Abstract
Introduction
The need for all physicians to function as leaders in their various roles is becoming more widely recognized. There are increasing opportunities for physicians at all levels ...including Graduate Medical Education (GME) to gain leadership skills, but most of these opportunities are only for those interested. Although not an Accreditation Council for Graduate Medical Education (ACGME) requirement, some US graduate medical education programs have incorporated leadership training into their curricula. Interestingly, the Royal College of Physicians and Surgeons of Canada adopted the Leader role in its 2015 CanMEDS physician training model and requires leadership training. We sought to understand the value of a leadership training program in residency in our institution.
Materials and Methods
Our 2017 pilot leadership training program for senior military internal medicine residents consisted of four one-hour sessions of mini-lectures, self-assessments, case discussions, and small group activities. The themes were: Introduction to Leadership, Emotional Intelligence, Teambuilding, and Conflict Management. Participants were given an 18-question survey (14 Likert scale multiple-choice questions and 4 open-ended response questions) to provide feedback about the course. The Brooke Army Medical Center Institutional Review Board approved this project as a Quality Improvement effort.
Results
The survey response rate was 48.1% (26 of 54). The majority of respondents (84.6%) agreed the leadership training sessions were helpful and relevant. Following the sessions, 80.8% saw a greater role for physicians to function as leaders. Most (88.4%) agreed that these sessions helped them understand the importance of their roles as leaders, with 80.8% feeling more empowered to be leaders in their areas, 76.9% gaining a better understanding of their own strengths and weaknesses as leaders, and 80.8% feeling better prepared to meet challenges in the future. After exposure to leadership training, 73.1% indicated a plan to pursue additional leadership development opportunities. All respondents agreed that internists should be able to lead and manage a clinical team, and every respondent agreed that leadership principles should be taught in residency.
Conclusions
This pilot project supports the premise that leadership training should be integrated into GME. Initial results suggest training can improve leadership skills and inspire trainees to seek additional leadership education. Moreover, much like the published literature, residents believe they should learn about leadership during residency. While more effort is needed to determine the best approach to deliver and evaluate this content, it appears even small interventions can make a difference. Next steps for this program include developing assessment tools for observation of leadership behaviors during routine GME activities, which would allow for reinforcement of the principles being taught. Additionally, our experience has led our institution to make leadership training a requirement in all of our GME programs, and we look forward to reporting future progress. Finally, an ACGME requirement to incorporate leadership training into GME programs nationwide would prove useful, as doing so would reinforce its importance, accelerate implementation, and expand knowledge of best approaches on a national level.
ABSTRACT
Military physicians are required to not only meet civilian accreditation standards upon completion of their Graduate Medical Education (GME) training programs but also be proficient in the ...military-unique aspects of their field, including medical care in austere environments and management of combat casualties. They must also be familiar with the administrative and leadership aspects of military medicine, which are often absent from the training curriculum. The San Antonio Uniformed Services Health Education Consortium Military Readiness Committee, by incorporating questions of military relevance into each GME program’s mandatory Annual Program Evaluation, identified curricular gaps upon which military readiness training objectives and opportunities were developed. These activities included a lecture series on the sustainment of medical and military readiness, an interactive procedural skills training event, trainee involvement in operational pre-deployment exercises, and the development of an elective operational rotation in Honduras. The Military Readiness Committee provides a model for other military GME institutions to develop training goals and opportunities to strengthen the preparedness of their trainees for military service.
In eastern North America, “tree bats” (Genera: Lasiurus and Lasionycteris) are highly susceptible to collisions with wind energy turbines and are known to fly offshore during migration. This raises ...concern about ongoing expansion of offshore wind-energy development off the Atlantic Coast. Season, atmospheric conditions, and site-level characteristics such as local habitat (e.g., forest coverage) have been shown to influence wind turbine collision rates by bats onshore, and therefore may be related to risk offshore. Therefore, to assess the factors affecting coastal presence of bats, we continuously gathered tree bat occurrence data using stationary acoustic recorders on five structures (four lighthouses on barrier islands and one light tower offshore) off the coast of Virginia, USA, across all seasons, 2012–2019. We used generalized additive models to describe tree bat occurrence on a nightly basis. We found that sites either indicated maternity or migratory seasonal occurrence patterns associated with local roosting resources, i.e., presence of trees. Across all sites, nightly occurrence was negatively related to wind speed and positively related to temperature and visibility. Using predictive performance metrics, we concluded that our model was highly predictive for the Virginia coast. Our findings were consistent with other studies—tree bat occurrence probability and presumed mortality risk to offshore wind-energy collisions is highest on low wind speed nights, high temperature and visibility nights, and during spring and fall. The high predictive model performance we observed provides a basis for which managers, using a similar monitoring and modeling regime, could develop an effective curtailment-based mitigation strategy.
Full text
Available for:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Along the mid-Atlantic coast of the United States, eastern red bats (Lasiurus borealis) are present during fall mating and migration, though little is currently known about most aspects of bat ...migration. To reveal migration patterns, and understand drivers of over-water flight, we captured and radio-tagged 115 eastern red bats using novel technology, and subsequently tracked and described their movements throughout the region. We compared over-water flight movements to randomly generated patterns using a use-availability framework, and subsequently used a generalized linear mixed effects model to assess the relationship of over-water flight to atmospheric variables. We used hidden Markov models to assess daily activity patterns and site residency. Most bats with long-distance movements traveled in a southwesterly direction, however path vectors were often oriented interior toward the continental landmass rather than along the coastline. We observed that some bats transited wide sections of the Chesapeake and Delaware bays, confirming their ability to travel across large water bodies. This over-water flight typically occurred in the early hours of the night and during favorable flying conditions. If flight over large water bodies is a proxy for over-ocean flight, then collision risk at offshore wind turbines - a major source of migratory bat fatalities - may be linked nightly to warm temperatures that occur early in the fall season. Risk, then, may be somewhat predictable and manageable with mitigation options linking wind-energy operation to weather conditions and seasonality.
The prevalence of prediabetes is estimated to be one-third of Americans with approximately 80% of these individuals unaware of the diagnosis. In the active duty military population, the prevalence of ...prediabetes is largely unexplored. The purpose of this study was to investigate the prevalence of prediabetes in military service members by quantifying those meeting prediabetes screening criteria, those actually being screened, and those being appropriately diagnosed.
Data were analyzed from calendar years 2014 to 2018 for active duty service members 18 years of age or older. Vitals records were collected to obtain body mass index values. Composite Health Care System laboratory data were queried for hemoglobin A1c (HbA1c) results as well as fasting plasma glucose (FPG) and oral glucose tolerance test (OGTT) results. The percentage of active duty service members meeting criteria for prediabetes screening was determined by totaling members age 45 and older with members age 18- to 44-year old with a body mass index ≥25.0 kg/m2, then dividing by the total number of members for each respective military branch. The percentage of active duty service members actually screened for prediabetes was determined based on members meeting prediabetes screening criteria who in fact had FPG, OGTT, or HbA1c labs. The total number of labs meeting prediabetes criteria was determined based on those aforementioned labs with results in the prediabetes range (FPG between 100 and 125 mg/dL, OGTT between 140 and 199 mg/dL, or HbA1c range of 5.7%-6.4%). The total number of service members with appropriate prediabetes International Classification of Disease (ICD) code was determined by identifying members with ICD-9 and ICD-10 codes 790.21, 790.22, and R73.01-R73.03 in their medical record.
From 2014 to 2018, 53.9% of 332,502, 56% of 543,081, and 47.3% of 531,313 active duty service members in the Air Force, Army and Navy, respectively, met criteria for prediabetes screening. The rates of actually screening for prediabetes were similar across the Air Force (4.8%), Army (6.7%), and Navy (5.5%). The percentage with labs meeting prediabetes criteria ranged from 17.9% to 28.4% in the Air Force, 24.2% to 30.3% in the Army, and 24.2% to 30.9% in the Navy. The rate of ICD coding for prediabetes increased from 2014 to 2018 across all branches (29.8%-65.3% for the Air Force, 24.6%-46.8% for the Army, and 40.0%-45.5% for the Navy).
Screening for prediabetes in the active duty military population is grossly inadequate, and even of those screened, diagnosing those meeting prediabetes criteria is similarly inadequate. Although this scenario is not unique to the Military Health System, but reflective of a larger national problem, efforts should be made within the Military Health System to increase the screening for this common disorder. Identifying service members with prediabetes enables opportunities for targeted interventions to delay or prevent the progression to diabetes mellitus.
Rationale
Since there are only 33 endocrinologists within the Department of Defence and over 150 000 beneficiaries with diabetes, most patients with diabetes will be treated by primary care providers ...(PCPs). Comprehensive diabetes care visits are extensive and the clinical practice guidelines (CPGs) routinely change; thus, providing current evidence‐based care is difficult. Most professional development courses aim to update PCPs on CPGs but are often inadequate as they focus on only the PCPs (not the interdisciplinary team) without a plan to implement changes into practice.
Objective
To evaluate the biannual (twice yearly), 3‐day, interprofessional Diabetes Champion Course (DCC) developed by the US Air Force Diabetes Center of Excellence on comprehensive diabetes care.
Methods
A mixed‐methods approach was used to evaluate three iterations of the DCC course (Sept 2014‐Sept 2015). Quantitatively, pre‐course and post‐course surveys were used to obtain impact on knowledge, skills, and intention to change clinical practice. Qualitatively, semi‐structured phone interviews were conducted with participants to obtain benefits to their clinic related to attending the DCC and barriers to implementation of the CPG process improvement project.
Results
Twelve of 19 responding clinics (63%) reported implementing all or part of their original CPG project developed at the DCC, and 17 of 19 clinics (89%) reported improvements associated with attending the DCC. Post‐course surveys, from on location participants, revealed significant improvements in knowledge (P < 0.01). Likewise, foot exam skills and ability to demonstrate glucose meters to patients improved. Even with high pre‐course confidence, 97% of providers reported acquiring new knowledge about prescribing and titrating insulin.
Conclusion
The DCC is innovative as it employs a team‐based, interprofessional, didactic, and interactive approach that is effective in improving knowledge, skills, and intention to change clinical practice, which should translate to better care for patients with diabetes.
Full text
Available for:
DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK
The ADA recommends psychosocial assessment as an integrated part of care for people with diabetes, which includes diabetes-related distress. Elevated diabetes-related distress is associated with poor ...self-management, lower medication adherence, and poorer quality of life. Intensive insulin delivery is achieved with a combination of basal and bolus dosing, which attempts to mimic normal pancreatic function. Delivery methods can be either multiple daily injections (MDI) via a syringe or pen or through continuous subcutaneous insulin injection (CSII). CSII is recommended for patients with type 1 diabetes (T1DM) who prefer pump therapy over MDI. Thus, we explored the relationship of insulin delivery method (MDI versus CSII) to diabetes-related distress in patients with T1DM.
The Diabetes Center of Excellence (DCOE), a specialty clinic for military health system beneficiaries, administered the 17-item Diabetes-related Distress Scale (DDS-17) from June 2015 through August 2016 as standard care. Adults with T1DM receiving diabetes care at the DCOE were included in this study.
There were 203 patients with T1DM who completed the DDS-17 during the time period. Patients were categorized as CSII (57.6%) or MDI (42.4%). There were no significant differences in diabetes-related distress by insulin delivery method. Furthermore, no significant differences were found in HbA1c between CSII (7.85%) and MDI (8.10%) users. In addition, no significant differences in BMI between patients using CSII (M=28.33 kg/m2) and MDI (28.49 kg/m2) users.
Our study demonstrated that there were no differences in diabetes distress scores, HbA1c, or BMI between CSII and MDI. As we move toward more patient-centered care, patients with T1DM may benefit from choosing the method of delivery that will enable them to achieve individual goals without increased diabetes-related distress.
Disclosure
J.L. Wardian: None. M.W. True: None. J.A. Colburn: None. I. Folaron: None. J.M. Tate: None. D. Beckman: None.
ABSTRACT
Introduction
The ability of military clinicians to conduct military medical research is often limited because of competing priorities and a lack of research mentorship. The ...Clinician-Scientist Investigator Opportunity Network (CSION) was developed with the intent of training clinicians how to engage in requirements-driven research within the DoD.
Materials and Methods
Three to five academic medical faculties were selected from a pool of applicants each year to participate in a 2-year research fellowship. To be eligible for the CSION program, applicants had to meet the following criteria: (1) Completed residency graduate medical education training, (2) not be currently enrolled as a graduate medical education trainee, and (3) obtained permission from their department leadership to focus 25% of their duty hours on CSION participation to include didactic and research efforts. The remaining 75% of fellows’ time was dedicated to clinical duties. Monthly didactics, intensive mentorship, and consistent support were offered to each fellow by the CSION leadership team. Metrics were recorded to include both research and clinical productivity.
Results
Between January 2019 and December 2022, 12 CSION fellows graduated from the program (four in the class of 2020, three in 2021, and five in 2022). From 2019 to 2021, the 12 CSION fellows initiated 204 research protocols, generated 489 publications/presentations, and secured 33 research grants. All graduates of the program remain active in clinical research with multiple graduates currently assigned to research positions.
Conclusions
The CSION research education program is a 2-year additional duty research fellowship producing clinician-scientists conducting military-relevant medical research and publications and may be considered a low-cost/highly efficient alternative to achieve the reported benefits of the MD–PhD tract. The expansion of the CSION program may improve the quality of military medical research and health care.
Reproductively successful and over-wintering populations of the endangered northern long-eared bat (Myotis septentrionalis) have recently been discovered on the Coastal Plain of North Carolina. ...Empirical data on resource selection within the region is limited, likely hindering management of these coastal forests. Our objectives were to determine roosting home range size, selection of day-roost tree species, second- and third-order roosting habitat selection, and to quantify the overall availability of resources in the surrounding landscape. We found core and peripheral roosting home range estimates were large, yet similar to observations from other areas of contiguous forests. Prior to juvenile volancy, female northern long-eared bats appear to select red maple (Acer rubrum), water ash (Fraxinus caroliniana), and loblolly pine (Pinus taeda) as day-roosts, but then use sweetgum (Liquidambar styraciflua), swamp bay (Persea palustris), and water tupelo (Nyssa aquatica) after juvenile volancy. At the second-order spatial scale, roosting home ranges were associated with woody wetlands farther from anthropogenic development and open water. However, within the third-order scale, northern long-eared bats were associated with undeveloped woody wetlands and upland forests, areas containing shorter trees and occurring proximal to open water. Peripheral and core areas were predicted to comprise approximately 20% of the local landscape. Our results show that complex and large tracts of woody wetlands juxtaposed with upland forests in this part of the Coastal Plain may be important for northern long-eared bats locally, results largely consistent with species management efforts in eastern North America.
PDF
