Retained surgical items (RSIs) are much dreaded, preventable complications associated with surgical and other invasive procedures. Despite much effort going into eliminating these “never events” and the associated heavy burden for patients, providers, and institutions, RSIs continue to occur. This manuscript reviews fundamental concepts related to RSI, including risk factors, prevention strategies, technology-assisted detection, team strategies, and pertinent safety education. In addition, we performed a secondary review of a database of all published case reports and series of RSI between 1909 and 2015, focusing on clinical presentation, symptomatology, morbidity, diagnostic workup, pathology findings, and temporal characteristics. Despite a vast body of knowledge regarding RSIs, more needs to be done to help further reduce and prevent these occurrences. The following core competencies are addressed in this article: Patient care, Medical knowledge, Practice based learning and improvement, Systems based practice, Professionalism, and Interpersonal skills and communication

Objectives: Extracorporeal membrane oxygenation (ECMO) is a well-established therapy for severe acute cardiac and respiratory distress. Management of complications, such as embolic strokes and intracranial hemorrhage, is essential during such treatment. However, the incidences of these complications as well as clinical outcomes have not been previously examined within a population with a homogenous disease process. Methods: Using de-identified clinical data submitted to the Extracorporeal Life Support Organization, we analyzed cases in which patients were treated with ECMO during the 2009 H1N1 pandemic. This data were examined with a specific focus on neurologic complications. Results: Twenty-two of the 248 patients experienced a confirmed neurological event. Patients with neurologic events were older, more acidotic, and had a higher prior incidence of cardiopulmonary arrest before ECMO therapy. There was also showed an increased incidence of cardiac arrhythmia, hyperbilirubinemia, and severe leukopenia as well as lower rates of successful weaning from ECMO and survival to discharge. Overall, within the patient population treated with ECMO, neurologic complications are not uncommon, and such patients exhibit greater morbidity and mortality. Conclusions: Thus, aggressive neurological assessment before and during ECMO could prove very useful in guiding clinical decisions with respect to further or ongoing therapies. The findings from this study will hopefully improve patient selection for ECMO therapy as well as clinical outcomes for this critically ill patient population. The following core competencies are addressed in this article: Patient care, Systems-based practice, Interpersonal skills and communication.

Background: International normalized ratio (INR) >1.5 may indicate need for reversal of coagulopathy or massive transfusion (MT) in trauma patients. Thus, obtaining INR values as early as possible would expedite both clinical decisions. This study evaluates the reliability of using a point-of-care (POC) device to obtain INR results more rapidly. Methods: A trained pharmacist used the CoaguChek^® XS Plus (Roche Diagnostics, Basel, Switzerland) device to determine POC INRs in venous blood from adult (>18 years) trauma patients not transfused prior to arrival. POC and laboratory INR (lab INR) values and times to availability were compared. The POC INR value was not used for clinical treatment decisions. Results: POC INR was performed on 177 patients; 43 were excluded due to missing lab INR or later recognition of prehospital blood transfusion. The mean lab INR was 1.163, and the mean POC INR was 1.167. The paired samples correlation was 0.958 (P < 0.001). The mean difference was − 0.0045 (±0.1268), P = 0.683. Ninety-four percent of all patients had POC INR within ±0.2 of the lab INR. POC INR results were available in < 1 min; 37.2 ± 20.0 min faster than the lab INR was reported. Conclusion: This study confirms that POC INR is a rapid, reliable tool to detect patients who may need prompt reversal of anticoagulant medications or initiation of MT. The following core competencies are addressed in this article: Patient care, Medical knowledge, Systems based practice

Objective: Several decades of armed conflict at a time of incredible advances in medicine have led to an acknowledgment of the importance of cognitive workload and environmental stress in both war and the health care sector. Recent advances in portable neurophysiological monitoring technologies allow for the continuous real-time measurement and acquisition of key neurophysiological signals that can be leveraged to provide high-resolution temporal data indicative of rapid changes in functional state, (i.e., cognitive workload, stress, and fatigue). Here, we present recent coordinated proof of concept pilot project between private industry, the health sciences, and the USA government where a paper-based self-reporting of workload National Aeronautics and Space Administration Task Load Index Scale (NASA TLX) was successfully converted to a real-time objective measure through an automated cognitive load assessment for medical staff training and evaluation (ACLAMATE). Methods: These real-time objective measures were derived exclusively through the processing and modeling of neurophysiological data. This endeavor involved health care education and training with real-time feedback during high fidelity simulations through the use of this artificial modeling and measurement approach supported by Aptima Corporation's FuSE², SPOTLITE, and PM Engine technologies. Results: Self-reported NASA TLX workload indicators were converted to measurable outputs through the development of a machine learning-based modeling approach. Workload measurements generated by this modeling approach were represented as a NASA TLX anchored scale of 0–100 and were displayed on a computer screen numerically and visually as individual outputs and as a consolidated team output. Conclusions: Cognitive workloads for individuals and teams can be modeled through use of feed forward back-propagating neural networks thereby allowing healthcare systems to measure performance, stress, and cognitive workload in order to enhance patient safety, staff education, and overall quality of patient care. The following core competencies are addressed in this article: Medical Knowledge, Interpersonal Skills, Patient Care, and Professionalism.

Objectives: Rapid response teams (RRTs) are multidisciplinary teams designed to respond to unstable patients within the hospital. Given the acuity of these patient encounters, this offers an opportunity to expose emergency medicine (EM) residents to a high concentration of experiences that are important for their training. This study was a retrospective observational study quantifying the value to an EM resident performing primary airway assessments while participating on the RRT. Methods: The study site is a community trauma center that hosts an EM residency. All RRT logs from 2008 to 2013 were reviewed by trained data abstractors. Abstractors recorded interventions performed by EM residents, which we a priori identified as endotracheal intubation, ordering of noninvasive positive pressure ventilation (NIPPV), placement of central vascular access, placement of intraosseous access, and/or ordering of resuscitative medications. Data were entered into a standardized Excel spreadsheet where abstractors chose from a closed list of possibilities and were analyzed with descriptive statistics. Results: One thousand nine hundred and eighty-four encounters were reviewed. 53.9% of patients had advancement in their level of care. 29.2% of rapid responses resulted in patient intubation and 17.8% of patients required initiation of NIPPV. In addition, 1.6% of patients required immediate placement of a central line and 0.4% required placement of intraosseous access. EM residents involved in the RRT ordered resuscitative medications in 17.2% of encounters. Conclusions: EM resident involvement on RRTs provides them exposure to a number of critical encounters and advanced procedures that are essential for their EM training. The following core competencies are addressed in this article: This article addresses the ACGME milestones pertaining to patient care as well as procedural skills.

Background: Faculty turnover is a major problem at academic medical institutions. A minority of medical school graduates choose academic careers and those that do have a high rate of attrition. Methods: We conducted an in-depth review of the medical and business literature to determine high-frequency reasons for faculty attrition, and explored what strategies have been suggested or employed to reduce this trend. Results: Medical and business literature demonstrate that faculty morale, perceptions of work-life balance, support from the institution, faculty development, rewards, protected time, relationship with superiors, and role clarity all play a role in faculty decisions to leave an institution. Institutions have shown some success in reducing attrition through recruiting to retain, formal mentorship programs, novel reward programs tied to longevity, faculty development, and attention to faculty professional and personal goals. Conclusions: Academic medical centers should conduct retention analyses to determine commonly cited reasons for attrition at the global and departmental level. Measures to improve retention can be taken at every step of the recruitment, training, and seasoned employee level. Retention efforts are guided and enhanced by open and frequent communication between faculty and administration. The following core competencies are addressed in this article: Professionalism, Practice-based learning and improvement, Systems-based practice, Interpersonal skills and communication

The mission of any academic healthcare institution is to strive in all three fronts of clinical care, research, and education. Despite the importance of teaching, research, and other related activities that contribute to the academic advancement of physicians and institutions, there currently is no standardized metric to quantitatively measure each physician's productivity and value in these areas. As the landscape for hospital reimbursements continue to change to include and expect quality domains and outcomes, so must the algorithm for determining the missing pieces of value in the traditional resource-based relative value scale. The authors review the traditional measurement of clinical productivity, namely, the work relative value unit (wRVU) and propose the development and implementation of additions to this existing wRVU to include quality RVU as well as academic RVU. The acceptance and implementation of this transformation will provide physicians with a more comprehensive portfolio for promotional opportunities and institutions with comparative data on the overall effectiveness of their tripartite academic mission. The following core competencies are addressed in this article: Practice-based Learning and Improvement, Systems-based Practice.

Emotional Intelligence (EI) was first defined in the 1990s and was quickly adopted by the business community. The role of EI in leadership has come to the forefront and is now recognized as the most important trait/skill set that a leader can possess. In the next decade, there will be many challenges to the leaders of Academic Health Centers (AHCs). Understanding the role of EI and the implementation of its precepts in the personal culture of leaders and the organization will be extremely important. EI theory, its tools for assessment, its studies for validation, and its use for the development of professional curriculum for individuals and organizations will continue to evolve over time. Here, we will define EI and explain its origins and its importance to the success of AHCs. Furthermore, its importance to medical students, residents, and subordinates, its measurement, its juxtaposition to nature versus nurture, and what role simulation may play in increasing the EI skills of members of AHCs will also be addressed. The following core competencies are addressed in this article: Core competencies addressed include systems-based practice, Interpersonal and communications skills, and Professionalism.

The phenomenon of “brain drain,” (BD) or the unanticipated and significant loss of skilled people and the talent they represent via voluntary turnover, continues to be a significant problem across many academic medical centers. This BD is a result of a multifactorial interplay between personal, professional, institutional, peer-driven, and socioeconomic factors and affects mainly academic healthcare organizations characterized by a specific set of leadership, economic, and competitive preconditions. Institutional impact of BD, both financial and nonfinancial, can be profound and is often underappreciated. Financial considerations of BD include loss of clinical and non-clinical income, contraction of institutional expertise, severance and recruitment expenses, as well as costs of onboarding new faculty. This article focuses on how to identify risk factors for BD at both institutional and personnel levels. Proposed steps for prevention and early intervention are outlined. The following core competencies are addressed in this article: Professionalism, Practice-based learning and improvement, Systems-based practice, Interpersonal skills, and Communication.

Authentic leadership is critical to spearheading the advancement of young surgeons in their developmental stages as they acquire the skill sets necessary to lead successful careers in surgery. It is predicated on the understanding of the aptitudes, learned skills, dedication, patience, agreeableness, and nurturing of one's cognitive and emotional intelligence. Resilience and humility are a few of the attributes required to master for those who hope to become leaders and mentors within surgery. Perspectives on learning and leadership from the young trainee to the seasoned surgeon, both of which are considered students of surgery, are presented here. Traits of great leaders are discussed in the hope of creating a culture that fosters the development of surgical mentors in the next generations to come. The following core competencies are addressed in this article: Interpersonal skills and communication, Professionalism, Systems based practice.

Background: Complexities in medical care delivery and an increasing focus on value in health care has spotlighted the need to develop physician leaders within healthcare organizations. Academic medical centers and their faculty are uniquely situated to further the healthcare industry through teaching of medical students and residents, introducing research and technology, and providing the body of knowledge that is the framework within which medicine is practiced. Methods: Through in-depth literature review, pertinent information about the role of faculty leaders and the methods to develop them will be presented. Results: Literature suggests that health care organizations with physician leaders provide higher quality care and that academic productivity can be enhanced by leadership development among faculty. Various processes of physician leadership development exist, including the simple mentor-mentee relationship, a less formal facilitated small group format, and a more formalized leadership development course. There is no research literature to suggest the superiority of one method over another to develop faculty members. Conclusions: It is important that healthcare organizations consider the role of physician leaders in their strategic planning to provide quality, high-valued care while maintaining the goals of academic leadership and performance. The following core competencies are addressed in this article: Interpersonal skills and communication, Practice based learning and improvement, Professionalism, Systems based practice.

Physicians face many significant challenges in these times of new laws and regulations, new institutional alignments and consolidations, government oversight, and scarce resources (especially in regard to reimbursement and research). In the face of these challenges, the independence and autonomy of the medical community are threatened, especially that of Academic Health Centers. This situation is further exacerbated by the flight of physicians, in order to protect their livelihood, to large umbrella organizations (including universities) to which they now must provide or express some allegiance and conformity. The writings and thoughts of Isaiah Berlin and Simone de Beauvoir, noted 20^th century philosophers, will be used to explain the evolution of society (using Berlin's view of nationalism) and of people (de Beauvoir's view of the serious man) in order to help interpret the 21^st century fracture of medical independence and autonomy in America. The following core competencies are addressed in this article: Practice Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, and Systems-based Practice.

When analyzing data for dependent groups (e.g., before and after intervention), one use repeated measures statistical tests that account for the correlated observations. For normally distributed data measured on a continuous/interval scale (e.g., fasting glucose) with only two points of measurement (e.g., before and after), one would conduct a paired t-test. For more than two measurement points (e.g., baseline, 3 months, 6 months), repeated measures analysis of variance is appropriate. For skewed continuous/interval data (e.g., body mass index in the general population), or ordinal data (e.g., visual analog pain scores), one could conduct a Wilcoxon signed-rank test (for two measurement points) or a Friedman's test (for more than two measurement points). The following core competencies are addressed in this article: Medical knowledge.

Patient-driven innovations are infrequent events in the healthcare system. Many times, careful assessment allows us to appreciate very creative and indigenous solutions to routine clinical problems in the form of simplified technique or devices. Proper identification and diffusion of some of these practices might prove beneficial to other patients. Besides it, these small sparks of creativity rekindle the need for a good option of turning our patients into a partner in healthcare with their out of the box thinking. The following core competencies are addressed in this article: Patient care, Interpersonal and communication skills, Communication, Improvement.

The selection process for Psychiatry Residency Training Programmes in India is quite different from Western developed nations. The Indian medical graduates are required to take a multiple-choice question based competitive entrance examination that covers all undergraduate subjects for entry to all postgraduate specialties. Residency position allocation is conducted through “counseling” based upon the rank or percentile secured in this examination. This process of resident selection is fraught with certain risks which are discussed. The alternative possible selection systems are also evaluated for their advantages and potential concerns. Residency selection procedure needs are constrained by the practicalities of local resources, social structure, and system of medical education. And changes, if any should be implemented after careful and cautious consideration. The following core competencies are addressed in this article: Systems-based practice, Professionalism, Interpersonal skills and communication.

We report the first case of varenicline-induced urticaria in a 43-year-old female patient. Varenicline is a partial agonist of the α₄β₂nicotinic acetylcholine receptor, which is a frequently prescribed smoking cessation aid. Patients need to be aware of drug-induced urticarial reaction, and that prompt medical attention is needed. We review the recognition of mechanisms of pathogenesis and treatment of drug-induced urticaria. In addition, we review the differential diagnosis of urticaria and side effects associated with varenicline and report a novel cutaneous reaction. The following core competencies are addressed in this article: Patient care and medical knowledge.

Gossypibomas are rare in modern surgery; however, present a significant medico-legal dilemma when they do arise. Treatment is surgical retrieval after identification. When seen years after the original procedure, a diagnostic dilemma arises. Diagnosis via radiologic means is often unreliable, thus, diagnosis involves excision or core needle biopsy. In this unique case, we were forced to make a diagnosis without tissue confirmation due to patient request. Gossypibomas have been described as having highly variable appearance on computed tomography, and thus, radiologic diagnosis is considered unreliable. Often, the characteristic spongiform appearance typically used to describe chronic gossypibomas is not observed. In our case, matching the radiodensity of surgical gauze with that of the gossypiboma helped to make a correct diagnosis, suggesting that radiologic diagnosis is possible in certain cases. The following core competencies are addressed in this article: Medical knowledge, Patient care, Practice based learning and improvement, Systems based practice.

A 23-year-old male presented to our emergency department with symptoms of intermittent abdominal discomfort, cyclic vomiting, and decreased appetite. The patient had a history of recurrent flatworm infection without recent travel, but a history of often consuming undercooked seafood in the form of sushi. The patient was found to have small bowel intussusception on computed tomography. Intussusception is a rare diagnosis with a bimodal distribution favoring the pediatric population with an increase in incidence again among the elderly. The pathophysiology of the condition requires the presence of a “lead point” which is typically a tumor in the elderly patient, but there is no identified common cause of intussusception in the sporadic cases of intussusception in healthy young adults. Intussusception should be considered in young adults with cyclical abdominal pain, and consideration should be given to helminthic infection in those with endemic travel or raw food consumption. The following core competencies are addressed in this article: Patient care, Medical knowledge.

Hypoplasia of the left anterior descending (LAD) coronary artery in the absence of other congenital cardiac anomalies is quite rare and presents a real therapeutic challenge. Few cases of this type coronary anomaly have been reported in children and young adults. We present a middle-aged man with clinical, electrocardiographic, and dobutamine stress echocardiographic evidence of myocardial ischemia caused by a hypoplastic distal LAD coronary artery originating from a septal perforator. Diagnostic and therapeutic challenges posed by this rare condition are discussed. The following core competencies are addressed in this article: Medical knowledge, Patient care

Autopneumonectomy simply describes the autolysis or almost complete destruction of the lung tissue without any surgical removal of the lung. This is not a common occurrence but is sometimes observed in areas where tuberculosis (TB) is endemic. The patients are usually diagnosed when they come to the hospital either with complications related to autopneumonectomy or a postpneumonectomy-like syndrome. Rarely, these patients remain asymptomatic until late age. Our case was an elderly female with an abnormal chest X-ray, who was referred to us for respiratory clearance for the surgical fixation of the fracture of the neck of femur. The history revealed that she had some chest infection and/or pulmonary TB in childhood that explained the autopneumonectomy. The patient underwent a successful surgery and was discharged with advice to follow-up for any chest complaints in the future. The following core competencies are addressed in this article: Patient care, Medical knowledge.