Aussama K. Nassar

Background: Systematic strategies to harness electronic health record (EHR) workflows, reduce redundancy, and support decision-making remain limited in acute care surgery (ACS). Understanding how EHR systems and workflows intersect with time-sensitive settings is critical to improving decision-making and outcomes in ACS. Objective: This study aimed to evaluate how ACS clinicians leverage the EHR for decision-making and to identify opportunities and challenges for EHR-enabled decision support. Methods: We conducted a qualitative ethnographic study over a 6-month period, combining in-depth interviews with 15 ACS surgeons and providers and 100 hours of “paired fieldwork” observations spanning the entire perioperative arc by a surgical provider and an organizational sociologist. Using constructivist grounded theory, we identified the enablers, challenges, and opportunities for EHR-enabled decision-making in ACS. Results: Surgeons fell into two groups: (1) those who accepted information overload as inherent to the EHR, relying on generic templates and standard attestations, and (2) others who viewed it as a problem to fix, actively correcting errors and composing individualized summaries. Ambiguity in billing requirements drove overdocumentation, resulting in “note bloat” that obscured high-yield information. EHR use during decision-making focused primarily on risk assessment, though navigation challenges hindered access to critical data. Forecasting key outcomes that alter management or facilitate shared decision-making was seen as valuable. Automated risk stratification, generated from live EHR data while minimizing alert fatigue, was seen as a potential solution. Conclusions: ACS clinicians use various tactics to navigate EHR challenges and focus on high-value tasks. Streamlined risk assessment using EHR data may strengthen decision-making in critical moments, but solutions must integrate seamlessly within existing workflows to provide rapid and accurate outputs that prioritize meaningful outcomes.

Background: Coaching programs in graduate medical education have the potential to impact trainee development across multiple core competencies but require rigorous program evaluation to ensure effectiveness. We sought to qualitatively evaluate the implementation of a multi-departmental, faculty-led communication coaching program using a logic model framework. Methods: Study participants were selected from four key stakeholder groups: resident coachees, faculty coaches, medical education leaders, and programmatic sponsors. 30–45 min semi-structured interviews were conducted via Zoom, transcribed, and de-identified for the analysis. Interviews captured stakeholders' perspectives on physicians' communication training needs, stakeholders perceived and actual roles, stakeholders’ involvement in the program, factors influencing the implementation process, and strategies for programmatic improvement, sustainment, and spread. The Consolidated Framework of Implementation Research (CFIR) guided the codebook development and data analysis. A combined inductive/deductive approach was used to develop a 20-item codebook, followed by a team-based thematic analysis. A strong intercoder agreement (Cohen’s kappa coefficient κ = 0.83) ensured coding consistency. The emerging themes were then mapped onto four domains of a logic model: Context, Inputs and Outputs, Outcomes, and Evaluation. Results: 35 interviews were conducted between November 2021 and April 2022 with representation from all stakeholder groups, including 10 resident coachees (who received coaching), 10 faculty coaches (who served as coaches and underwent coaching-specific faculty development), 9 medical education leaders (who designed and implemented program), and programmatic sponsors (who provided financial support). We mapped 8 emergent themes onto the critical domains of a logic model for program evaluation. For the domain of Context, themes included (1) gap in communication education and (2) patient-centeredness. For the domain of Inputs/Outputs, themes included (1) investment in the program and (2) perceived program value. For the domain of Outcomes, themes included (1) learning-focused outcomes and (2) patient-related outcomes. For the domain of Evaluation, themes included (1) defining success and (2) challenges with evaluation. Conclusions: Mapping CFIR-informed themes onto a logic model for program evaluation presents a novel strategy for integrating program implementation and evaluation, both of which are essential to effective educational programming. These findings can be used to guide future programmatic modifications to better meet the needs of key stakeholders.

Coaching interventions in graduate medical education have proven successful in increasing technical and communication skills, reducing errors, and improving patient care. Effective stakeholder engagement enhances the relevance, value, and long-term sustainability of interventions, yet specific strategies for stakeholder engagement remain uncertain. The purpose of this article is to identify strategies to foster engagement of diverse stakeholder groups in coaching interventions. We conducted 35 semi-structured interviews between November 2021 and April 2022 with purposively sampled key stakeholders that captured participants' perspectives on physicians' communication training needs, roles, and involvement in, as well as contextual factors, facilitators, barriers, and improvement strategies of the multi-departmental Communication Coaching Program at our institution. We utilized the Consolidated Framework of Implementation Research to guide data collection and analysis. An analytic approach relied on team-based thematic analysis with high inter-coder agreement between three raters (Cohen's kappa coefficient 0.83). Several validation techniques were used to enhance the credibility and trustworthiness of the study. Analysis of transcribed interviews with stakeholders directly involved in the Communication Coaching Program, including 10 residents, 10 faculty coaches, 9 medical education leaders, and 8 programmatic sponsors, revealed five key engagement strategies: (1) embrace collaborative design, (2) enable flexible adjustments and modifications, (3) secure funding, (4) identify champions, and (5) demonstrate outcomes. Additionally, a patient-centered approach to delivering the best possible patient care emerged as a primary objective that linked all stakeholder groups. Evaluating the experiences of key stakeholders in the Communication Coaching Program helped identify targetable strategies to facilitate participant engagement across all organizational levels. The analysis also revealed universal alignment around the importance of providing high-quality patient care. Insights from this work provide guidance for clinical training programs moving toward the implementation of coaching interventions.

Background: While communication is an essential skill for providing effective medical care, it is infrequently taught or directly assessed, limiting targeted feedback and behavior change. We sought to evaluate the impact of a multi-departmental longitudinal residency communication coaching program. We hypothesized that program implementation would result in improved confidence in residents’ communication skills and higher-quality faculty feedback. Methods: The program was implemented over a 3-year period (2019–2022) for surgery and neurology residents at a single institution. Trained faculty coaches met with assigned residents for coaching sessions. Each session included an observed clinical encounter, self-reflection, feedback, and goal setting. Eligible residents completed baseline and follow-up surveys regarding their perceptions of feedback and communication. Quantitative responses were analyzed using paired t-tests; qualitative responses were analyzed using content analysis. Results: The baseline and follow-up survey response rates were 90.0% (126/140) and 50.5% (46/91), respectively. In a paired analysis of 40 respondents, residents reported greater confidence in their ability to communicate with patients (inpatient: 3.7 vs. 4.3, p < 0.001; outpatient: 3.5 vs. 4.2, p < 0.001), self-reflect (3.3 vs. 4.3, p < 0.001), and set goals (3.6 vs. 4.3, p < 0.001), as measured on a 5-point scale. Residents also reported greater usefulness of faculty feedback (3.3 vs. 4.2, p = 0.001). The content analysis revealed helpful elements of the program, challenges, and opportunities for improvement. Receiving mentorship, among others, was indicated as a core program strength, whereas solving session coordination and scheduling issues, as well as lowering the coach-resident ratio, were suggested as some of the improvement areas. Conclusions: These findings suggest that direct observation of communication in clinical encounters by trained faculty coaches can facilitate long-term trainee growth across multiple core competencies. Future studies should evaluate the impact on patient outcomes and workplace-based assessments.

We commend Duffy et al on their study, which uses qualitative thematic methods to address a substantial gap in perioperative (preoperative, intraoperative, and

Morning rounds by an acute care surgery (ACS) service at a level one trauma center are uniquely demanding, given the fast pace, high acuity, and increased patient volume. These demands notwithstanding, communication remains integral to the success of surgical teams. Yet there are limited published curricula that address trauma inpatient communication needs. Observations at our institution confirmed that the surgical team lacked a shared mental model for communication. We hypothesized that creating a relationship-centered rounding conceptual framework model would enhance the provider-patient experience. A mixed-methods approach was used for this study. A multi-pronged needs assessment was conducted. Provider communion items for Press Ganey and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys were used to measure patients’ expressed needs. Faculty with experience in relationship-centered communication observed morning rounds and documented demonstrated behaviors. A five-hour workshop was designed based on the identified needs. A pre-and post-course Assessment and course evaluation were conducted. Provider-related patient satisfaction items were measured six months before the course and six months after the workshop. Needs assessment revealed a lack of a shared communication framework and a lack of leadership skills for senior trauma residents. Barriers included: time constraints, patient load, and interruptions during rounds. The curriculum was very well received. The self-reflected behaviors that demonstrated the most dramatic change between the pre and post-workshop surveys were: I listened without interrupting; I spoke clearly and at a moderate pace; I repeated key points; and I checked that the patient understood. All these changed from being performed by 50% of respondents “about half of the time” to 100% of them “always”. Press Ganey top box likelihood to recommend (LTR) and provider-related top box items showed a trend towards improvement after implementing the training with a percentage difference of up to 20%. The Inpatient Relationship Centered Communication Curriculum (I-RCCC) targeting senior residents and Nurse Practitioners (NP) was feasible, practical, and well-received by participants. There was a trend of an increase in LTRs and provider-specific patient satisfaction items. This curriculum will be refined based on the study results and potentially scalable to other surgical specialties.

Background: Morning rounds by an acute care surgery (ACS) service at a level one trauma center are uniquely demanding, given the fast pace, high acuity, and increased patient volume. These demands notwithstanding, communication remains integral to the success of surgical teams. Yet there are limited published curricula that address trauma inpatient communication needs. Observations at our institution confirmed that the surgical team lacked a shared mental model for communication. We hypothesized that creating a relationship-centered rounding conceptual framework model would enhance the provider-patient experience.Study Design: A mixed-methods approach was used for this study. A multi-pronged needs assessment was conducted. Provider communion items for Press Ganey and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys were used to measure patients' expressed needs. Faculty with experience in relationship-centered communication observed morning rounds and documented demonstrated behaviors. A five-hour workshop was designed based on the identified needs. A pre-and post-course Assessment and course evaluation were conducted. Provider-related patient satisfaction items were measured six months before the course and six months after the workshop. Results: Needs assessment revealed a lack of a shared communication framework and a lack of leadership skills for senior trauma residents. Barriers included: time constraints, patient load, and interruptions during rounds. The curriculum was very well received. Press Ganey top box likelihood to recommend (LTR) and provider-related top box items showed a trend towards improvement after implementing the training with a percentage difference up to 20%.Conclusion: The Inpatient Relationship Centered Communication Curriculum (I-RCCC) targeting the senior residents and Nurse Practitioners (NP) was feasible, practical, and well-received by participants. There was a trend of increase in LTRs and provider-specific patient satisfaction items. This curriculum will be further refined based on the study results and potentially scalable to other surgical specialties.

Background: Medical education is continually evolving particularly through the modern implementation of educational technology. Enhancing interactive learning in the classroom or lecture settings is one of the growing uses of educational technology. The role and potential benefits of such technology may not be as evident in developing educational systems like the one in Iraq. The purpose of this study was to examine the effect and perception of the use of an audience response system (ARS) on interactive medical education in Iraq. A mixed quantitative and qualitative research methodology approach was used to study the effects and users’ perceptions (both student and tutor) of the ARS. Method: The study was conducted in an Iraqi medical school in the Head and Neck course during the spring semester for third-year medical students. The course involved fifteen one-hour lectures over fifteen weeks. Users’ perceptions were evaluated by survey and focus group discussions (FGD). Descriptive statistics were used for quantitative measures and thematic analysis for the qualitative data. An ARS system was installed and integrated into the course lectures throughout the course period of three months to enhance interactive learning. Three to five interactive questions were used in each lecture. Anonymous participation and answers were maintained. The appropriate discussion was initiated when pertinent depending on students’ answers. Result: Most students (77% of survey, 85% of FGD) perceived the use of ARS as impactful on their learning. They found the ARS engaging (70%), motivating (76%), promoting interactions (73%), and augment learning through better understanding and remembering (81%). Through the FGD, students expressed improved focus, enhanced thinking and reflection, and joyful learning. The educator perceived the ARS use as practical, interactive, thinking-stimulator, and reflective of student’s understanding. The required technology skills were reasonable; however, it demanded extra non-insignificant time to learn the use. Conclusion: The perception of the ARS in this study was overall positive, providing encouragement for wide application of this technology in medical education in the developing world. Further studies are needed to validate and prioritize ARS usage in medical education in Iraq.

Acquiring surgical skills is one of the major objectives of surgical training. Trainees face increasing challenges to meet the continuously evolving surgical techniques and approaches during the limited time course of their surgical training. The limited availability of training tools for teaching advanced surgical skills is an additional barrier. Educators have increasingly used simulation tools for surgical skills training around the globe. However, current simulation training modules and curricula focus mainly on basic surgical skills. Hence, the development of advanced virtual simulation modules offers a precious laparoscopic training opportunity. This article provides an educational technology-based review and proposal (with selected examples) of simulation training modules on advanced surgical skills that can be used for advanced surgical training approaches.