1) to investigate the utility of an inexpensive model for mastoidectomy and (2) to assess whether the model can be used as an evaluation tool to discern the experience level of the surgeon performing mastoidectomy. Methods: Three-dimensional printed temporal bone models from the CT scan of a 7-year old patient were created using a consumer-level stereolithography 3D printer for a raw material cost of $10 each. Mastoidectomy with facial recess approach was performed by 4 PGY-2 residents, 4 PGY-5 residents, and 4 attending surgeons on the models who then filled out an evaluation. The drilled models were collected and then graded in a blinded fashion by 6 attending otolaryngologists. Results: Both residents and faculty felt the model was useful for training (mean score 4.7 out of 5; range: 4-5) and case preparation (mean score: 4.3; range: 3-5). Grading of the drilled models revealed significant differences between junior resident, senior resident, and attending surgeon scores ( P = .012) with moderate to excellent interrater agreement (ICC = 0.882). Conclusion: The described operable model that is patient-specific was rated favorably for pediatric mastoidectomy case preparation and training by residents and faculty. The model may be used to differentiate between experience levels and has promise for use in formative and summative evaluations.

Resident Education and Wellness: A Strategy for Future Pandemics

Background: The Coronavirus Disease 2019 (COVID-19) pandemic presents a novel challenge to modern healthcare systems and medical training. Resource allocation and risk mitigation has dramatically affected resident training with the subsequent cancellation of elective procedures, 14-day isolation recommendations, and social distancing requirements. To combat the unique challenges to resident education and wellness, academic leaders must develop new strategies to maintain a healthy, competent residency program. Methods: Our institution implemented a revolving 3-Team system. While the “Inpatient-Team” delivered direct care to orthopaedic patients, the “Back-up Team” and “Quarantine-Team” managed the telemedicine virtual clinic and education-wellness strategy, respectively. The education strategy included active learning methods on virtual platforms, junior resident-specific sessions, and subspecialty-interest panels. Research teams were built and rapidly deployed virtually for large scale retrospective studies. For the wellness strategy plan, our prior resident “family” organization (peer support group) was supplemented by friendly interdepartmental competitions and virtual faculty social hours. In order to evaluate the effectiveness of our implemented strategies a blinded survey was completed by the residents affected by the pandemic. Results: Our 3-Team system allowed for the delivery of safe, high-quality patient care while optimizing resident education, research, and wellness. One hundred percent of residents felt they had the tools necessary to protect themselves throughout the pandemic and 94% felt that program leadership cared about their wellness and safety. In terms of our education and wellness strategy plan, the efficient use of technology led to both improved virtual education outside of the hospital and intentional wellness opportunities despite social distancing restrictions. Eighty-eight percent of residents felt the program was able to offer valuable educational opportunities despite the pandemic. Overall, 76% of residents did not feel the COVID-19 pandemic negatively impacted their training or preparedness for their career, however 75% of PGY4’s felt they missed important subspecialty exposure and 50% felt that it negatively impacted their training. Conclusions: The COVID-19 pandemic is unlikely to be the last challenge the medical training community faces. Utilization of virtual platforms for patient care, education, research, and wellness grew out of necessity in this pandemic, yet represents an opportunity for lasting improvement with re-entry.

Assessing leadership in junior resident physicians: using a new multisource feedback tool to measure Learning by Evaluation from All-inclusive 360 Degree Engagement of Residents (LEADER)

BackgroundThe multifaceted nature of leadership as a construct has implications for measuring leadership as a competency in junior residents in healthcare settings. In Canada, the Royal College of Physicians and Surgeons of Canada’s CanMEDS physician competency framework includes the Leader role calling for resident physicians to demonstrate collaborative leadership and management within the healthcare system. The purpose of this study was to explore the construct of leadership in junior resident physicians using a new multisource feedback tool.MethodsTo develop and test the Learning by Evaluation from All-Inclusive 360 Degree Engagement of Residents (LEADER) Questionnaire, we used both qualitative and quantitative research methods in a multiphase study. Multiple assessors including peer residents, attending physicians, nurses, patients/family members and allied healthcare providers as well as residents’ own self-assessments were gathered in healthcare settings across three residency programmes: internal medicine, general surgery and paediatrics. Data from the LEADER were analysed then triangulated using a convergent-parallel mixed-methods study design.ResultsThere were 230 assessments completed for 27 residents. Based on key concepts of the Leader role, two subscales emerged: (1) Personal leadership skills subscale (Cronbach’s alpha=0.81) and (2) Physicians as active participant-architects within the healthcare system (abbreviated to active participant-architects subscale, Cronbach’s alpha=0.78). There were seven main themes elicited from the qualitative data which were analogous to the five remaining intrinsic CanMEDS roles. The remaining two themes were related to (1) personal attributes unique to the junior resident and (2) skills related to management and administration.ConclusionsFor healthcare organisations that aspire to be proactive rather than reactive, we make three recommendations to develop leadership competence in junior physicians: (1) teach and assess leadership early in training, (2) empower patients to lead and transform training and care by evaluating doctors, (3) activate frontline care providers to be leaders by embracing patient and team feedback.

Antibiotic utilization variability among training services at an academic medical center: An observational study

Objective: Evaluate the difference in antibiotic prescribing between various levels of resident training or attending types. Design: Observational, retrospective study. Setting: Tertiary-care, academic medical center in Madison, Wisconsin. Methods: We measured antibiotic utilization from January 1, 2016, through December 31, 2018, in our general medicine (GM) and hospitalist services. The GM1 service is staffed by outpatient internal medicine physicians, the GM2 service is staffed by geriatricians and hospitalists, and the GM3 service is staffed by only hospitalists. The GMA service is led by junior resident physicians, and the GMB service is led by senior resident physicians. We measured utilization using days of therapy (DOT) per 1,000 patient days (PD). In a secondary analysis based on antibiotic spectrum, we used average DOT per 1,000 PD. Results: Teaching services prescribed more antibiotics than nonteaching services (671.6 vs 575.2 DOT per 1,000 PD; P < .0001). Junior resident–led services used more antibiotics than senior resident–led services (740.9 vs 510.0 DOT per 1,000 PD; P < .0001). Overall, antibiotic prescribing was numerically similar between various attending physician backgrounds. A secondary analysis showed that GM services prescribed more broad-spectrum, anti-MRSA, and anti-pseudomonal antibiotics than the hospitalist services. GM junior resident–led services prescribed more broad-spectrum, anti-MRSA, and antipseudomonal therapy compared to their senior counterparts. Conclusions: Antibiotics were prescribed at a significantly higher rate in services associated with trainees than those without. Services led by a junior resident physician prescribed antibiotics at a significantly higher rate than services led by a senior resident. Interventions to reduce unnecessary antibiotic exposure should be targeted toward resident physicians, especially junior trainees.

Impact of general medicine rotation training on the in-training examination scores of 11, 244 Japanese resident physicians: a Nationwide multi-center cross-sectional study

Background Although general medicine (GM) faculty in Japanese medical schools have an important role in educating medical students, the importance of residents’ rotation training in GM in postgraduate education has not been sufficiently recognized in Japan. To evaluate the relationship between the rotation of resident physicians in the GM department and their In-Training Examination score. Methods This study is a nationwide multi-center cross-sectional study in Japan. Participants of this study are Japanese junior resident physicians [postgraduate year (PGY)-1 and PGY-2] who took the General Medicine In-Training Examination (GM-ITE) in fiscal years 2016 to 2018 at least once (n = 11,244). The numbers of participating hospitals in the GM-ITE were 381, 459, and 503 in 2016, 2017, and 2018.The GM-ITE score consisted of four categories (medical interview/professionalism, symptomatology/clinical reasoning, physical examination/procedure, and disease knowledge). We evaluated relationship between educational environment (including hospital information) and the GM-ITE score. Results A total of 4464 (39.7%) residents experienced GM department rotation training. Residents who rotated had higher total scores than residents who did not rotate (38.1 ± 12.1, 36.8 ± 11.7, and 36.5 ± 11.5 for residents who experienced GM rotation training, those who did not experience this training in hospitals with a GM department, and those who did not experience GM rotation training in hospitals without a GM department, p = 0.0038). The association between GM rotation and competency remained after multivariable adjustment in the multilevel model: the score difference between GM rotation training residents and non-GM rotation residents in hospitals without a GM department was estimated as 1.18 (standard error, 0.30, p = 0.0001), which was approximately half of the standard deviation of random effects due to hospital variation (estimated as 2.00). Conclusions GM rotation training improved the GM-ITE score of residents and should be considered mandatory for junior residents in Japan.

Creating an Opioid Recommendation Card for Trainees: Methods, Use, and Impact

Background In academic hospitals, surgical residents write most of the postoperative prescriptions; yet, few residents are trained on postoperative analgesia. This leads to wide variability in practices and often excess opioid prescribing. We sought to create an opioid guideline pocket card for surgical residents to access when prescribing opioids postoperatively and to evaluate the impact of this initiative. Methods A comprehensive literature review was conducted to generate evidence-based procedure-specific opioid recommendations; additional recommendations were formulated via consensus opinion from surgical divisions at an academic institution. A pocket-sized guideline card was developed to include these procedure-specific recommendations as well as opioid guidelines for discharges after inpatient stays, non-opioid analgesic recommendations, access to opioid safety and disposal instructions for patients discharge, an equianalgesic dosing chart, and instructions for naloxone use. The card was distributed to all General Surgery house staff at a university-affiliated hospital in the spring of 2018. Following the distribution, trainees were surveyed on their use of the card. Descriptive statistics were used to analyze the survey. Results Of 85 trainees, 62 (72.9%) responded to the survey in full; 58% use the card regularly. Of the 27 junior resident respondents, 70.4% use the card at least monthly including 48.1% who use the card daily-to-weekly. Overall, 81.6% of residents changed their opioid-prescribing practices because of this initiative and 89.8% believe the card should continue to be distributed and used. Discussion An evidence-based guideline card for postoperative analgesia is highly valued and utilized by surgical trainees, especially those most junior in their training.