Home visits are a required training component of many Family Medicine residency programs in the United States. However, they are becoming less popular due to such factors as increasing resident responsibilities, decreasing reimbursement, and a decline in resident intention to incorporate home visits into future practice. This study’s aims are: (1) to evaluate the current practices of one Family Medicine residency training program’s time and resource expenditure to conduct home visits, and (2) to evaluate resident and faculty experiences of home visits. Residents and faculty in a Family Medicine training program were provided with a 12- question survey immediately after completing a home visit. A total of 19 surveys from residents and faculty were collected and analyzed. Average reported time spent per home visit was 90 minutes (range = 50-180 minutes), and the home visit teams included an average of 4 members (range = 2-6 members). The providers felt that they knew their patients and the patients’ circumstances better after the home visit with a score of 4.1 (on a 1-5 scale with 5 being a positively framed statement). Resident opinions were neutral (average score 3.1 on a 1-5 scale) regarding whether they found home visits to be educational to their residency training in Family Medicine. Residents also had mixed feelings (average score 2.9) regarding whether they would perform more home visits during their residency training if given the opportunity. Most faculty members (5/7) indicated they had done home visits during their residency training and all faculty (7/7) felt that home visits added value to their training in Family Medicine. Finally, qualitative recommendations were collected from respondents which may allow this training program to improve home visits in the future. Overall, significant time is currently being spent conducting home visits, with a difference in perceived efficacy between residents and faculty. Future research may include a cost analysis to quantify financial value, as well as expanding data collection to other Family Medicine residency training programs to improve generalizability.

The implementation of Electronic Health Records (EHR) has improved medical documentation in terms of accuracy, team communication, and ease of ordering tests and prescriptions; however, charting in an EHR strains the provider/patient relationship and contributes to physician burnout. Medical scribes are a promising potential solution to these problems. Our study aims to demonstrate that implementation of scribes into a medical residency program positively affects provider/patient satisfaction and improves quality and efficiency of EHR documentation. Our study evaluated the effectiveness and utility of scribes in a residency training program utilizing the established implementation framework “RE-AIM,” or Reach, Effectiveness, Adoption, Implementation (quality), and Maintenance. During the study’s initial “Training Phase,” 11 first and second-year Family Medicine residents conducted scribe-facilitated patient visits. Patient and provider satisfaction ratings were collected, note quality was evaluated, and time to note closure was measured. During the subsequent “Choice Phase,” residents were given the option of whether to utilize scribes, and the same data measures were collected. Resident satisfaction ratings during the Training Phase showed an average score of 6.03 (on a 1-7 scale where “7” = “strongly agree” with positive statements), and a pilot sample of 9 patients showed an average patient satisfaction rating of 4.77 (on a 1-5 scale where “5” = “strongly agree” with positive statements). Scribe-facilitated notes coded for quality had an average score of 3.375 (on a 1-5 scale where 5 is “extremely” high quality). Finally, residents’ average time to note closure was decreased by more than 8 hours in scribe-facilitated visits. During the Choice Phase, all 11 participating residents requested scribe-facilitated visits, again with very high patient satisfaction scores (4.67 on a 1-5 scale) as well as high clinician satisfaction scores (6.06 on a 1-7 scale). Choice Phase note quality and note-closure time are currently being assessed. These results demonstrate that scribes improve clinician and patient satisfaction, as well as quality and efficiency of EHR documentation. Limitations include a small sample size of clinicians and patients. Further research is needed with larger sample sizes to determine whether scribes in a medical residency program represent a sustainable and effective intervention.

Bottlenose dolphins inhabiting coastlines and estuaries in Florida have been impacted in the past decade by development, algal blooms, catastrophic pollution, and fishery interactions (FI). Dolphins react to disturbance and environmental stressors by modifying their movements and habitat use, which may put them in jeopardy of conflict with humans. FI plays an increasing role in contributing to dolphin mortalities. I investigated dolphin movements, habitat use, residency patterns, and frequency of FI with sport fishing. Tagging studies with short-term data tags and bolt on radio-transmitters were done in several locations in Florida and the east coast providing fine-scale measurements of swimming, daily travels, and foraging activity. Transit speeds agreed with the predicted mean cost of transport as dolphins spent much of their day and night travelling and resting while swimming. Increased foraging was detected by stomach temperature changes revealing dolphins fed at night with a peak starting just after sunset. Dolphin abundance, site fidelity, ranging, stranding mortality, and community structure was characterized at Choctawhatchee and Pensacola Bays in the Florida Panhandle via surveying and photo-identification. Results showed they made frequent inshore movements, maintained site fidelity to specific areas, and comprised several distinct communities. FI was assessed at offshore reefs and coastal fishing piers near Destin, FL and Orange Beach, AL, showing that some dolphins demonstrate affinity to this activity. Harmful interactions with dolphins on reefs and at fishing piers negatively affect their resident communities. Mitigation of FI is suggested by use of avoidance strategies, gear modifications, and improved fish release practices.

No description available.

Purpose The purpose of this study was to quantify the number of surgical programs currently training osteopathic residents and to solicit advice for current osteopathic medical students who are interested in pursuing a surgical residency. Methods A questionnaire was sent to all listed Electronic Residency Application Service® (ERAS®) email contacts for the following specialties: General Surgery, Neurological Surgery, Orthopedic Surgery, Otolaryngology, Urology, Integrated Vascular Surgery, Integrated Plastic Surgery, and Integrated Thoracic Surgery. The questionnaire was sent a total of three times. Results Two hundred sixty-four of the 1,040 surgical residency programs responded to the questionnaire. Of these responses, 19% were formerly American Osteopathic Association (AOA) accredited programs. About 47.3% of responding programs indicated they are not currently training an osteopathic physician. One hundred thirteen programs provided additional comments on how osteopathic medical students may improve the competitiveness of their residency applications. These comments included increasing volumes of research activities, performing well on the United States Medical Licensing Exam (USMLE), and completing a sub-internship in the desired field or at a specific institution. Conclusion Osteopathic students still face many barriers to matching into surgical residencies. This study provides concrete steps students may take to increase the competitiveness of their application.

Background In July 2014, the Institute of Medicine released a review of the governance of Graduate Medical Education (GME), concluding that changes to GME financing were needed to reward desired performance and to reshape the workforce to meet the nation's needs. In light of the rapid emergence of alternative payment systems, we evaluated the financial value of resident participation in operative surgical care. Methods The Department of Surgery provided Current Procedural Terminology (CPT) codes for procedures performed by the general surgical service at our institution for the 2011 academic year. For each code, the charge and total instances were provided. CPTs allowing an assistant fee were identified using the Searchable Medicare Physician Fee Schedule. This approach enabled calculation of the potential resident contribution to GME funding. Results A total of 515 unique CPTs were potentially billable for a total of 6,578 procedures, of which 2,552 (39%) were reimbursable. These CPTs would have generated $1,882,854 in assistant charges. The top 50 most frequent CPTs resulted in 4,247 procedures. Within the top 50, 1362 procedures (32% of the top 50, 21% of the total) were reimbursable. Of the total assistant charges, $963,227 (51%) occurred in the top 50 most frequent CPTs. Conclusions Credit for resident participation in operative care as co-surgeon would average $67,244 per resident, compared to our current funding of $142,635 per resident. This type of alternative funding could provide 47% of current educational support. The skew in distribution of procedures also suggests that such a system could provide guidance to a more balanced operative experience. Such performance-based credentialing could be used to ensure appropriate housestaff for a given case; these reimbursements could also be adjusted based on quality metrics to provide for transformational change in patient outcomes.

Background: There is limited research on how web-based, point-of-care, evidence-based medicine (EBM) tools, such as evidence summaries, are being implemented and used in developing countries. Objectives: To investigate accessibility, use, and impact of an online EBM knowledge dissemination portal in orthopaedic surgery. To explore whether receiving daily targeted evidence summaries results in more frequent use of an EBM tool compared with receiving general weekly reports. To identify and explain the barriers and benefits of a point-of-care resource in the Indian context. Methods: Forty-four orthopaedic surgeons in Pune, India, were provided free access to OrthoEvidence (OE), a for-profit, online EBM knowledge dissemination portal. Participants were subsequently randomized to an Intervention group receiving daily targeted evidence summaries or a Control group receiving general weekly summaries. This study employed an explanatory sequential mixed methods design that incorporated two questionnaires, OE usage data, and semi-structured interviews to gain insight into the surgeons’ usage, perceptions and impact of OE. Results: There were no observable differences in OE usage between the Intervention and Control groups. OE was deemed to be comprehensive, practical, useful, and applicable to clinical practice by the majority of surgeons. The exit survey data revealed no differences between groups’ perceptions of the OE tool. Semi-structured interviews revealed barriers to keeping up with evidence that included limited access to relevant medical literature (limited internet connection, lack of time, minimal access to medical journals) and limited incentive to keep up with it (limited decision-making powers for residents, textbook-based residency curriculum, lack of research methods knowledge, limited context-specific research). Changing trauma practices at the hospital were noted following the intervention. Recommendations: The practice of EBM and the use of point-of-care tools in India can be promoted by investing in adequate electronic infrastructure (improvements to internet access) and by integrating EBM into training programs and surgical cultures. / Thesis / Master of Science (MSc)

No description available.

This thesis explores the experiences of belonging and waiting of young Hazara refugees from Afghanistan living in Sweden under temporary residence permits. The study aims to investigate the experiences of social and political belonging of young Hazara refugees with temporary residence permits, focusing on their experiences of waiting for permanent legal decisions in the context of their asylum process. The case study utilises a transformative worldview and delves into the young Hazara's narratives of social and political belonging amidst prolonged legal uncertainty through semi-structured interviews with four young Hazara refugees, aged 18-22, who arrived in Sweden as unaccompanied asylum-seeking children and have lived in Sweden since 2015. It focuses on themes such as the importance of Home, social networks, and the impact of legal liminality. It further explores the refugee's worry about deportation, challenges in pursuing education, experiences of waiting, and aspirations for the future. The findings highlight the experiences of legal uncertainty and its impact on their social and political belonging. Further research is needed on social and political belonging and waiting in the context of temporary border control. This can help improve policies for young Hazaras with temporary residency permits and other disadvantaged groups.

Introduction: Competency-based medical education (CBME) is a learner-centered outcomes-based approach. Competence by Design (CBD) is a hybrid time-based and outcomes-based CBME model that was adopted by all Royal College of Physicians and Surgeons of Canada-based residency training programs, with the primary objective of enhancing postgraduate medical education quality. However, preliminary findings suggest that residents experience higher levels of stress, anxiety, and exhaustion in CBD than with previous curricula. This thesis aims to identify and understand the emotional effects of CBME on residents, faculty, and administrative staff. Methods: This study used a qualitative approach, specifically hermeneutic phenomenology. Seven residents, six faculty members (several with education leadership roles), and one administrative staff member from a postgraduate Psychiatry program were recruited. Participants underwent semi-structured, one-on-one interviews where they were probed on their emotions with CBME. Interviews were transcribed and analyzed using a line-by-line approach that generated individual meaning units and, subsequently, themes. Results: Five themes were identified: 1) Education is an emotional experience; 2) The emotional toll of CBD; 3) CBD is a failed educational promise—Expectations vs. realities; 4) Structural and administrative burdens of CBD; and 5) Survival of educational demands—The quest for coping. Participants initially struggled to articulate their emotions, but expressed surprise at realizing they did have strong, often negative, emotions related to CBD. There was also a dissonance identified between the anticipated benefits and the execution of CBD. Furthermore, participants highlighted administrative and structural challenges of CBD, specifically regarding Entrustable Professional Activities, which were a burden and lacked much educational value. Participants discussed using various coping strategies to manage CBD’s demands. Conclusion: The findings of this work suggest that CBD has a negative emotional impact on residents and faculty, specifically due to tension between CBD’s theoretical benefits and its practical challenges, including increased emotional burden and structural challenges. / Thesis / Master of Science (MSc) / Competency-based medical education (CBME) is a learner-centered outcomes-based approach. Competence by Design (CBD) is a hybrid time-based and outcomes-based CBME model that was adopted by all Royal College of Physicians and Surgeons of Canada-based residency training programs, with the primary objective of enhancing the quality of postgraduate medical education. However, preliminary findings suggest that residents experience higher levels of stress, anxiety, and exhaustion in a CBD model than with previous curricula. This thesis aims to understand the emotional effects of CBME on residents, faculty, and administrative staff in a postgraduate Psychiatry program. In this qualitative study, participants underwent semi-structured, one-on-one interviews where they were probed on their emotions and experiences with CBME. The findings suggest that CBD has a negative emotional impact on residents and faculty, specifically due to tension between CBD’s theoretical benefits and its practical challenges, including increased emotional burden and structural challenges associated with the assessment methods.