Forum Theatre to Address Peer-to-Peer Mistreatment in General Surgery Residency.

OBJECTIVE: Mistreatment is widespread in graduate medical education, and much attention has been generated on this topic and its relationship to burnout in general surgery residency. In particular, peer-to-peer mistreatment poses a developmental dilemma - as junior residents find themselves mistreated and some turn around and perpetuate that mistreatment. There is a paucity of effective interventions. Forum Theatre (FT) is a novel educational tool to engage participants in solving difficult situations. We present the use of FT as a tool to explore solutions to address peer-to-peer mistreatment in a surgery residency. FT starts with the performance of a culture-specific conflict scenario and then invites the audience to participate in renditions of the situation ending in a collective solution. DESIGN: Stakeholder support was obtained from the general surgery program leadership. Time was protected during two 1-hour scheduled wellness didactic sessions. First, focus groups with each PG year identified the residents' experience of mistreatment. Themes regarding peer-to peer mistreatment were identified and presented to a group of 3 volunteer actor residents who chose to focus on the unintended consequences of public, corrective feedback with the understanding this would be presented to the residency at large. Following this, they developed a scenario for enactment which was implemented during the second didactic session. The enacted scenario posed a problem with public feedback ending unsatisfactorily. The audience was then invited to engage the actors and participate in replays of the situation until a collective solution was identified. Retrospective pre-post survey and a 6-month post survey were administered. SETTING: General surgery residency at University of Texas Health San Antonio. PARTICIPANTS: General surgery residents. 32 of 66 (48.5%) residents participated. RESULTS: Participants noted an improved understanding of mistreatment, felt more confident in recognizing mistreatment, reported improved confidence in their ability to intervene when witnessing mistreatment and to recognize when they themselves were involved in mistreatment (p < 0.001 for all). In fact, of the residents who reported participating in mistreatment, 100% reported directing it towards peers. After the FT, 89% of residents said they "definitely" or "most likely" recommended participating in a FT to address mistreatment. 85.7% reported that the intervention was moderately to extremely effective for teaching topics in professionalism. These trends remained steady in the survey 6 months after the intervention as well. CONCLUSIONS: We found FT was feasible to implement in a busy general surgery residency and well received with sustained, self- reported behavior change. FT is a novel tool to engage residents to self-evaluate and participate in methods to address mistreatment. FT interventions can be tailored to the local culture to address conflicts specific to that setting.

Lived Experiences of Mistreatment in a General Surgery Residency.

OBJECTIVE: Explore the lived experiences of General Surgery residents to identify how they perceive, define mistreatment, and which factors can contribute to or mitigate mistreatment within the Clinical Learning Environment. DESIGN: This is a phenomenological study conducted during 2019-2020 using Giorgi's psychological descriptive phenomenology methodology. Researcher bias, trustworthiness, and triangulation were addressed using bracketing, check-ins with program leadership, comparisons to resident survey, and team consensus based on Consensual Qualitative Research. SETTING: General Surgery Residency program at Long School of Medicine, UT Health San Antonio, Texas. PARTICIPANTS: All residents in the general surgery program were invited to participate (n= 66, 43% female and 63% non-Hispanic). Specific demographic and identifying data for each participant was not collected. Approximately 50 (76% of program) residents from General Surgery participated. RESULTS: We were able to identify four themes that helped to delineate the lived experience of residents including program cultural factors, resident internal processing, and perceived effects of mistreatment by the residents. The resulting psychological structure and conceptual framework help clarify the interrelations between the themes and the Clinical Learning Environment. The scenarios discussed were adapted and depersonalized to use as prompts for the Forum Theater intervention. This project set out to explore resident's lived experiences and allow the data to reveal the main outcomes. The data was coded and analyzed following strict guidelines from descriptive psychological phenomenology and Consensual Qualitative Research with the aim of informing a later experiential intervention based on Forum Theater. CONCLUSIONS: The lived experience of general surgery residents helped identify cultural factors and behaviors that contribute to and/or mitigate mistreatment providing information to plan interventions at the resident and faculty level. Mitigating or stopping mistreatment can improve the Clinical Learning Environment and hence, the quality of training.

The Clinical Safety and Effectiveness Course: Ten Years of Experiential Training in Quality Improvement for Practicing Professionals.

Training in quality improvement (QI) and patient safety for clinicians are needed for continued progress in health care quality. A project-based QI curriculum training faculty, residents, and staff in an academic health center for >10 years are reviewed and evaluated. Didactic curriculum includes QI knowledge domains, and QI methods are applied to a project during the course. There are 638 graduates and 239 projects since implementation. Most projects (84%) effected behavior change, change in clinical practice, and benefit to patients. Faculty have used the training to develop formal QI programs for Graduate Medical Education (GME). Graduates value the skills for their professional and personal lives, and for career enhancement. Experiential QI training for practicing professionals is valuable and effective. Collaboration and support from stakeholders are key factors in success. The Clinical Safety & Effectiveness course is a reproducible and relevant model of interprofessional QI education for practicing professionals and staff.