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Association of Program Directors in Vascular Surgery (APDVS) survey of program selection, knowledge acquisition, and education provided as viewed by vascular trainees from two different training paradigms

2011; Elsevier BV; Volume: 55; Issue: 2 Linguagem: Inglês

10.1016/j.jvs.2011.09.011

1097-6809

Michael C. Dalsing, Michel S. Makaroun, Linda M. Harris, Joseph L. Mills, John F. Eidt, George J. Eckert,

Innovations in Medical Education

Methods of learning may differ between generations and even the level of training or the training paradigm, or both. To optimize education, it is important to optimize training designs, and the perspective of those being trained can aid in this quest. The Association of Program Directors in Vascular Surgery leadership sent a survey to all vascular surgical trainees (integrated [0/5], independent current and new graduates [5 + 2]) addressing various aspects of the educational experience. Of 412 surveys sent, 163 (∼40%) responded: 46 integrated, 96 fellows, and 21 graduates. The survey was completed by 52% of the integrated residents, 59% of the independent residents, and 20% of the graduates. When choosing a program for training, the integrated residents are most concerned with program atmosphere and the independent residents with total clinical volume. Concerns after training were thoracic and thoracoabdominal aneurysm procedures and business aspects: 40% to 50% integrated, and 60% fellows/graduates. Integrated trainees found periprocedural discussion the best feedback (79%), with 9% favoring written test review. Surgical training and vascular laboratory and venous training were judged “just right” by 87% and ∼71%, whereas business aspects needed more emphasis (65%-70%). Regarding the 80-hour workweek, 82% felt it prevented fatigue, and 24% thought it was detrimental to patient care. Independent program trainees also found periprocedural discussion the best feedback (71%), with 12% favoring written test review. Surgical training and vascular laboratory/venous training were “just right” by 87% and 60% to 70%, respectively, whereas business aspects needed more emphasis (∼65%-70%). Regarding the 80-hour workweek, 62% felt it was detrimental to patient care, and 42% felt it prevented fatigue. A supportive environment and adequate clinical volume will attract trainees to a program. For “an urgent need to know,” the integrated trainees are especially turning to online texts rather than traditional textbooks, which suggests an opportunity for a shift in educational focus. Point-of-care is the best time for education and feedback, suggesting a continued need for dedicated faculty. The business side of training is underserved and should be addressed. Methods of learning may differ between generations and even the level of training or the training paradigm, or both. To optimize education, it is important to optimize training designs, and the perspective of those being trained can aid in this quest. The Association of Program Directors in Vascular Surgery leadership sent a survey to all vascular surgical trainees (integrated [0/5], independent current and new graduates [5 + 2]) addressing various aspects of the educational experience. Of 412 surveys sent, 163 (∼40%) responded: 46 integrated, 96 fellows, and 21 graduates. The survey was completed by 52% of the integrated residents, 59% of the independent residents, and 20% of the graduates. When choosing a program for training, the integrated residents are most concerned with program atmosphere and the independent residents with total clinical volume. Concerns after training were thoracic and thoracoabdominal aneurysm procedures and business aspects: 40% to 50% integrated, and 60% fellows/graduates. Integrated trainees found periprocedural discussion the best feedback (79%), with 9% favoring written test review. Surgical training and vascular laboratory and venous training were judged “just right” by 87% and ∼71%, whereas business aspects needed more emphasis (65%-70%). Regarding the 80-hour workweek, 82% felt it prevented fatigue, and 24% thought it was detrimental to patient care. Independent program trainees also found periprocedural discussion the best feedback (71%), with 12% favoring written test review. Surgical training and vascular laboratory/venous training were “just right” by 87% and 60% to 70%, respectively, whereas business aspects needed more emphasis (∼65%-70%). Regarding the 80-hour workweek, 62% felt it was detrimental to patient care, and 42% felt it prevented fatigue. A supportive environment and adequate clinical volume will attract trainees to a program. For “an urgent need to know,” the integrated trainees are especially turning to online texts rather than traditional textbooks, which suggests an opportunity for a shift in educational focus. Point-of-care is the best time for education and feedback, suggesting a continued need for dedicated faculty. The business side of training is underserved and should be addressed. We have some information regarding why medical students and residents choose vascular surgery as their profession, baseline data on integrated and traditional vascular surgery applicants, and the increased attractiveness of the integrated training program.1Calligaro K.D. Doughtery M.J. Sidawy A.N. Cronenwett J.L. Choice of vascular surgery as a specialty: survey of vascular surgery residents, general surgery chief residents, and medical students at hospitals with vascular surgery training programs.J Vasc Surg. 2004; 40: 978-984Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar, 2Lee J.T. Teshome M. de Virgilio C. Ishaque B. Qiu M. Dalman R.L. A survey of demographics, motivations, and backgrounds among applicants to the integrated 0 + 5 vascular surgery residency.J Vasc Surg. 2010; 51: 496-503Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar, 3Schanzer A. Nahmias J. Korenda K. Eslami M. Arous E. Messina L. An increasing demand for integrated vascular residency training far outweighs the limited supply of positions.J Vasc Surg. 2009; 50: 1513-1518Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar In general, however, little has been reported on how our residents view their training experience. Generational differences and technologic improvements influence how we teach and how our residents learn. A clear understanding of our residents' impressions of the best ways to retain and incorporate knowledge into daily patient care is central to developing an optimal training experience. Their impressions of how their own programs are doing in providing the wide breadth of education needed for a well-rounded vascular surgeon can suggest what is being provided well and what needs improvement. In addition, the residents' impression of their abilities to act as a vascular surgeon after training provides valuable insight into our educational system. A survey regarding aspects of how and why our residents choose their vascular program, how they best learn in general and during a busy clinical day, and how they perceive the experience provided by their particular training program was sent to all vascular residents and those having recently completed training in mid-2010. The survey was delivered by e-mail, with 4 weeks to complete the survey. The first three questions determined gender, age, and training track (integrated [0/5] vs independent/training completed [5+2 program]). Based on training track, one of two parallel survey options was completed. The responses considered for this report were the same questions simply answered by those on a different training track. Six questions were included to determine what factors influenced why the resident chose the training program, how satisfied each was with the selection process, and if each was satisfied with the selection now, once completed. Three questions concentrated on how knowledge is best gained and what is the best method of feedback that constructively helps the trainee to learn. These questions had multiple responses to be ranked in order of most-to-least benefit in the view of the respondent. Two multiple-choice questions considered how well their own program performed in delivering the training needed for vascular surgical training. One question asked how comfortable and competent residents will feel after training based on their experience or that observed of those who had finished training in their program. There was a multiple-choice question regarding their feeling regarding the 80-hour workweek. Two questions considered the excellence of didactic and hands-on training for the vascular laboratory and for venous disorders. Other questions were included regarding the resident's impression of aspects of vascular surgery separate from the educational component and are not discussed here. The Association of Program Directors in Vascular Surgery (APDVS) was the association providing the list of residents to survey and also sent the survey to the residents. APDVS leadership constructed the questionnaire. The residents were informed that this survey was voluntary and completely anonymous but would be helpful and used by program directors to improve vascular surgery training where needed. The survey was ultimately sent to 412 appropriate candidates (63 integrated, 150 independent, 99 graduates) for their response. The survey results were collected, each question response was collated to provide an overall response, and a rating average was provided for responses that were ranked or scored. The best response (very important, best, most, excellent, very competent) was ranked as a 1 with decreasing digital ranking (2, 3, etc.) to the least favored choice available. The average rating was calculated by multiplying the ranking by the number of respondents choosing that rank, adding these, and dividing by the overall respondents. The lower the average ranking, the more favored that particular response overall. Comparisons between the integrated and independent vascular surgical training groups were performed using Pearson χ2 tests when the response categories did not have a natural ordering and using Mantel-Haenszel χ2 tests when the responses were ordered categories. For questions where multiple factors or choices were ranked or scored, comparisons among the factors were performed using Cochran-Mantel-Haenszel tests for stratified categoric data. Comparisons were considered to be statistically significant at P < .05. Of those invited, 163 (∼40%) responded to the survey request; of these 77% were male, and there were 33% females in the integrated program participants and 19% in the independent program (P = .052, therefore not statistically significant). Most participants were aged between 26 and 38 years, with only 5.6% aged >38, and the independent program respondents were older. By vascular surgical training paradigm, 46 survey participants (28.3% of all responders) were in the integrated program, with 41 in their first 3 years of training; 96 were currently in the independent program, 50 in the first year and 46 in their final year of training; and 21 respondents (12.9% of all respondents) had finished training. The percentage of those completing the survey was quite similar for those still training: 52% of those in the integrated program and 58% of those in the independent program, but only 20% of those who had completed training returned the survey. The independent program was represented by those still training and those who had recently completed training. Even though 46 integrated vascular surgical residents initiated the survey, on average 33 completed the bulk of the survey. For percentage and statistical calculations, the actual number completing the question was used for analysis. The responses regarding factors important to the resident in ranking a program in the match are reported in Table I. To these residents, the atmosphere of the program (71% ranked this as very important), followed closely by the teaching faculty (68.8%) and program director (62.5%), were most important to their decision regarding ranking of a program to attend for further education. Also very important were the reputation of the program (56.3%) and recommendation of their medical school faculty (53.1%). Facilities and case volume were considered very important by 40% to 50% of respondents. Location nearly reached the very important category; however, 34.4% rated this factor as important and 31.2% as very important. Didactic teaching, clinical research output, total clinical volume, and vascular laboratory volume were all rated as important rather than very important by ∼50% of respondents.Table IFactors important to the vascular surgery resident in ranking the programs they desired to match into for trainingFactors important to ranking programVery important,aVery important was given a 1 rank with decreasing digital ranks to not important ranked at 4. %Important, %Somewhat important, %Not important, %Rating averageIntIndIntIndIntIndIntIndIntIndRecommendation of PeersbSignifies a statistical difference between training paradigms.28.139.837.548.512.55.821.95.82.281.78 School faculty53.134.015.634.015.612.615.619.41.942.17Program reputation56.351.540.644.73.12.90.01.01.471.53City/geographic location31.332.434.442.218.819.615.55.92.191.99Teaching faculty68.865.015.933.06.31.00.01.01.381.38Program director62.550.531.335.96.311.70.01.91.441.65Atmosphere of program71.062.725.835.33.22.00.00.01.321.39Total clinical volumebSignifies a statistical difference between training paradigms.46.967.050.030.10.02.93.10.01.591.36Call schedule and work hours15.613.725.038.250.036.39.411.82.532.46Physician extender support12.511.731.327.240.643.715.617.52.592.67Didactic teaching31.316.550.054.412.521.46.37.81.942.20Clinical research15.618.450.041.728.129.16.310.72.252.32Open aortic volume43.853.437.539.818.85.80.01.01.751.54Open carotid volume40.644.737.538.821.913.60.02.91.811.75Endovascular volume64.852.029.041.216.15.90.01.01.611.56Thoracic aorta volume37.628.234.436.921.928.26.36.81.972.14Endovascular facilities60.038.837.541.712.516.50.02.91.631.83Vascular lab volume18.811.960.044.625.036.66.36.92.192.39Simulation labbSignifies a statistical difference between training paradigms.3.12.031.316.034.433.031.349.02.943.29Board pass rate12.510.734.439.837.634.015.615.52.562.54Jobs obtained15.624.334.439.840.827.29.48.72.442.20Ind, Independent program responses; Int, integrated program.Bold numbers in each column signify the most commonly chosen response for that factor.a Very important was given a 1 rank with decreasing digital ranks to not important ranked at 4.b Signifies a statistical difference between training paradigms. Open table in a new tab Ind, Independent program responses; Int, integrated program. Bold numbers in each column signify the most commonly chosen response for that factor. The presence of an independent vascular surgery program generally had no effect on the decision to favorably rank a program (53.1%) or had a positive effect (18.8%). Electronic Residency Application Service (ERAS) submission, the interview process, and the National Resident Matching Program (NRMP) match were thought satisfactory by 70% to 75% of respondents. They all were currently satisfied with their residency selection. There were seven choices to be ranked (Table II), from best to worst learning, so that each respondent chose only one answer per choice. The best choice was given a 1 ranking and the worst a 7 ranking, such that the lower the overall average ranking the more favored the response. Obviously one-on-one instruction was considered the best way to learn by 43.3%, with a rating average of 2.03, nearly one and one-half that of the next best method, which was reading a textbook at 3.65, and twice that of any other method. An urgent need to know is an important stimulus for 28.1% of residents. A lecture series was not considered the best way to learn by any of those surveyed and came in fifth of the seven choices given.Table IIBest methods of learning from the perspective of the trainees as gained from a survey of vascular surgery residentsLearning methodBest to worst in resident's estimation, %Rating average1 (best)234567 (worst)IntIndIntIndIntIndIntIndIntIndIntIndIntIndIntIndReading a textbook16.116.319.418.619.417.49.712.816.112.83.210.516.111.63.653.65Lecture series0.03.512.98.116.115.125.820.916.122.125.822.13.28.14.354.49Online didactic with questions to answer6.31.19.411.518.814.912.516.115.626.49.412.628.117.24.634.62Small group discussionaSignifies a statistical difference between training paradigms.6.13.40.011.29.131.524.224.724.29.018.215.718.24.54.883.90One-on-one apprenticeship instruction43.357.436.718.13.37.410.08.53.32.13.31.10.05.32.032.04Simulation experienceaSignifies a statistical difference between training paradigms.3.21.012.912.125.811.19.710.119.416.222.625.36.524.24.235.01An urgent need to know (on-the-job learning)28.123.89.427.66.311.49.49.56.38.615.66.725.012.44.033.21Ind, Independent program responses; Int, integrated program responses.Bold numbers in each column signify the most commonly chosen response for that factor.a Signifies a statistical difference between training paradigms. Open table in a new tab Ind, Independent program responses; Int, integrated program responses. Bold numbers in each column signify the most commonly chosen response for that factor. Seven specific options were given for how one obtains clinical information during a busy day on the wards or before an operation and were ranked from most-often to least-often used (Table III). Common on-line texts were the first choice by 31.3%, and the rating average was 2.72, with the next most often used option asking a colleague (25.8%), with a rating average of 3.19. A condensed handbook had the next highest rating average of 3.47. The best feedback that constructively helped the resident to learn (Table IV) was discussion of a particular clinical problem centering around a clinical experience, with 78.8% choosing this as the best method and with a rating average of 1.42, whereas small group discussion of a clinical case with feedback was next best, with an rating average of 2.36.Table IIIThis table contains the results of a question to vascular surgery trainees regarding how they best obtain clinical information during a busy day on the wards or before an operationMethod used to obtain clinical informationMost often to least often method to obtain clinical information during a busy day, %Rating average1 (most)234567 (least)IntIndIntIndIntIndIntIndIntIndIntIndIntIndIntIndRead a condensed handbookaSignifies a statistical difference between training paradigms.20.08.010.011.526.711.510.017.213.310.320.012.60.028.73.474.63Read a textbookaSignifies a statistical difference between training paradigms.6.727.210.021.73.316.323.315.230.09.810.01.116.68.74.562.96Ask a colleague25.822.016.115.49.719.825.819.812.912.13.27.76.53.33.193.21Use provided online texts31.317.015.614.818.828.428.115.90.010.23.18.03.15.72.723.34Use your local library online system3.312.213.314.420.010.06.77.816.726.716.717.823.311.14.634.15Use the general Internet12.57.028.121.012.511.06.313.015.610.03.114.021.924.03.814.36Use an organization's informationbAmerican College of Surgeons, Association of Program Directors in Vascular Surgery, etc.3.34.16.74.113.36.20.010.313.314.430.028.933.331.95.375.41Ind, Independent program responses; Int, integrated program responses.Bold numbers in each column signify the most commonly chosen response for that factor.a Signifies a statistical difference between training paradigms.b American College of Surgeons, Association of Program Directors in Vascular Surgery, etc. Open table in a new tab Table IVThe best methods of feedback as estimated by vascular surgery traineesMethod of feedbackIn the resident's estimation, what is the best method of feedback that constructively helps you to learn? %1 (best)234 (worst)Rating averageIntIndIntIndIntIndIntIndIntIndWritten test with feedback on questions missed9.411.715.612.812.522.362.563.23.283.17Discussion before a clinical experience, instruction during and review immediately after the completed task78.871.46.120.49.17.16.11.01.421.38Small group discussion of clinical cases, solution presented, and feedback on that solution6.115.260.652.224.229.39.13.32.362.2Large group discussion of clinical cases with input from many and then discussion of best approach3.04.015.216.242.435.439.444.43.183.20Ind, Independent program responses; Int, integrated program responses.Bold numbers in each column signify the most commonly chosen response for that factor. Open table in a new tab Ind, Independent program responses; Int, integrated program responses. Bold numbers in each column signify the most commonly chosen response for that factor. Ind, Independent program responses; Int, integrated program responses. Bold numbers in each column signify the most commonly chosen response for that factor. Each resident was given a chance to grade his or her program regarding 14 aspects of training. Table V provides the specific data. There were two areas where most respondents did not choose excellent as the primary response: appropriate feedback on performance (42.4% good; 36.4% excellent) and open thoracic aortic training (30.3% good; 21.2% excellent). Support in the search for a job did not seem pertinent to 57.6% of respondents. They were also asked if they were provided appropriate training in nine categories (Table VI). The business aspect of practice as reflected in training to code and bill were consider areas of deficiency by ∼65% to 68% of respondents.Table VThe results regarding how the vascular residents' grade their own program on various aspects of trainingCategoryGrade provided by the resident for their training program, %ExcellentGoodFairPoorNot applicableIntIndIntIndIntIndIntIndIntIndDidactic teaching42.438.539.434.618.221.20.05.80.00.0Educational material provided (library resources, etc.)42.442.339.435.612.114.46.17.70.00.0Involvement of teaching faculty62.563.531.327.96.36.70.01.90.00.0Appropriate feedback on performance36.431.742.440.415.224.06.13.80.00.0Responsiveness to resident stresses and complaints42.445.236.440.415.210.66.13.80.00.0Support to attend outside meetings57.660.615.226.06.17.76.15.815.20.0Adherence to 80-hour work rules45.551.927.328.818.213.59.15.80.00.0Visiting professors33.325.015.241.324.221.26.112.521.20.0Training Vascular lab33.335.030.331.16.123.36.110.724.20.0 Endovascular69.773.115.223.19.13.80.00.06.10.0 Venous procedures42.438.824.237.915.222.33.01.015.20.0 Open thoracic aortic21.230.130.319.415.225.221.225.212.10.0Open abdominal aortic, mesenteric, renalaSignifies a statistical difference between training paradigms.42.466.027.328.218.24.90.01.012.10.0Support in job search18.242.318.244.26.18.70.04.857.60.0Ind, Independent program responses; Int, integrated program responses.Bold numbers in each column signify the most commonly chosen response for that factor.a Signifies a statistical difference between training paradigms. Open table in a new tab Table VIVascular surgery residents' opinion on the appropriateness of training in various categories as provided by their own programTraining categoryResident estimation of appropriate training level in various categoriesNeed more, %Just right, %Not important, %IntIndIntIndIntIndProcedural training Endovascular6.110.693.987.50.01.9 Open surgical12.510.787.587.40.01.9 Vascular lab25.835.971.064.13.20.0 Venous25.031.471.967.63.11.0Coding and billing65.664.121.934.012.51.9Business aspects of practice68.869.921.929.19.41.0Ethics of practice25.014.668.879.66.35.8Basic research in vascular disease28.119.459.455.312.525.2Formal clinical research training27.335.069.757.33.07.8Ind, Independent program responses; Int, integrated program responses.Bold numbers in each column signify the most commonly chosen response for that factor. Open table in a new tab Ind, Independent program responses; Int, integrated program responses. Bold numbers in each column signify the most commonly chosen response for that factor. Ind, Independent program responses; Int, integrated program responses. Bold numbers in each column signify the most commonly chosen response for that factor. Most respondents thought they knew all the requirements of the 80-hour workweek well (84.8%), and 81.8% considered this limitation in training hours essential to avoiding fatigue and errors, with 75.8% not considering it detrimental to continuity of care. Two specific areas of vascular surgical training were further surveyed. The noninvasive vascular laboratory training to actually perform such studies was considered excellent by 16.1%, good by 35.5%, fair by 35.9%, and nonexistent by 12.9%. Training in interpreting noninvasive vascular laboratory studies was excellent in 25.8%, good in 45.2%, fair in 25.8%, and nonexistent in 3.2%, and 84.8% thought that a vascular laboratory was essential in their future office. Didactic instruction of venous disorders was excellent in 15.6%, good in 56.3%, fair in 25%, and nonexistent in 3.1%. Most respondents (80%) thought that their hands-on venous operative experience would allow them to confidently perform all venous procedures both open and endovascular, whereas 57.6% thought that care of patients with venous disease would be an essential component of their future practice. Table VII lists the procedures or jobs required by vascular surgeons at the completion of training and those surveyed were to grade what they believed would be their level of competence and comfort in dealing with these tasks after training. The respondents thought that they would be only somewhat confident in three areas: open thoracic and thoracoabdominal aortic procedures, billing and coding, and the business aspects of vascular surgical practice.Table VIIOverall opinion of vascular surgery residents on how they feel regarding competence and comfort of various aspects required of a practicing vascular surgeon after completing trainingProcedure or SkillResident self-grading of level of competence and comfort, %VeryCompetentSomewhatNot at allRating averageIntIndIntIndIntIndIntIndIntIndOpen procedures Thoracic and thoracoabdominal aortic15.613.337.527.840.633.36.325.62.382.71 Abdominal aortic and mesenteric46.944.431.348.918.84.43.12.21.781.64 Lower extremity arterial reconstructions71.978.915.618.912.52.20.00.01.411.23Carotid endarterectomy78.176.79.420.012.53.30.00.01.341.27Thoracic outlet decompression25.024.446.937.825.025.63.112.22.062.28Venous procedures46.932.634.448.315.618.03.11.11.751.88Endovascular General78.180.015.615.66.34.40.00.01.281.24 Carotid stenting38.734.438.735.622.618.90.011.11.842.07 EVAR and TEVAR68.874.215.619.112.52.23.14.51.501.37 Mesenteric and renal59.447.828.138.99.47.83.15.61.561.71 Infrapopliteal62.555.615.632.221.911.10.01.11.591.58Lytic therapy56.350.031.331.112.511.10.07.81.561.77Vascular lab technologyaSignifies a statistical difference between training paradigms.50.028.934.443.315.623.30.04.41.662.03Radiation safetyaSignifies a statistical difference between training paradigms.46.927.843.851.19.420.00.01.11.631.94Imaging equipment34.435.653.147.812.515.60.01.11.781.82Medical aspects of vascular disease50.041.143.846.76.38.90.03.31.561.74Billing and coding6.311.134.424.446.945.612.518.92.662.72Business aspects of vascular practice9.410.134.428.143.838.212.523.62.592.75EVAR, Endovascular aortic repair, Ind, independent program responses; Int, integrated program responses; TEVAR, thoracic endovascular aortic repair.Bold numbers in each column signify the most commonly chosen response for that factor.a Signifies a statistical difference between training paradigms. Open table in a new tab EVAR, Endovascular aortic repair, Ind, independent program responses; Int, integrated program responses; TEVAR, thoracic endovascular aortic repair. Bold numbers in each column signify the most commonly chosen response for that factor. Of the 117 initial responders generally, 105 completed the full survey. To the independent program respondents, the total clinical volume was very important in selecting a training program (67%; rating average, 1.36), but also very important was the teaching faculty (65%; rating average, 1.38), atmosphere of the program (62.7%; rating average, 1.39), open aortic volume (53.4%; rating average, 1.54), endovascular volume (52%; rating average, 1.56), reputation of the program (rating average, 1.53), program director (rating average, 1.65), and open carotid volume (rating average, 1.75). The data regarding those factors influencing a resident's decision to rank a given program are provided in Table I. The presence of an integrated vascular surgery program generally had no effect on the decision to favorably rank a program (69.8%) or had a positive effect (8.5%). ERAS submission, the interview process, and the NRMP match were thought satisfactory as is by 71.8% to 82.5%, and 96.2% were currently satisfied with their residency selection. Table II includes the data regarding how a resident believes he or she best learns. The responses from the independent program participants place one-on-one instruction as the best way to learn, with 57.4% so responding as their first choice and with a rating average of 2.04, nearly one and one-half that of the next-best method which was reading a textbook at 3.65. An urgent need to know is a stimulus to learning, but most did not consider it the best learning situation (rating average, 3.21). A lecture series was not considered the best way to learn (rating average of 4.49 and sixth of the seven choices given), with a simulation experience being rated last (rating average, 5.01). Of the seven specific options given for how one obtains clinical information during a busy day on the wards, the results obtained from the independent residents are included in Table III. For the independent progra