Defining the need for faculty development in assessment.

BACKGROUND: High-quality workplace-based assessments are essential for competency-based surgical education. We explored education leaders' perceptions regarding faculty competence in assessment. METHODS: Surgical education leaders were surveyed regarding which areas faculty needed improvement, and knowledge of assessment tools. Respondents were queried on specific skills regarding (a)importance in resident/medical student education (b)competence of faculty in assessment and feedback. RESULTS: Surveys (n = 636) were emailed, 103 responded most faculty needed improvement in: verbal (86%) and written (83%) feedback, assessing operative skill (49%) and preparation for procedures (50%). Cholecystectomy, trauma laparotomy, inguinal herniorrhaphy were "very-extremely important" in resident education (99%), but 21-24% thought faculty "moderately to not-at-all" competent in assessment. This gap was larger for non-technical skills. Regarding assessment tools, 56% used OSATS, 49% Zwisch; most were unfamiliar with all non-technical tools. SUMMARY: These data demonstrate a significant perceived gap in competence of faculty in assessment and feedback, and unfamiliarity with assessment tools. This can inform faculty development to support competency-based surgical education.

Identifying Sources of Stress Across Years of General Surgery Residency.

Stressors during surgical residency training are common and can contribute to impaired technical performance, medical errors, health problems, physician burnout, and career turnover. This survey of general surgery recent graduates and chief residents examined threats to resident health and well-being. An electronic survey composed of multiple-choice, checkbox, dropdown, and open-ended questions was developed to determine the most stressful general surgery residency year, sources of the stress, and potential interventions to manage resident well-being. The survey was sent to five program directors across the United States to be forwarded to chief residents and recent graduates less than five years from graduation. Twenty-three residents and recent graduates responded to the survey. Seventy percent reported they "never" got enough sleep, and 39% reported they did not have a healthy lifestyle. Financial concerns were the most frequently cited source of stress. During post-graduate-years (PGY) 1 and 2, residents were most likely to fear hurting a patient or being "in over their head." In PGY-3, residents were most likely to consider leaving the residency program. The current findings suggest that each year of general surgery residency is linked with certain stressors, and no year is particularly stressful relative to the other years. There can be more research and efforts to focus on additional PGY-specific training and supervision, as well as added general measures to promote resident health and financial stability throughout all years. Regarding stress mitigation, residents may benefit from faculty, peer, and community interaction rather than from formal professional counseling.

Unique Epidemiology of Spinal Cord Injury in Hawai'i: Wave-related Incidents.

Spinal cord injury remains one of the most devastating forms of traumatic injury. The purpose of this study was to characterize the clinical characteristics of spinal cord injury patients and the geographic location where the injury occurred in the state of Hawai'i. Spinal cord injury cases from 2009-2017 were identified using the State Trauma Registry, which included demographics, mechanism of injury, and outcomes. In 1170 spinal cord injury cases, the second most frequent etiology was an ocean-wave related incident. Over half of wave related spinal cord injury occurred on ten beaches on four islands. Compared to other mechanisms, patients with wave related spinal cord injury were significantly less likely to be Hawai'i residents (15%), screen positive for alcohol (4%), or have an injury in the lower thoracic or lumbar region (4%). These patients were also less likely to die (1%) and more likely to be discharged to home (66%). Wave related incidents are a major cause of spinal cord injury in Hawai'i, disproportionately affecting visitors. Education focused toward middle-aged male visitors at beaches with moderate to severe shorebreak may reduce the incidence of injury.

An Uncommon Pairing of common Tumors: Case Report of Ductal Carcinoma in situ Within Fibroadenoma.

Fibroadenomas are common benign tumors of the female breast. In the appropriate clinical setting, they are often managed expectantly without excision. Rarely, cancer may arise within a fibroadenoma, and this diagnosis mandates prompt treatment for malignancy. We present the case of a 70-year-old Samoan woman with ductal carcinoma in situ (DCIS) arising within a fibroadenoma. Health care practitioners should be aware of the possibility, particularly in older women, of finding carcinoma within a fibroadenoma, which informs the rationale for prompt surgical evaluation and follow up of all breast masses.

American College of surgeons /Association for Surgical Education Medical Student Simulation-based Surgical Skills Curriculum: Alignment with Entrustable Professional Activities.

BACKGROUND: We hypothesized that medical experts would concur the American College of Surgeons/Association for Surgical Education Medical Student Simulation-based Surgical Skills Curriculum ("ACS/ASE Curriculum") could be used to teach and assess Entrustable Professional Activities (EPAs). METHODS: A "crosswalk" was created between ACS/ASE Curriculum modules and eight EPAs. Medical education experts participated in a Delphi process regarding feasibility of using the modules for teaching and assessing EPAs. RESULTS: Twenty-eight educators from six clinical fields participated. There was consensus that five of the EPAs could be taught and assessed by the ACS/ASE Curriculum. A median of nine hours per month outside the surgical clerkship was recommended for skills training. CONCLUSIONS: The ACS/ASE Curriculum lays the framework for implementing select EPAs into medical student education. Experts recommended increased time for skills training with incorporation of the modules into the first three years of medical education, with assessments planned in the third to fourth years.

Rural Level III centers in an inclusive trauma system reduce the need for interfacility transfer.

BACKGROUND: Development of Level III trauma centers in a regionalized system facilitates early stabilization and prompt transfer to a higher level center. The resources to care for patients at Level III centers could also reduce the burden of interfacility transfers. We hypothesized that the development and designation of Level III centers in an inclusive trauma system resulted in lower rates of transfer, with no increase in morbidity or mortality among the non-transferred patients. METHODS: State trauma registry data from January 2009 through September 2015 were examined from five rural hospitals that transfer patients to our highest (Level II) trauma center and resource hospital. These five rural hospitals began receiving state support in 2010 to develop their trauma programs and were subsequently verified and designated Level III centers (three in 2011, two in 2013). Multivariate logistic regression was used to examine the adjusted odds of patient transfers and adverse outcomes, while controlling for age, gender, penetrating mechanism, presence of a traumatic brain injury, arrival by ambulance, and category of Injury Severity Score. The study period was divided into "Before" Level III center designation (2009-2010) and "After" (2011-2015). RESULTS: 7,481 patient records were reviewed. There was a decrease in the proportion of patients who were transferred After (1,281/5,737) compared to Before (516/1,744) periods (22% vs. 30%, respectively). After controlling for the various covariates, the odds of patient transfer were reduced by 32% (p < 0.0001) during the After period. Among non-transferred patients, there were no significant increases in adjusted odds of mortality, or hospitalizations of seven days or more, Before versus After. CONCLUSIONS: Development of rural Level III trauma centers in a regionalized system can significantly reduce the need for transfer to a remote, higher level trauma center. This may benefit the patient, family, and trauma system, with no adverse effect upon patient outcome. LEVEL OF EVIDENCE: Epidemiological, level III.

Motor vehicle crash fatalaties and undercompensated care associated with legalization of marijuana.

BACKGROUND: Half of the US states have legalized medical cannabis (marijuana), some allow recreational use. The economic and public health effects of these policies are still being evaluated. We hypothesized that cannabis legalization was associated with an increase in the proportion of motor vehicle crash fatalities involving cannabis-positive drivers, and that cannabis use is associated with high-risk behavior and poor insurance status. METHODS: Hawaii legalized cannabis in 2000. Fatality Analysis Reporting System data were analyzed before (1993-2000) and after (2001-2015) legalization. The presence of cannabis (THC), methamphetamine, and alcohol in fatally injured drivers was compared. Data from the state's highest level trauma center were reviewed for THC status from 1997 to 2013. State Trauma Registry data from 2011 to 2015 were reviewed to evaluate association between cannabis, helmet/seatbelt use, and payor mix. RESULTS: THC positivity among driver fatalities increased since legalization, with a threefold increase from 1993-2000 to 2001-2015. Methamphetamine, which has remained illegal, and alcohol positivity were not significantly different before versus after 2000. THC-positive fatalities were younger, and more likely, single-vehicle accidents, nighttime crashes, and speeding. They were less likely to have used a seatbelt or helmet. THC positivity among all injured patients tested at our highest level trauma center increased from 11% before to 20% after legalization. From 2011 to 2015, THC-positive patients were significantly less likely to wear a seatbelt or helmet (33% vs 56%). They were twice as likely to have Medicaid insurance (28% vs 14%). CONCLUSION: Since the legalization of cannabis, THC positivity among MVC fatalities has tripled statewide, and THC positivity among patients presenting to the highest level trauma center has doubled. THC-positive patients are less likely to use protective devices and more likely to rely on publically funded medical insurance. These findings have implications nationally and underscore the need for further research and policy development to address the public health effects and the costs of cannabis-related trauma. LEVEL OF EVIDENCE: Prognostic, level III.

Variation in training and use of the focused assessment with sonography in trauma (FAST).

BACKGROUND: Training in ultrasound is variable among residents and practicing traumatologists. Focused Assessment with Sonography in Trauma (FAST) may be underused in non-urbanized areas, possibly due to lack of training. METHODS: State trauma registry data from January 2014-June 2016 were reviewed for FAST results. Trauma practitioners were surveyed querying training, confidence, and obstacles to performing FAST. RESULTS: 12,855 records revealed highest FAST use at the urban Level II center (39%, p < 0.0001). Despite similar injury patterns, non-urban/Level III centers' frequency of FAST was only 1-28%. 39 practitioners were surveyed, those with training (54%) were more likely to use FAST (p < 0.05). 61% of practitioners outside the Level II center cited lack of confidence in their ability to perform FAST as the primary reason for omitting the exam. CONCLUSIONS: FAST is relatively underused in non-urbanized areas of the state. Lack of confidence in ability to perform FAST was cited as the primary barrier.

Impact of Helmet Use on Injury and Financial Burden of Motorcycle and Moped Crashes in Hawai'i: Analysis of a Linked Statewide Database.

Helmet use reduces injury severity, disability, hospital length of stay, and hospital charges in motorcycle riders. The public absorbs billions of dollars annually in hospital charges for unhelmeted, uninsured motorcycle riders. We sought to quantify, on a statewide level, the healthcare burden of unhelmeted motorcycle and moped riders. We examined 1,965 emergency medical service (EMS) reports from motorcycle and moped crashes in Hawai'i between 2007-2009. EMS records were linked to hospital medical records to assess associations between vehicle type, helmet use, medical charges, diagnoses, and final disposition. Unhelmeted riders of either type of vehicle suffered more head injuries, especially skull fractures (adjusted odds ratio (OR) of 4.48, P < .001, compared to helmeted riders). Motorcyclists without helmets were nearly three times more likely to die (adjusted OR 2.85, P = .001). Average medical charges were almost 50% higher for unhelmeted motorcycle and moped riders, with a significant (P = .006) difference between helmeted ($27,176) and unhelmeted ($40,217) motorcycle riders. Unhelmeted riders were twice as likely to self-pay (19.3%, versus 9.8% of helmeted riders), and more likely to have Medicaid or a similar income-qualifying insurance plan (13.5% versus 5.0%, respectively). Protective associations with helmet use are stronger among motorcyclists than moped riders, suggesting the protective effect is augmented in higher speed crashes. The public financial burden is higher from unhelmeted riders who sustain more severe injuries and are less likely to be insured.

Trauma team discord and the role of briefing.

BACKGROUND: Briefing of the trauma team before patient arrival is unstructured in many centers. We surveyed trauma teams regarding agreement on patient care priorities and evaluated the impact of a structured, physician-led briefing on concordance during simulated resuscitations. METHODS: Trauma nurses at our Level II center were surveyed, and they participated in four resuscitation scenarios, randomized to "briefed" or "nonbriefed." For nonbriefed scenarios, nurses independently reviewed triage sheets with written information. Briefed scenarios had a structured 4-minute physician-led briefing reviewing triage sheets identical to nonbriefed scenarios. Teams included three to four nurses (subjects) and two to four confederates (physicians, respiratory therapists). Each team served as their own control group. Confederates were blinded to nurses' briefed or nonbriefed status. Immediately before, and at the midpoint of each scenario, nurses estimated patients' morbidity and mortality and ranked the top 3 of 16 designated immediate care priorities. Briefed and nonbriefed groups' responses were compared for (1) agreement using intraclass correlation coefficient, (2) concordance with physicians' responses using the Fisher exact test, (3) teamwork via T-NOTECHS ratings by nurses and physicians using t-test, and (4) time to complete clinical tasks using t test. RESULTS: Thirty-eight nurses participated. Ninety-seven percent "agreed/strongly agreed" briefing is important, but only 46% agreed briefing was done well. Comparing briefed versus nonbriefed scenarios, nurses' estimation of morbidity and mortality in the briefed scenarios showed significantly greater agreement with each other and with physicians' answers (p < 0.01). Rank lists also better agreed with each other (intraclass correlation coefficient, 0.64 vs 0.59) and with physicians' answers in the briefed scenarios. T-NOTECHS Leadership ratings were significantly higher in the briefed scenarios (3.70 vs 3.39; p < 0.01). Time to completion of key clinical tasks was significantly faster for one of the briefed scenarios. CONCLUSIONS: Discordant perceptions of patient care goals was frequently observed. Structured physician-led briefing seemed to improve interprofessional team concordance, leadership, and task completion in simulated trauma resuscitations.

Role confusion and self-assessment in interprofessional trauma teams.

BACKGROUND: Trauma care requires coordinating an interprofessional team, with formative feedback on teamwork skills. We hypothesized nurses and surgeons have different perceptions regarding roles during resuscitation; that nurses' teamwork self-assessment differs from experts', and that video debriefing might improve accuracy of self-assessment. METHODS: Trauma nurses and surgeons were surveyed regarding resuscitation responsibilities. Subsequently, nurses joined interprofessional teams in simulated trauma resuscitations. After each resuscitation, nurses and teamwork experts independently scored teamwork (T-NOTECHS). After video debriefing, nurses repeated T-NOTECHS self-assessment. RESULTS: Nurses and surgeons assumed significantly more responsibility by their own profession for 71% of resuscitation tasks. Nurses' overall T-NOTECHS ratings were slightly higher than experts'. This was evident in all T-NOTECHS subdomains except "leadership," but despite statistical significance the difference was small and clinically irrelevant. Video debriefing did not improve the accuracy of self-assessment. CONCLUSIONS: Nurses and physicians demonstrated discordant perceptions of responsibilities. Nurses' self-assessment of teamwork was statistically, but not clinically significantly, higher than experts' in all domains except physician leadership.

Perioperative management in the patient with substance abuse.

Drug and alcohol use is a pervasive problem in the general population and in those requiring anesthesia for an operation. History and screening can help delineate those who may be acutely intoxicated or chronic drug and alcohol users. Both acute intoxication and chronic abuse of these substances present challenges for anesthetic management during and after an operation. The clinician should be aware of problems that may be encountered during any part of anesthesia or postoperative care.

Helmet use among motorcycle and moped riders injured in Hawaii: Final medical dispositions from a linked database.

BACKGROUND: Reports regarding helmets in motorcycle crashes have been limited by the lack of data across the spectrum of injury outcomes, generally excluding low-severity injuries that do not require further medical treatment. We hypothesized that the protective effect of helmets may be underestimated in studies that focused only on patients who arrive at a trauma center and that it may differ depending on whether the crash involved a motorcycle or moped. METHODS: The emergency medical service reports of 2,553 crash patients treated from 2007 to 2009 were linked to police crash reports, hospital billing data, death certificates, and the Fatal Analysis Reporting System for a more complete description of the crashes throughout the state. RESULTS: The number of unhelmeted riders (n = 1,674) was nearly double those who were helmeted (n = 879). Multivariate logistic regression models estimated 45% greater odds of a hospital admission (vs. no hospital treatment or a discharge from the emergency department setting) among unhelmeted riders, compared with helmeted riders. Unhelmeted riders also had an adjusted odds of a fatal injury that was more than double that of helmeted riders (odds ratio, 2.71; 95% confidence interval, 1.68-4.46). Stratified analyses showed that these protective associations between helmet use and medical disposition were apparent only among motorcyclists. CONCLUSION: The magnitude of the protective associations between helmets and medical outcomes was generally greater than that reported by other studies. Motorcyclists seem to benefit from helmet use more than moped riders. This data could be used to promote helmet use through education and public policy. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

Team size impact on assessment of teamwork in simulation-based trauma team training.

Non-technical skills (teamwork) assessment is used to improve competence during training for interprofessional trauma teams. We hypothesized non-technical skills assessment is less reliable for large size teams, and evaluated team size effects during teamwork training. Small-teams (n = 5; 5-7 members) and Large-teams (n = 6; 8-9 members) participated in three simulation-based trauma team training scenarios. Following each scenario, teamwork was scored by participating trauma attending physicians (TA), non-participating critical care trauma nurses (CRN), and two expert teamwork debriefers (E), using the Trauma Nontechnical Skills Assessment tool (T-NOTECHS). Large-team scores by TA and CRN were higher than E scores (P < .003); small-team scores did not differ by rater. Small-team inter-observer agreement was substantial (ICC = 0.60); large-team agreement was low (ICC = 0.29). E and TA scores showed no concordance, whereas E and CRN scores showed poor concordance for large teams (ICC = 0.41, r = 0.53, P = .02). By contrast, correlation between E and TA (ICC = 0.52, r = 0.80, P < .001) as well as E and CRN (ICC = 0.57, and r = 0.65, P < .01) for small teams was high. Team size should be considered in team-training design, and when using teamwork rating instruments such as T-NOTECHS for assessment of simulated or actual trauma teams. Modified rating scales and enhanced training for raters of large groups versus small groups may be warranted.

Assessing teamwork in the trauma bay: introduction of a modified "NOTECHS" scale for trauma.

BACKGROUND: A modified nontechnical skills (NOTECHS) scale for trauma (T-NOTECHS) was developed to teach and assess teamwork skills of multidisciplinary trauma resuscitation teams. In this study, T-NOTECHS was evaluated for reliability and correlation with clinical performance. METHODS: Interrater reliability (intraclass correlation coefficient) and correlation with the speed and completeness of resuscitation tasks were assessed during simulation-based teamwork training and during actual trauma resuscitations. RESULTS: For T-NOTECHS ratings done in real time, intraclass correlation coefficients were .44 for simulated and .48 for actual resuscitations. Reliability was higher (intraclass correlation coefficient = .71) for video review of resuscitations. Better T-NOTECHS scores were correlated with better performance during simulations, evidenced by a greater number of completed resuscitation tasks (r = .50, P < .01) and faster time to completion (r = -.38, P < .05) In actual resuscitations, T-NOTECHS ratings improved after teamwork training (P < .001). Higher T-NOTECHS scores were correlated with better clinical performance, evidenced by faster resuscitation (r = -.13, P < .05) and fewer unreported resuscitation tasks (r = -.16, P < .05). CONCLUSIONS: Improvement in T-NOTECHS scores after teamwork training, and correlation with clinical parameters in simulated and actual trauma resuscitations, suggest its clinical relevance. Further evaluation, aiming to improve reliability, may be warranted.

In situ, multidisciplinary, simulation-based teamwork training improves early trauma care.

OBJECTIVE: Evaluate the impact of a team training curriculum for residents and multidisciplinary trauma team members on team communication, coordination and clinical efficacy of trauma resuscitation. DESIGN: Prospective, cohort intervention comparing pre- vs. post-training performance. The intervention was a human patient simulator (HPS)-based, in situ team training curriculum, comprising a one-hour web based didactic followed by HPS training in the emergency department (ED). Teams were trained in multidisciplinary groups of 5-8 persons. Each HPS session included three fifteen minute scenarios with immediate video-enabled debriefing. Structured debriefing and teamwork assessment was performed with a modified NOTECHS scale for trauma (T-NOTECHS). Teams were assessed for performance changes during HPS-based training, as well as in actual trauma resuscitations. SETTING: The Queen's Trauma Center (Level II); the primary teaching hospital for the University of Hawaii Surgical Residency. PARTICIPANTS: 137 multidisciplinary trauma team members, including residents (n = 24), ED and trauma attending physicians, nurses, respiratory therapists, and ED technicians. RESULTS: During HPS-based training sessions, significant improvements in teamwork ratings, and in clinical task speed and completion rates were noted between the first and the last scenario.244 real-life blunt trauma resuscitations were observed for six months before and after training. There was a significant improvement in mean teamwork scores from the pre-to post-training resuscitations. Moreover, there were significant improvements in the objective parameters of speed and completeness of resuscitation. This was manifest by a 76% increase in the frequency of near-perfect task completion (≤ 1 unreported task), and a reduction in the mean overall ED resuscitation time by 16%. CONCLUSIONS: A relatively brief (four-hour) HPS-based curriculum can improve the teamwork and clinical performance of multidisciplinary trauma teams that include surgical residents. This improvement was evidenced both in simulated and actual trauma settings, and across teams of varying composition. HPS-based trauma teamwork training appears to be an educational method that can impact patient care.

Breast cancer worry among women awaiting mammography: is it unfounded? Does prior counseling help?

The purpose of this study was to explore the prevalence of breast cancer anxiety and risk counseling in women undergoing mammography, and the association with known risk factors for cancer. Women awaiting mammography were surveyed regarding anxiety, prior breast cancer risk counseling, demographic and risk factors. Anxiety was assessed via 7-point Likert-type scale (LS). Risk was defined by Gail model or prior breast cancer. Data were analyzed by nonparametric methods; significance determined at alpha = 0.05. Of 227 women surveyed, 54 were classified "higher risk". Counseling prevalence was similar (52%) for all ethnic groups, but higher (72%, P<0.001) for "higher risk" women. On average, women awaiting screening/diagnostic mammography were somewhat worried (median LS = 4). Worry was significantly higher (P<0.05) in "higher risk" women (LS = 5), and in women living outside Honolulu (LS = 6). Counseling by primary care physicians (PCP) did not correlate with lower worry scores. It was concluded that most women awaiting mammography are not unduly anxious. Additionally, the findings showed a correlation between a woman's concern about developing cancer with known risk factors and rural residence.

Student-written simulation scenarios: a novel cognitive assessment method in a trauma curriculum.

INTRODUCTION: Global cognitive and psychomotor assessment in simulation based curricula is complex. We describe assessment of novices' cognitive skills in a trauma curriculum using a simulation aligned facilitated discovery method. METHODS: Third-year medical students in a surgery clerkship completed two student-written simulation scenarios (SWSS) as an assessment method in a trauma curriculum employing high fidelity human patient simulators (manikins). SWSS consisted of written physiologic parameters, intervention responses, a performance evaluation form, and a critical interventions checklist. RESULTS: Seventy-one students participated. SWSS scores were compared to multiple choice test (MCQ), checklist-graded solo performance in a trauma scenario (STS), and clerkship summative evaluation grades. The SWSS appeared to be slightly better than STS in discriminating between Honors and non-Honors students, although the mean scores of Honors and non-Honors students on SWSS, STS, or MCQ were not significantly different. SWSS exhibited good equivalent form reliability (r=0.88), and higher interrater reliability versus STS (r=0.93 vs r=0.79). CONCLUSION: SWSS is a promising assessment method for simulation based curricula.