Comparison of Operative Experiences of PGY-1 and PGY-2 General Surgery Residents During Night-Float vs. 24-Hour Call Systems.

OBJECTIVE: We aimed to specifically compare the impact of a night-float system vs. a 24-hour call system on the number and types of cases performed by PGY-1 and PGY-2 general surgery residents to determine if both of these schedules could meet the ACGME first two-year 250 case minimum requirement, and if so, which schedule provided the best operative experience for PGY-1 and PGY-2 residents. DESIGN: This is a retrospective review of call schedules and operative case logs of PGY-1 and PGY-2 general surgery residents. Residents were separated into two groups based on type of call schedule: 24-hour vs. night-float. The case logs of PGY-1 and PGY-2 residents were obtained from the ACGME Case Log System and data analysis was performed between the two groups. SETTING: This study was performed at a general surgery residency at a hybrid academic center. PARTICIPANTS: Forty-three residents met inclusion criteria. Twenty-three were part of the night-float system and 20 were part of the 24-hour call system. RESULTS: Total cases and major cases for PGY-1 and PGY-2 years were compared between the two groups. The 24-hour call group had a significantly higher total number of cases than the night-float group (646.0 ± 181.5 vs. 504.8 ±148.9, p = 0.008). Major cases were also significantly higher in the 24-hour call group than the night-float group (418.5 ± 99.6 vs. 355 ± 99.5, p = 0.043). CONCLUSIONS: Both the 24-hour call and night-float systems were able to meet the ACGME first two year 250 case minimum requirement as well as follow work-hour guidelines. The 24-hour call system was associated with PGY-1 and PGY-2 residents having a better operative experience than the night-float system.

Progressive Surgical Autonomy Observed in a Hand Surgery Resident Clinic Model.

OBJECTIVE: Resident clinics (RCs) are intended to catalyze the achievement of educational milestones through progressively autonomous patient care. However, few studies quantify their effect on competency-based surgical education, and no previous publications focus on hand surgery RCs (HRCs). We demonstrate the achievement of progressive surgical autonomy in an HRC model. DESIGN: A retrospective review of all patients seen in a weekly half-day HRC from October 2010 to October 2015 was conducted. Investigators compiled data on patient demographics, provider encounters, operational statistics, operative details, and dictated surgical autonomy on an ascending 5 point scoring system. SETTING: A tertiary hand surgery referral center. RESULTS: A total of 2295 HRC patients were evaluated during the study period in 5173 clinic visits. There was an average of 22.6 patients per clinic, including 9.0 new patients with 6.5 emergency room referrals. Totally, 825 operations were performed by 39 residents. Trainee autonomy averaged 2.1/5 (standard deviation [SD] = 1.2), 3.4/5 (SD = 1.3), 2.1/5 (SD = 1.3), 3.4/5 (SD = 1.2), 3.2/5 (SD = 1.5), 3.5/5 (SD = 1.5), 4.0/5 (SD = 1.2), 4.1/5 (SD = 1.2), in postgraduate years 1 to 8, respectively. Linear mixed model analysis demonstrated training level significantly effected operative autonomy (p = 0.0001). Continuity of care was maintained in 79.3% of cases, and patients were followed an average of 3.9 clinic encounters over 12.4 weeks. CONCLUSIONS: Our HRC appears to enable surgical trainees to practice supervised autonomous surgical care and provide a forum in which to observe progressive operative competency achievement during hand surgery training. Future studies comparing HRC models to non-RC models will be required to further define quality-of-care delivery within RCs.

Teachers as Learners: Developing Professionalism Feedback Skills via Observed Structured Teaching Encounters.

This Conversations Starter article presents a selected research abstract from the 2017 Association of American Medical Colleges Southern Region Group on Educational Affairs annual spring meeting. The abstract is paired with the integrative commentary of 4 experts who shared their thoughts stimulated by the study. These thoughts explore the value of the Observed Structured Teaching Encounter in providing structured opportunities for medical students to engage with the complexities of providing peer feedback on professionalism.

Progressive Surgical Autonomy in a Plastic Surgery Resident Clinic.

BACKGROUND: Resident clinics are thought to catalyze educational milestone achievement through opportunities for progressively autonomous surgical care, but studies are lacking for general plastic surgery resident clinics (PSRCs). We demonstrate the achievement of increased surgical autonomy and continuity of care in a PSRC. METHODS: A retrospective review of all patients seen in a PSRC from October 1, 2010, to October 1, 2015, was conducted. Our PSRC is supervised by faculty plastic surgery attendings, though primarily run by chief residents in an accredited independent plastic surgery training program. Surgical autonomy was scored on a 5-point scale based on dictated operative reports. Graduated chief residents were additionally surveyed by anonymous online survey. RESULTS: Thousand one hundred forty-four patients were seen in 3,390 clinic visits. Six hundred fifty-three operations were performed by 23 total residents, including 10 graduating chiefs. Senior resident autonomy averaged 3.5/5 (SD = 1.5), 3.6/5 (SD = 1.5), to 3.8/5 (SD = 1.3) in postgraduate years 6, 7, and 8, respectively. A linear mixed model analysis demonstrated that training level had a significant impact on operative autonomy when comparing postgraduate years 6 and 8 (P = 0.026). Graduated residents' survey responses (N = 10; 100% response rate) regarded PSRC as valuable for surgical experience (4.1/5), operative autonomy (4.4/5), medical knowledge development (4.7/5), and the practice of Accreditation Council of Graduate Medical Education core competencies (4.3/5). Preoperative or postoperative continuity of care was maintained in 93.5% of cases. CONCLUSION: The achievement of progressive surgical autonomy may be demonstrated within a PSRC model.

Speaking up: using OSTEs to understand how medical students address professionalism lapses.

BACKGROUND: Objective-structured teaching encounters (OSTEs) are used across many disciplines to assess teaching ability. The OSTE detailed in this paper assesses 191 fourth-year medical students' (M4) ability to identify and address lapses in professionalism based on Association of American Medical Colleges' professionalism competencies. The research questions addressed are How frequently do M4s address professionalism lapses observed during an OSTE? What factors influence whether M4s provide feedback when they observe professionalism lapses in an OSTE? METHODS: Standardized patients (SPs) and standardized learners (SLs) were recruited and trained to participate in a standardized encounter with specific cognitive, social, and behavioral errors, including professionalism lapses. M4s viewed this encounter and then offered feedback to the SL, while remotely observed by faculty. Post-encounter, the SL and faculty completed identical checklists to assess both teaching readiness and ability to address professionalism concerns. RESULTS: An analysis of frequencies showed that six of the Association of American Medical Colleges' nine professional competencies were addressed in the checklist and/or discussed in the focus group. Analysis of transcribed debriefing sessions confirmed that M4s did not consistently address professionalism lapses by their peers. CONCLUSIONS: In focus groups, M4s indicated that, while they noticed professionalism issues, they were uncomfortable discussing them with the SLs. Findings of the current study suggest how medical educators might support learners' ability to address lapses in professionalism as well as topics for future research.

Social Information Processing in Anger Expression and Partner Violence in Returning U.S. Veterans.

We examined social information processing factors that could represent pathways through which posttraumatic stress disorder (PTSD) symptoms relate to anger expression and intimate partner violence (IPV) perpetration in returning U.S. veterans. The sample included 92 male Operation Enduring Freedom/Operation Iraqi Freedom veterans, primarily Caucasian (77.4%), with smaller numbers of African American, Asian, Hispanic or Latino, American Indian or Alaskan Native, and other minority participants (9.7%, 2.2%, 2.2%, 3.2%, and 5.3% respectively). The average age was 40.37 (SD = 9.63) years. Data were collected through self-report questionnaires (PTSD Checklist, State-Trait Anger Expression Scale, Revised Conflict Tactics Scales) and the Articulated Thoughts in Simulated Situations experimental protocol. Laboratory-based assessment of cognitive biases and hostile attributions were tested as mediators of associations between PTSD symptoms and anger expression and IPV. Among the PTSD symptom clusters, hyperarousal symptoms were most strongly associated with anger expression (r = .50) and IPV perpetration (r = .27). Cognitive biases mediated associations between PTSD total scores and 3 of 4 PTSD cluster scores as well as anger expression. Hostile attribution biases were also associated with IPV perpetration (r = .23). We discuss the implications of these findings for understanding social information processing mechanisms for the relationship between PTSD symptoms and aggression.

Posttraumatic stress disorder symptoms, emotion dysregulation, and aggressive behavior among incarcerated methamphetamine users.

OBJECTIVE: Methamphetamine use remains a prevalent problem in the United States and is linked to numerous deleterious outcomes, including aggressive behavior, criminal activity, and incarceration. Given these associations, a greater understanding of factors that contribute to aggression among users of methamphetamine is needed, particularly within criminal justice settings, where users of this drug are overrepresented. METHODS: The present study examined the relationships between posttraumatic stress disorder (PTSD) symptoms and emotion dysregulation and in-prison physical aggression among incarcerated males who identified as methamphetamine users (N = 60). RESULTS: Participants' average age was 34.4 years (SD = 7.9), and they were predominantly European American (n = 48, 80%), had spent an average of 6.53 years incarcerated (SD = 4.64), and perpetrated about 1.54 acts of aggression (SD = 6.74) during the past three months. Bivariate correlations found that greater PTSD symptoms (p < .001), greater impulse control difficulties (p < .001), and limited access to emotion regulation strategies (p < .05) were associated with aggression perpetrated in prison. However, results from multiple regression analyses indicated that only PTSD symptoms (p <.001) and nonacceptance of emotional responses (p < .03) were predictive of aggression. Regression analyses also suggested that impulse control difficulties (p < .001), limited access to emotion regulation strategies (p < .04), and nonacceptance of emotional responses (p < .001) interacted with PTSD symptoms to predict increased aggressive behavior. The first interaction ran counter to study hypotheses: At greater levels of PTSD symptoms, those with greater acceptance of emotional responses reported greater aggression perpetration than those with lesser acceptance of emotional responses. The other two interactions were in line with hypotheses, showing that at greater levels of PTSD symptoms, those with greater impulse control difficulties (or lesser access to emotion regulation strategies) reported more aggressive behaviors. CONCLUSIONS: Consistent with theories of aggression, study findings suggest that PTSD symptoms bolster the risk of aggression via various forms emotion dysregulation. Results shed light on potential mechanisms that promote in-prison aggression and violent recidivism among this population.

Negative urgency and emotion regulation strategy use: Associations with displaced aggression.

The numerous public health consequences of interpersonal aggression highlight the necessity of a comprehensive understanding of factors influencing its perpetration. This study examined direct and interactive associations between negative urgency and emotion regulation strategy use in predicting displaced aggression under conditions of negative mood. Participants were 197 male and female undergraduate students who were randomly assigned to employ either cognitive reappraisal or expressive suppression in response to a negative mood induction. Immediately afterwards, participants engaged in an analog displaced aggression task. Results revealed direct, positive associations between negative urgency and aggression. In addition, the use of suppression was associated with greater aggression than was the use of reappraisal alone. Counter to the hypothesis, there were no interactive effects between negative urgency and emotion regulation strategy use in predicting aggression. Findings suggest reducing negative urgency and use of suppression as potential intervention targets for individuals who engage in aggressive behavior.

Examining intimate partner aggression assessment among returning veterans and their partners.

There is a growing research base focusing on intimate partner aggression (IPA) in combat veterans, although little work has focused on IPA assessment. In the current study, the authors investigated IPA assessment among 65 male Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) combat veterans and their female partners. Specifically, we compared overall levels of veteran- and partner-perpetrated IPA, conducted concordance analyses to examine the degree of interpartner agreement on IPA occurrence and frequency, and investigated both veterans' and partners' relationship satisfaction and posttraumatic stress disorder (PTSD) symptoms as correlates of concordance. Results indicated that female partners perpetrated higher levels of physical IPA than did the male veterans, according to both veteran and combined reports. Concordance analyses revealed low to moderate levels of agreement between veterans and their partners on the perpetration of physical and psychological IPA, with particularly low agreement on the veterans' physical IPA. Female partners' relationship satisfaction was associated with reporting less of the veterans' and their own IPA relative to the veterans' reports, and their PTSD symptoms were associated with reporting more of the veterans' and their own IPA. In contrast, the veterans' PTSD symptoms were associated with reporting less of their own IPA relative to their partners' reports. The findings emphasize the need for those researching and treating IPA among military couples to assess IPA perpetrated by both members of the relationship and to consider possible factors that might impact the accuracy of IPA reporting.

Labile sex differences in long calling in cotton-top tamarins.

Sex differences in behavior are quite common among nonhuman primates. In sexually monomorphic species, sex differences might be expected to be less evident than in polygynous and highly dimorphic species. Callitrichid primates (marmosets and tamarins) are cooperative breeders that exhibit little sexual size dimorphism. However, several sex differences in the structure and usage of vocalizations have been reported. In one such study, McConnell and Snowdon [Behaviour 97:273-296, 1986] reported that female cotton-top tamarins (Saguinus oedipus) emitted significantly more normal long calls than males during simulated intergroup encounters. In the course of collecting a library of normal long calls, we replicated a portion of that study 20 years later with the same colony and similar methods. To our surprise we found a reversal of sex differences. In the same experimental situation, males gave significantly more normal long calls than females. In a further replication 2 years later, males still called more but the effect was less pronounced. The dramatic change in sex differences within the same species and colony over a 22-year period suggests that behavioral sex differences in callitrichids may be quite labile, and that repeated sampling over several years may be necessary to establish true sex differences.

Neuroendocrine response to female ovulatory odors depends upon social condition in male common marmosets, Callithrix jacchus.

Male mammals show rapid behavioral and hormonal responses to signals from sexually receptive females. However, rapid endocrine responses to female signals have not been observed in a nonhuman primate. Here, we tested the behavioral and hormonal response of male common marmosets (Callithrix jacchus) to isolated scent secretions from ovulatory females or to vehicle control scent. Fifteen males were tested in their home cage for behavioral and hormonal responses. These males showed increased investigative and arousal behaviors to the ovulatory scent compared to the vehicle scent. Time sniffing the scent substrate and the duration of erections were significantly elevated in relation to the vehicle scent. Thirty minutes after presentation of ovulatory scent, males showed a significant increase in testosterone compared to the vehicle, but there was no difference in cortisol values. To better control for scent presentation, 15 additional males were tested under a controlled scent exposure. Current social housing condition influenced the male's testosterone response to the ovulatory scent. Single and paired males showed significant increases in testosterone levels with the ovulatory scent but did not increase cortisol levels. Single males also showed the highest change in testosterone with the ovulatory scent, but fathers showed no changes. These results indicate that a rapid hormonal response to sexually arousing cues occurs in marmosets, and the data suggest that a male's social condition influences how he responds to sexually relevant cues.