Unprofessionalism in anesthesiology: A qualitative study on classifying unprofessional behavior in anesthesiology residency education.

STUDY OBJECTIVE: This study aims to identify the domains that constitute behaviors perceived to be unprofessional in anesthesiology residency training programs. DESIGN: Qualitative study. SETTING: Anesthesiology residency training programs. PATIENTS: Not applicable. The participants involved residents, fellows, and faculty members purposefully sampled in four US-based anesthesiology residency programs. INTERVENTIONS: Participants were asked to submit examples of unprofessional behavior they witnessed in anesthesiology residents, fellows, or faculty members via a Qualtrics link. MEASUREMENTS: Not applicable. The behavior examples were independently reviewed and categorized into themes using content analysis. MAIN RESULTS: A total of 116 vignettes were collected, resulting in a final list of 111 vignettes after excluding those that did not describe behavior exhibited by anesthesiology faculty or trainees. Fifty-eight vignettes pertained to unprofessional behaviors observed in faculty members and 53 were observed in trainees (residents and fellows). Nine unprofessionalism themes emerged in the analysis. The most common themes were VERBAL, SUPERVISION, QUALITY, ENGAGEMENT, and TIME. As to the distribution of role group (faculty versus trainee) by theme, unprofessional behaviors falling into the categories of BIAS, GOSSIP, LEWD, and VERBAL were observed more in faculty; whereas themes with unprofessional behavior primarily attributed to trainees included ENGAGEMENT, QUALITY, TIME, and SUPERVISION. CONCLUSION: By reviewing reported professionalism-related vignettes within residency training programs, we identified classification descriptors for defining unprofessional behavior specific to anesthesiology residency education. Findings from this study enrich the definition of professionalism as a multi-dimensional competency pertaining to anesthesiology graduate medical education. This framework may facilitate preventative intervention and timely remediation plans for unprofessional behavior in residents and faculty.

Family Anesthesia Experience: Improving Social Support of Residents Through Education of Their Family and Friends.

Introduction: The prevalence of burnout among anesthesiology residents is 41%-51%. Burnout is associated with medical errors, physician turnover, and substance use disorder. Social support and wellness may reduce burnout, but a barrier is support persons' lack of understanding of an anesthesiologist's work demands. We developed the Family Anesthesia Experience (FAX) to help support persons best support their resident. Methods: FAX consisted of a 4-hour event with hands-on experience, didactics portion, and panel discussion. Participants learned about a typical day in the life of an anesthesiology resident, wellness, burnout, substance use disorder, and available support resources, and had hands-on experience with procedures. The panel discussion offered logistical information about anesthesiology residency and allowed support persons to ask panel members questions. A postevent survey collected feedback on the event. Results: Fifty-one participants (first-year anesthesiology residents and their support persons) attended the event. Eight of 11 residents (73%) and 32 of 40 support persons (80%) completed the survey. All enjoyed the event, would recommend it to other anesthesiology resident support persons, and felt the event would improve communication and support. Most learned a moderate (35%) to large amount (50%) from the event. Qualitative feedback suggested most support persons found the event helpful in improving their understanding of anesthesiology residents' work demands. Discussion: The FAX was well liked by participants. Although we did not assess specific knowledge gained and long-term effects of the 2022 event, evaluations of previous years' events suggest that the event improved participants' understanding of anesthesiology residents' work and stressors.

No Miracles in Two Minutes: A Randomized Controlled Study on the Impact of Preparatory Expansive Posing on Anesthesiology Residents' Performance in Mock Structured Oral Examinations.

Background: The objective of this study was to evaluate the impact of engaging in preparatory expansive posing on the performance of anesthesiology trainees during a mock structured oral examination. Methods: A total of 38 clinical residents at a single institution participated in this prospective randomized controlled study. Participants were stratified by clinical anesthesia year and randomly assigned to 1 of 2 orientation rooms to prepare for the examination. The preparatory expansive posing participants stood for 2 minutes with their hands and arms above their heads and with their feet approximately 1 ft apart. Conversely, the control participants sat quietly in a chair for 2 minutes. All participants then received the same orientation and examination. Faculty evaluation of resident performance, residents' self-assessment of performance, and anxiety score were collected. Results: There was no evidence to support our primary hypothesis that residents who engaged in preparatory expansive posing for 2 minutes prior to a mock structured oral examination would score higher than their control counterparts (P = .68). There was no evidence to support our secondary hypotheses that preparatory expansive posing increases self-assessment of one's performance (P = .31) or reduces perceived anxiety during a mock structured oral examination (P = .85). Conclusions: Preparatory expansive posing did not improve anesthesiology residents' mock structured oral examination performance or self-assessment of their performance, nor did it reduce their perceived anxiety. Preparatory expansive posing is likely not a useful technique in improving the performance of residents in structured oral examinations.

A Multi-Site Survey Study on the Association Between the COVID-19 Pandemic and United States Anesthesiology Residents' Mental Health.

BACKGROUND:  At the onset of the coronavirus disease 2019 (COVID-19) pandemic, anesthesiology residency programs were impacted differently due to various factors such as the local severity of COVID-19, exposure to patient suffering, and inability to complete rotations. We sought to investigate the impact of local-level pandemic severity on the well-being of anesthesiology residents. METHODS:  This multi-site study surveyed postgraduate year two residents from 15 United States (US) anesthesiology programs using the Perceived Stress Scale, Mini-Z, Patient Health Questionnaire-9,WHO-5 Well-Being Index,and the Multidimensional Scale of Perceived Social Support before the pandemic (baseline survey) and during the first COVID-19 surge (post survey). RESULTS:  A total of 144 (65%) residents responded to the initial baseline survey; 73 (33%) responded to the post survey, and 49 (22%) completed both surveys. There was not a statistically significant difference in any well-being outcomes of participants between the surveys, nor was there a significant difference based on the severity of COVID-19 impact at the program's hospital. Male participants had higher perceived stress scores (ß = 4.05, 95%CI: 0.42, 7.67, P = 0.03) and lower social support from family (ß = -6.57, 95%CI: -11.64, -1.51, P = 0.01) at the post survey compared to female participants after controlling for baseline scores. Additionally, married participants or those with domestic partners reported higher perceived social support in the post survey (ß = 5.79, 95%CI: -0.65, 12.23, P = 0.03). CONCLUSION:  The local COVID-19 severity at a residency program did not disproportionately impact well-being scores among anesthesiology residents. Those most vulnerable to diminished well-being appeared to be male and single participants. As a result, targeted well-being interventions, including those aiming to increase social support, to higher-risk resident groups may be indicated. Future work is needed to assess the longstanding COVID-19 pandemic impacts on resident well-being.

Defining and Addressing Anesthesiology Needs in Simulation-based Medical Education.

Background: This study's primary aim was to determine how training programs use simulation-based medical education (SBME), because SBME is linked to superior clinical performance. Methods: An anonymous 10-question survey was distributed to anesthesiology residency program directors across the United States. The survey aimed to assess where and how SBME takes place, which resources are available, frequency of and barriers to its use, and perceived utility of a dedicated departmental education laboratory. Results: The survey response rate was 30.4% (45/148). SBME typically occurred at shared on-campus laboratories, with residents typically participating in SBME 1 to 4 times per year. Frequently practiced skills included airway management, trauma scenarios, nontechnical skills, and ultrasound techniques (all ≥ 77.8%). Frequently cited logistical barriers to simulation laboratory use included COVID-19 precautions (75.6%), scheduling (57.8%), and lack of trainers (48.9%). Several respondents also acknowledged financial barriers. Most respondents believed a dedicated departmental education laboratory would be a useful or very useful resource (77.8%). Conclusion: SBME is a widely incorporated activity but may be impeded by barriers that our survey helped identify. Barriers can be addressed by departmental education laboratories. We discuss how such laboratories increase capabilities to support structured SBME events and how costs can be offset. Other academic departments may also benefit from establishing such laboratories.

A Perspective on Wellness in Anesthesiology Residency Programs: A Multi-Strategy Approach.

Addressing resident wellness is an important topic given the high risk for burnout and depression in resident physicians compared with the general U.S. population. This article provides an overview of various approaches to help conceptualize and intervene on resident wellness, based on the 9-strategies framework to improve wellness laid out by Shanafelt and colleagues. This article outlines the most relevant literature in each strategy followed by the authors' experience within their anesthesiology residency program.

Reinvigorating an Academy of Medical Educators Using Ecological Systems Theory.

The educational framework of communities of practice postulates that early learners join medical communities as social networks that provide a common identity, role modeling and mentorship, and experiential learning. While being elected into a medical society is an honor, member engagement in these groups can falter if the society membership is seen as an honorific rather than one requiring continuing participation. As an example, Academies of Medical Educators have been established by many academic medical centers to encourage collaboration, skill development, professional identity formation, and scholarship. The University of North Carolina established the Academy of Educators in 2006 to create a diverse community of educators to promote the scholarship, teaching skills, and professional identity of educators. Despite rapid growth to over 500 members, we had less than 30 participants at events over the 2017-2018 academic year. To increase member engagement and participation, our academy leadership team used Bronfenbrenner's Ecological Systems Theory to design interventions at each layer of environmental influence, specifically at the microsystem, mesosystem, exosystem, macrosystem, and chronosystem levels. In this paper, we describe the multipronged approach used to increase the University of North Carolina Academy of Medical Educators event attendance from 30 to 1,000 faculty participants over the course of one academic year (2018-2019). This paper provides a model as to how medical societies can use ecological systems theory as a natural and comprehensive approach to plan and improve their member engagement and experience.

Transitioning to Virtual Meetings: Experiences From the Society for Education in Anesthesia Virtual Fall 2020 Meeting.

The COVID-19 pandemic has forced organizers of traditional in-person continuing medical education conferences to transition to a virtual format. There are both advantages and disadvantages to this change in format. When planning a virtual meeting, several factors require consideration, including costs, virtual platforms, sponsorship, networking, and meeting logistics. This manuscript describes the authors' experiences of transforming the Society of Education in Anesthesia 2020 Fall Meeting into a virtual conference and explores the lessons learned and future impacts of this new medium.

Educating Anesthesiologists During the Coronavirus Disease 2019 Pandemic and Beyond.

The coronavirus disease 2019 (COVID-19) pandemic has altered approaches to anesthesiology education by shifting educational paradigms. This vision article discusses pre-COVID-19 educational methodologies and best evidence, adaptations required under COVID-19, and evidence for these modifications, and suggests future directions for anesthesiology education. Learning management systems provide structure to online learning. They have been increasingly utilized to improve access to didactic materials asynchronously. Despite some historic reservations, the pandemic has necessitated a rapid uptake across programs. Commercially available systems offer a wide range of peer-reviewed curricular options. The flipped classroom promotes learning foundational knowledge before teaching sessions with a focus on application during structured didactics. There is growing evidence that this approach is preferred by learners and may increase knowledge gain. The flipped classroom works well with learning management systems to disseminate focused preclass work. Care must be taken to keep virtual sessions interactive. Simulation, already used in anesthesiology, has been critical in preparation for the care of COVID-19 patients. Multidisciplinary, in situ simulations allow for rapid dissemination of new team workflows. Physical distancing and reduced availability of providers have required more sessions. Early pandemic decreases in operating volumes have allowed for this; future planning will have to incorporate smaller groups, sanitizing of equipment, and attention to use of personal protective equipment. Effective technical skills training requires instruction to mastery levels, use of deliberate practice, and high-quality feedback. Reduced sizes of skill-training workshops and approaches for feedback that are not in-person will be required. Mock oral and objective structured clinical examination (OSCE) allow for training and assessment of competencies often not addressed otherwise. They provide formative and summative data and objective measurements of Accreditation Council for Graduate Medical Education (ACGME) milestones. They also allow for preparation for the American Board of Anesthesiology (ABA) APPLIED examination. Adaptations to teleconferencing or videoconferencing can allow for continued use. Benefits of teaching in this new era include enhanced availability of asynchronous learning and opportunities to apply universal, expert-driven curricula. Burdens include decreased social interactions and potential need for an increased amount of smaller, live sessions. Acquiring learning management systems and holding more frequent simulation and skills sessions with fewer learners may increase cost. With the increasing dependency on multimedia and technology support for teaching and learning, one important focus of educational research is on the development and evaluation of strategies that reduce extraneous processing and manage essential and generative processing in virtual learning environments. Collaboration to identify and implement best practices has the potential to improve education for all learners.

Family Comes First: A Pilot Study of the Incorporation of Social Support Into Resident Well-being.

BACKGROUND: Recent work has shown that understanding of work-related stress by family and friends is associated with increased resident well-being. However, it is often difficult for residents to communicate with their support persons (SPs), especially those who have minimal understanding of the medical field, regarding even the most basic functions of their role in the health care system. This study aimed to pilot test an innovative wellness event focusing on the social relatedness component of resident well-being. METHODS: The target population included 30 new residents at 2 anesthesiology residency programs and their SPs in 2017. The Family Anesthesia Experience (FAX) began with didactic presentations and a panel discussion about wellness topics. It concluded with a multifaceted simulation experience. Participants were surveyed before and after the event. Measures included SPs' understanding of residents' work and residents' stress, burnout, resilience, and social support levels. Student t tests, Mann-Whitney U tests, Wilcoxon signed-rank tests, and repeated measures analysis of variance were used to examine the impact of the event. RESULTS: Twenty-two (84.6%) of the 26 intervention clinical anesthesia year 1 residents who attended FAX completed the postevent surveys, and all intervention SPs (100%, n = 33) completed both pre-event and postevent surveys. The event was well received by the residents (100%) and their SPs (100%). Improvement in perceived understanding in the intervention SPs group (Pre: 1.44 ± 0.63, Post: 2.69 ± 0.33, P < .0001) was observed. Not all metrics of well-being for the residents achieved significance in change; however, decreased stress was observed compared with historical controls (Control: 1.91 ± 0.61, Intervention: 1.54 ± 0.42, P = .019). CONCLUSION: The event led to improved SPs' understanding of the role of an anesthesiology resident.

Learners and Luddites in the Twenty-first Century: Bringing Evidence-based Education to Anesthesiology.

Anesthesiologists are both teachers and learners and alternate between these roles throughout their careers. However, few anesthesiologists have formal training in the methodologies and theories of education. Many anesthesiology educators often teach as they were taught and may not be taking advantage of current evidence in education to guide and optimize the way they teach and learn. This review describes the most up-to-date evidence in education for teaching knowledge, procedural skills, and professionalism. Methods such as active learning, spaced learning, interleaving, retrieval practice, e-learning, experiential learning, and the use of cognitive aids will be described. We made an effort to illustrate the best available evidence supporting educational practices while recognizing the inherent challenges in medical education research. Similar to implementing evidence in clinical practice in an attempt to improve patient outcomes, implementing an evidence-based approach to anesthesiology education may improve learning outcomes.

Anesthesia myTIPreport: A Web-Based Tool for Real-Time Evaluation of Accreditation Council for Graduate Medical Education's Milestone Competencies and Clinical Feedback to Residents.

Feedback in clinical education is essential but challenged by multiple barriers. This report describes the use of myTIPreport, a web-based tool, which streamlines the dual purpose of milestone evaluation and real-time feedback from faculty to residents in a US anesthesiology program. In a 6-month trial, faculty members and residents used myTIPreport for daily clinical feedback. We believe myTIPreport will be a valuable tool for clinical feedback given further refinement of the tool and improved faculty and resident development on program use.

Experience Is the Teacher of All Things: Prior Participation in Anesthesiology OSCEs Enhances Communication of Treatment Options With Simulated High-Risk Patients.

BACKGROUND: The objective of this study was to investigate whether previous experiences within an anesthesiology-based Objective Structured Clinical Examination (OSCE) assessing communication and professionalism skills was associated with improved performance in a subsequent anesthesiology-based OSCE scenario. METHODS: This retrospective multi-center study used the performance data of 44 Post Graduate Year 4 clinical anesthesia residents from 3 US anesthesiology residency programs on an OSCE scenario that assessed the residents' effectiveness of discussing anesthesiology-specific treatment options with a high-risk patient. Residents from 2 of the programs had no prior anesthesiology-based OSCE experience. Residents from the third program had previously participated in 4 separate multi-scenario anesthesiology-based OSCE sessions in the 2 years prior to this study. Participating residents completed the same scenario at their respective institutions' simulation center. Ten performances were randomly selected for double rating to assess the interrater reliability of the assessments. Interrater reliability was good for the scenario (intraclass correlation coefficient = 0.66, 95% confidence interval = 0.12-0.90). Performance difference between groups with different OSCE experience status were examined using an independent sample t test, with a Wilcoxon-Mann-Whitney test as a sensitivity analysis. RESULTS: Independent sample t test found prior OSCE experience was significantly associated with higher performance scores (t = 2.53, P = .02). The Wilcoxon-Mann-Whitney test result confirmed this finding (z = 3.28, P = .001). CONCLUSIONS: Findings from this study provide preliminary evidence that anesthesiology-based OSCE experience is associated with improved performance in an OSCE scenario, specifically regarding discussions of treatment options with high-risk patients.

Surgical Echocardiography of the MV: Focus on 3D.

The mitral valve remains a complex structure where multiple forms of pathology can be seen. Mitral regurgitation continues to be one of the most common valvular diseases in the industrialized world. While intraoperative 2-dimensional transesophageal echocardiography has been commonplace for some time, 3-dimensional technology has emerged and has shown great benefit for diagnosis and guidance during mitral valve surgery. In the hands of a trained sonographer, high-quality real-time images can easily be obtained and correlate well with gross anatomical findings. The use of multiple angled views and color Doppler within 3-dimensional transesophageal echocardiography has become a valuable asset in the understanding and interpretation of the mitral valve for surgical interventions.

Utilization of the Flipped Classroom in Anesthesiology Graduate Medical Education: An Initial Survey of Faculty Beliefs and Practices About Active Learning.

BACKGROUND: Flipped classroom (FC) is an active learning (AL) technique thought to have potential benefits in anesthesiology resident education. This survey aimed to determine the frequency of FC utilization, barriers of utilization, and means to overcome these barriers. METHOD: A web-based questionnaire was developed to survey anesthesiology faculty on their knowledge of and experience with FC. The Society of Academic Associations of Anesthesiology and Perioperative Medicine sent the survey to all United States core program directors (PD) via their list serve with a request for the PDs to forward the survey invitation to their clinical faculty. Descriptive statistics were summarized. RESULTS: A total of 244 anesthesiology faculty completed the survey. Reported faculty understanding of AL and FC were 57%. Of these faculty, 87% utilized AL and 57% utilized FC in their personal teaching practice during the past year (spring 2015-spring 2016). The most prevalent barriers to utilization of FC were faculty concern that learners would not come to class prepared or participate in class, faculty comfort with delivering traditional lectures, lack of faculty knowledge of necessary technological tools, and faculty concern about perceived increase in time needed to create a FC session. Eighty-nine percent of all faculty desired education on FC with preference for institutional workshops or grand rounds. CONCLUSIONS: Our survey found a discrepancy between faculty knowledge of FC and usage of this method in anesthesiology resident teaching. More educational resources are warranted to address barriers and familiarize faculty with FC applications in anesthesiology resident education.

The Use of Simulation to Improve Family Understanding and Support of Anesthesia Providers.

Introduction  Burnout in medical providers is associated with work dissatisfaction, reduction in patient safety, and provider depression. Simulation is a tool effectively used for specific task training but has not been broadly used as a means to combat medical professional stress and enhance wellness. The authors created a medical simulation program targeted at those involved in the social support of medical providers. The hypothesis was that education of non-medical persons involved in social support would translate into an enhanced understanding of the demands among medical providers in anesthesiology. This understanding would thereby open communication pathways within the social support system and contribute to enhanced wellness among providers. Methods To assess effectiveness and benefits of the event, survey data were obtained from anesthesia providers and their adult support persons before and after the event. The anesthesia providers were queried on their perception regarding the benefit of the event for their support persons. Support persons were asked questions regarding their understanding of the role of an anesthesia provider. Results Sixty-three family members and friends (adult=30, child=33) participated in a two-hour simulation event including activities for participants of all ages. Twenty-nine (96.7%) adult participants (age ≥ 14) completed the support person surveys before and/or after the event. The post-event survey results revealed participants' satisfaction with the event (n=26, 100%). This simulation event also demonstrated an improved understanding of the demands among anesthesia providers by their support persons (seven items, P values range from less than .0001 to .0313). Most anesthesia providers who attended the event enjoyed it a significant amount (n=19, 82.6%). Most providers whose primary work-related support persons attended the event believed that it would be easier to communicate work-related issues (n=12, 85.7%). Conclusion We outline "The Family Anesthesia Experience Day" as a wellness initiative for anesthesia providers. Our study demonstrated improved understanding of support persons' knowledge about anesthesia providers' work-related stress via an immersive two-hour simulation-based learning experience. The event was well-received and may be a useful approach to provide support persons with an opportunity to learn about and better support their beloved anesthesia provider.