United States

Background
Lumbar fusion has long been the gold standard operation for degenerative disc disease; however, lumbar disc replacement has recently gained popularity due to its motion-sparing benefits and increasing patient demand influenced by social media. The social media platform X (formerly Twitter) is widely used in healthcare for sharing patient experiences, and sentiment analysis can assess the emotional tone of these tweets to gauge public perception of medical procedures. The aim of this study was to analyze tweets referencing lumbar fusion and lumbar disc replacement to evaluate the tone of the content and to assess the trend of patient preference for disc replacement over fusion.

Methods
All tweets containing keywords most frequently adopted in discussions related to lumbar fusion and disc replacement were collected from January 2013 through August 2023. These phrases included: lumbar fusion, lumbar arthrodesis, lumbar interbody fusion, lumbar disc replacement, lumbar disk replacement, total disc replacement, total disk replacement, lumbar disc arthroplasty, lumbar disk arthroplasty, total disc arthroplasty, and total disc arthroplasty. Sentiment analysis was then performed using TweetNLP, a cutting-edge natural language processing library, and sentiment analysis time series plots were created. ANOVA was used for combined sentiment analysis, and the Wilcoxon Rank-Sum test for time series plots.

Results
There were 7377 and 1572 tweets mentioning lumbar fusion and lumbar disc replacement, respectively. Sentiment analysis demonstrated 1254 positive, 1389 negative, and 4734 neutral lumbar fusion related tweets (p &lt; 0.001). For lumbar disc replacement, there were 248 positive, 113 negative, and 1211 neutral tweets (p &lt; 0.001). The percentage of positive tweets each month was slightly higher for lumbar fusion (16.16% ± 7.28%) compared to disc replacement (15.20% ± 14.41%), while negative sentiment was 2.6 times higher for lumbar fusion (17.79% ± 8.42%) than disc replacement (6.77% ± 7.89%) (p &lt; 0.001), with a continued rise over the past 5 years.

Conclusion
Over the past decade, patients have increasingly used X to share opinions on lumbar fusion vs. disc replacement. Though the number of tweets discussing lumbar fusion outnumber those of disc replacement, there has been considerably more negative sentiment across tweets discussing lumbar fusion. This trend may reflect the growing preference for disc replacement among patients, and spine surgeons should recognize the influence of social media on patient perceptions and its potential impact on their practice.

AMA Research Challenge 2024 

Understanding Public Perception Through Natural Language Processing: Lumbar Fusion vs. Disc Replacement

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Background
Lumbar fusion has long been the gold standard operation for degenerative disc disease; however, lumbar disc replacement has recently gained popularity due to its motion-sparing benefits and increasing patient demand influenced by social media. The social media platform X (formerly Twitter) is widely used in healthcare for sharing patient experiences, and sentiment analysis can assess the emotional tone of these tweets to gauge public perception of medical procedures. The aim of this study was to analyze tweets referencing lumbar fusion and lumbar disc replacement to evaluate the tone of the content and to assess the trend of patient preference for disc replacement over fusion.

Methods
All tweets containing keywords most frequently adopted in discussions related to lumbar fusion and disc replacement were collected from January 2013 through August 2023. These phrases included: lumbar fusion, lumbar arthrodesis, lumbar interbody fusion, lumbar disc replacement, lumbar disk replacement, total disc replacement, total disk replacement, lumbar disc arthroplasty, lumbar disk arthroplasty, total disc arthroplasty, and total disc arthroplasty. Sentiment analysis was then performed using TweetNLP, a cutting-edge natural language processing library, and sentiment analysis time series plots were created. ANOVA was used for combined sentiment analysis, and the Wilcoxon Rank-Sum test for time series plots.

Results
There were 7377 and 1572 tweets mentioning lumbar fusion and lumbar disc replacement, respectively. Sentiment analysis demonstrated 1254 positive, 1389 negative, and 4734 neutral lumbar fusion related tweets (p < 0.001). For lumbar disc replacement, there were 248 positive, 113 negative, and 1211 neutral tweets (p < 0.001). The percentage of positive tweets each month was slightly higher for lumbar fusion (16.16% ± 7.28%) compared to disc replacement (15.20% ± 14.41%), while negative sentiment was 2.6 times higher for lumbar fusion (17.79% ± 8.42%) than disc replacement (6.77% ± 7.89%) (p < 0.001), with a continued rise over the past 5 years.

Conclusion
Over the past decade, patients have increasingly used X to share opinions on lumbar fusion vs. disc replacement. Though the number of tweets discussing lumbar fusion outnumber those of disc replacement, there has been considerably more negative sentiment across tweets discussing lumbar fusion. This trend may reflect the growing preference for disc replacement among patients, and spine surgeons should recognize the influence of social media on patient perceptions and its potential impact on their practice.

poster

Strong physician communication skills are an essential component to physician training that help strengthen patient satisfaction and health outcomes. Our study will analyze how implementation of a communication training program into standard medical education conferences will improve physician-patient communication skills and overall patient satisfaction. Our study has three goals: to improve physician-patient relations through a strong communication curriculum focused on relationship centered care and empathy, to build a strong foundation in physician-patient communication skills using communication tools, and to assess resident comfort level before and after interventions with education on physician communication skills. Our QI project followed a group of pediatric residents and attendings through a 10-month, block-based curriculum with each month catered towards a specific communication goal. Participants completed monthly surveys throughout the intervention to assess for efficacy and a post-intervention survey was administered to assess for changes in resident comfort in utilizing communication techniques. Through the mid-intervention survey’s, an increased number of individuals began utilizing these techniques and subjective level of comfort with these phrases was widely noted. Our study reinforces the importance of integrating hands-on, cumulative communication education and emphasizes how helpful techniques can create stronger doctor-patient relationships and more confident, empathetic physicians.

Pediatric Implementation of a Standardized Physician Communication
Curriculum

Background: Positional plagiocephaly, characterized by cranial asymmetry, has increased significantly following the implementation of the Back-to-Sleep campaign. While this initiative successfully reduced the incidence of Sudden Infant Death Syndrome, it inadvertently led to a 5-fold increase in plagiocephaly cases. This condition can result in aesthetic concerns, psychosocial issues, and functional challenges, including difficulties with headgear fitting. Despite its prevalence, many parents and caregivers remain unaware of plagiocephaly and its prevention strategies. This study aims to assess the impact of targeted parental education on plagiocephaly prevention and to provide evidence-based recommendations for clinical practice.

Methods: Our prospective, randomized control trial included full-term newborns (≤14 days old) without congenital craniofacial anomalies. Subjects were randomly assigned to intervention (n=75) or control (n=75) groups using a computer-generated randomization sequence. The intervention group received a comprehensive educational package consisting of an informative pamphlet and a 3-minute video on plagiocephaly awareness, risk factors, and prevention strategies. The control group received standard care without additional educational materials.

Cephalic index, calculated from head circumference, biparietal diameter, and anteroposterior diameter, was assessed at enrollment and subsequent 2, 4, and 6-month well-child visits. The primary outcome measure was the difference in cephalic index between groups at the 6-month follow-up. 

Results: Our institution's previous pilot study (n=39) demonstrated a statistically significant difference in cephalic index between intervention and control groups. The intervention group showed a smaller average cephalic index, indicating reduced plagiocephaly incidence. The interim findings are limited by gaps in the 2, 4, and 6-month follow-up data. Our goal is to complete data collection for all 150 patients by year-end, which will reinforce the statistical significance of the study and allow for more robust conclusions. Currently, forty new subjects have been enrolled (n=79) and 18 two-month follow-ups have been completed. While preliminary analysis of this additional data is ongoing, it is premature to draw definitive conclusions about its statistical impact on the overall study results.

Conclusion: Our interim findings indicate that targeted parental education may effectively reduce plagiocephaly incidence and improve long-term cranial development outcomes. This study underscores the importance of preventive education in pediatric care and its potential to mitigate an avoidable condition with long-term implications. The educational intervention appears to enhance parental knowledge and promote adherence to preventive measures.


Impact of Parental Education on Positional Plagiocephaly Prevention: A Randomized Controlled Trial

Background
Annually, close to 290,000 adult patients experience in-hospital cardiac arrest in the United States. Internal medicine residents in our program felt the need for code blue training and simulation sessions to run in-hospital cardiac arrest. We conducted a quality improvement project to enhance residents’ knowledge, readiness, and confidence in leading code blue.

Methods
Residents had mock code simulation sessions every three months over 9 months (July/2023-April/2024) at Northwestern Medicine Huntley Hospital's simulation lab. In each session, residents were divided into two teams. These sessions aimed to be interactive, one team performed a scenario during each session while the other team observed, followed by a debriefing session to discuss what went well and what could be improved. The simulations focused on the roles of code blue leaders, rhythm recognition, and ACLS protocols. Pre-mock code session surveys were emailed to residents to assess their overall knowledge of ACLS protocol (medications, doses, ability to do other tasks like chest compressions, recording...) and confidence in leading code blue. Surveys included questions with a rating scale from (1-5). Following the mock code sessions, we sent post-session surveys that mirrored the initial ones, to reevaluate residents’ knowledge after the intervention.
We used McNemar’s test to determine the significance of change between the 2 surveys before and after intervention. 

Results
Of the 39 residents in our internal medicine residency program, 86.8% felt that code blue simulations significantly helped them. A significant increase was observed in residents' knowledge of code blue leader roles with 42.1% feeling "Very knowledgeable" compared to 3% before (p = 0.05). Confidence in leading code blue also rose significantly with 44.7% feeling "Confident" compared to 18.1% before the intervention (p = 0.008). Knowledge of the ACLS algorithm improved significantly with 44.7% feeling "Very Knowledgeable" compared to 18.1% before (p = 0.025). Knowledge of ACLS medications and doses also increased significantly with 29% feeling "Very Knowledgeable" compared to none before (p = 0.011). While there was no significant change in interpreting rhythm strips during a code blue, more residents reported running code more frequently post-intervention (42% vs 30.3%).

Conclusion
Most residents believed that code blue simulation sessions helped them run code blue confidently. Residents' confidence in leading code blue and knowledge of the ACLS algorithm increased after mock code simulation sessions. We anticipate that this project will positively impact patients’ outcomes following in-hospital cardiac arrest. Therefore, we plan to continue conducting these sessions annually for incoming interns.

Optimizing Internal Medicine Residents Response to In-Hospital Cardiac
Arrest: A Quality Improvement Project

Appropriate use of radiological studies is of utmost importance in medical practice, guiding care and reimbursement. The American College of Radiology Appropriateness Criteria (ACR-AC) is a free, online evidence-based resource dedicated to supporting practitioners with radiology decision-making. However, this resource has historically been underutilized by physicians and medical students, with those groups often opting to use alternative resources such as UpToDate
(UTD). Increasing awareness and user-friendliness of the ACR-AC within medical education is necessary to integrate regular use of this resource in practice. This study seeks to investigate medical student performance with and perception of the ACR-AC and UpToDate when presented with radiology decision-making cases.

Methods
First-year osteopathic medical students were presented with a clinical case and utilized either UpToDate or ACR to assist in determining the most appropriate imaging modality for the case. Following the case, students were surveyed to assess their familiarity with each resource, its effectiveness in establishing a differential diagnosis, ease of selecting the appropriate imaging, perceived usefulness, impact on confidence in imaging selection, and likelihood of future utilization. The accuracy of their decisions was also evaluated based on which resource they used. 

Results
Our survey had 82 respondents for the UTD group, and 83 respondents for the ACR group. The results showed that more students have used UTD over ACR coming into the study (20% vs 8%, p=0.01). The students also more strongly agreed that UTD was more helpful in establishing a differential diagnosis for the cases (56.1% vs 49.4%, p= 0.04). However, students found that ACR was easier to use as a resource for determining the appropriate imaging modality (3.9 vs 4.2, p=0.02). The accuracy of the tests showed a trent towards significance with case one showing 92.1% correct vs 82.6% with UTD (p=0.06) and 84.9% vs 75.6% on case two (p=0.13). 

Conclusion
The awareness of imagining resources among first year medical students is generally low. Following a case presentation, students more strongly agreed that UTD is a more helpful resource in establishing a differential diagnosis. However, students found that ACR was easier to use to determine the appropriate imaging modality. The results also showed a trend towards significance with students making more accurate decisions utilizing ACR over UTD.

Comparing ACR Appropriateness Criteria and UpToDate in Medical Student Radiology Decision Making

Introduction
While the proportion of women in surgery has grown, more than 90% of practicing cardiothoracic surgeons are men. The 2010s and early 2020s have witnessed a heightened awareness of gender disparity, with increased focus placed on career mentorship. We sought to examine the current landscape of female representation at different points along the cardiothoracic surgery training and career path.

Methods
Medical student, resident, and active practice surgeon demographics were obtained from the AAMC. We identified five major U.S. cardiothoracic surgical societies, noting members of all committees. Gender was probabilistically determined using Gender Guesser (NamSsor SAC LLC, France), a commercially available artificial intelligence tool.

Results
We identified 456 individuals occupying both junior and senior level committee positions across five major US cardiothoracic surgical societies. Of committee members, 78 (26%) were identified as likely female. Among committee chairs and executive leadership boards, 48 individuals (31%) were likely female. Gender probability ranged from​​ 0.52-0.99 across the cohort, with average probability of 0.95. Female ACGME thoracic surgery residents represented 29.5% of the incoming class in 2023. Comparatively, women were noted to account for only 8.3% of active thoracic surgeons. Across a composite of ACS recognized surgical subspecialties with AAMC data (General, Neurological, Orthopedic, Plastic, Thoracic and Vascular, Obstetrics and Gynecology, Ophthalmology, Otolaryngology, Urology, Sports Medicine (Orthopedic Surgery)) women accounted for 29.1% of all practicing surgeons in the US.

Conclusion

While gender distribution in cardiothoracic surgery shows balance at early career stages, current practice remains skewed. Despite this, women are present and active at junior and senior levels within major cardiothoracic societies. The presence of women in leadership roles from which they may provide mentorship and guidance may be positively influencing career choices of trainees.


Gender Trends in Cardiothoracic Surgery: Examining Female Participation in Training, Practice, and Leadership Roles

Medical students' involvement in research is crucial for their professional development, yet challenges often hinder their access to meaningful opportunities. Mentorship and connection with research personnel enhance student research involvement, but facilitating these connections poses a common obstacle for students.
A committee comprising six medical students and four faculty advisors created a cutting-edge Microsoft database, compiling contact details, areas of expertise, and projects of researchers open to mentoring medical students. This platform serves as a bridge, connecting faculty needing research assistance with students seeking experience. Powered through the Microsoft Universe, it empowers students to select mentors aligned with their objectives and skills.
The committee also crafted student researcher online profiles, illuminating the pathways of success for underclassmen. Moreover, in-person mentorship sessions led by upperclassmen became hubs of knowledge exchange by imparting research skills and insider insight.
Emphasizing continuous improvement, the committee embraced feedback loops and surveys, including collaborative efforts with faculty-administered surveys, to capture the nuanced perspectives of students on the accessibility of research.
The creation of a Microsoft database, mentorship sessions, and student researcher profiles has generated a catalog of over fifty established researchers eager to mentor students. A list of 45 projects across six different departments has been compiled, each spearheaded by a faculty member who is ready to invest in student success. Three student-led mentorship sessions have been held, covering topics such as research methodology and its impact on specialty choice, with plans to continue events monthly. Surveys indicated all attendees found the events beneficial and hoped to attend more. Additionally, nearly 20 student researcher profiles have been published on an institution-associated website, promoting collaboration and transparency. Profiles include contact details, enabling other students to have increased approaches to research-based networking and knowledge.
Three avenues, a Microsoft Universe powered database, student-led mentorship sessions, and student research profiles, each offer a unique route of mentorship that together make medical student research easier to navigate. The database distinctly connects students and faculty, fostering long-lasting relationships with added faculty expertise. Mentorship sessions allow upperclassmen to disburse insight to a large group, while student profiles promote one-on-one mentorship, encouraging conversation and tailored collaboration. Together, these three cornerstones, each offering a unique form of mentorship, synchronize to create a strong foundation for medical students to navigate and succeed in research.


A Student-Led Database and Mentorship Model for Facilitating High Quality Research

Background
Biostatistics is an increasing focus in current medical school curricula, even appearing as a topic on the United States Medical Licensing Exam Steps 1, 2, and 3 (USMLE). Physicians already in practice who did not have the benefit of biostatistics training in medical school likely can benefit from clarification and instruction of statistical methods. The goal of the study is to document and evaluate statistical methods utilized in a high-impact factor Journal, then to develop a guide to those statistics that can be applied to facilitate the interpretation of statistics for practicing physicians, fellows, residents, and medical students. 

Methods 
In Part I of our tandem manuscripts, the 100 most recent primary articles, dating from February 2021 to December 2021, were extracted and analyzed from the Journal of Intensive Care Medicine. The evaluation consisted of study temporality, study design, types of descriptor variables, and types of statistical tests. Statistical analyses was conducted using the Fisher’s Exact test with p-values <0.05 considered statistically significant.

Results
Retrospective studies were most common (75/100, 75%), followed by prospective (23/100, 23%), and cross-sectional studies (2/100, 2%). The most popular designs were cohort (82/100, 82%), followed by case series (9/100, 9%), randomized control trials (4/100, 4%), and case-control (3/100, 3%). The most commonly utilized descriptor variables were frequency and proportion (100/100, 100%), followed by both median (74/100, 74%), average (71/100, 71%), and interquartile range (68/100, 68%). The chi-square test was the most frequently used statistical test (59/100, 59%), while logistic regression (48/100, 48%), Mann-Whitney-U (46/100, 46%), and two-sample independent t-test (40/100, 40%) also were popular. A subgroup analysis of cohort studies showed higher use of the chi-square test (44/63, 70% vs 8/19, 42%; p = 0.03) and logistic regression (40/63, 63% vs 5/19, 26%; p = 0.008) in retrospective compared to prospective studies.

Conclusion 
This review of statistics used in 100 primary journal articles revealed that retrospective and cohort studies were utilized most frequently. The chi-square test was used in the majority of studies, particularly in retrospective cohort studies. This information can help determine areas in which supplemental training will be most beneficial to improve the understanding of statistical methods in medical journals by practicing physicians, fellows, residents, and students. As an outgrowth of this study, we have developed a practical guide to relevant statistical methods serving as part 2 of this double manuscript, and plan to conduct a larger study based on this methodology.

Analysis of Statistics Utilized in Primary Articles in the Journal of Intensive Care Medicine: A Prelude to Practical Pedagogy in Biostatistics

Abstract Title:
Addressing Training for Medical Students to Cope with Traumatic Situations
Background:
‘Second victim phenomenon’ refers to feelings of guilt or failure following an unanticipated outcome or error. This phenomenon is prevalent in the medical field, with some articles stating that over half of healthcare workers experience a ‘second victim phenomenon’ at least once in their career.
Within medical school curriculums, students learn to identify many diseases and disorders. Despite this extensive coverage, there remains a significant gap in preparing medical students for the inevitable trauma they will face as physicians. 
Methods:
A systematic literature review was performed. Informal and small group discussions from professional meetings were conducted. We then created an IRB-approved survey to send to medical students of all four years at six MD/DO schools throughout Virginia. The survey is open for two weeks and includes questions that ask how prepared students feel to cope with traumatic events, whether their school currently has a curriculum that teaches healthy coping mechanisms, and whether they believe a formal curriculum should be implemented.
Results:
Our preliminary data revealed 86.1% of 2287 newly graduated residents in 2015 reported feeling comfortable presenting physical exams, and 92.3% felt prepared to take patient histories. Only 46.3% of these residents felt prepared to cope with death, and only 34.1% felt capable of managing their fatigue. In a 2019 study, 534 internal medicine residents were surveyed. 90% reported that they had never heard of ‘second victim phenomenon’ prior to the study. After learning what it was, 59% of these residents reported experiencing at least one or multiple ‘second victim’ events during their careers. 12% (n=287) either required more than a year to recover or never recovered.
At a professional meeting in April 2024, several topic experts agreed that a curriculum is necessary, and one resident agreed that he and his colleagues have experienced ‘second victim phenomenon.’
Preliminary data from our survey is showing that 95.7% of medical students voted to include educational resources on healthy coping mechanisms during their time in school, with 60.9% of these students responding that they would prefer a mandatory course.
Conclusion:
This study aims to not only bring awareness to mental health challenges associated with a career in medicine but to also work with topic experts to implement a curriculum within medical schools. Addressing this issue is crucial, as the well-being of physicians directly impacts patient care. Providing students with a curriculum is a strong step forward in preparing physicians for the psychological demands of this profession.

Are You Ready For It? A Call For A Second Victim Phenomenon Training

Background
The spread of pathogens poses a significant threat to public health, but strategies like herd immunity and social distancing can mitigate this risk. Despite the well-documented benefits of these strategies, their effectiveness hinges on widespread public adherence and understanding. Recent events, such as the SARS-CoV-2 pandemic, have underscored the challenges posed by public resistance and misinformation. Studies have highlighted increased skepticism and misinformation regarding vaccination, undermining herd immunity efforts. To address this growing need for resources to counter doubts about public health decisions, we sought to develop software using cellular automaton models that can not only educate individuals on the value of practices like social distancing and vaccinations on disease spread, but also showcase realistic results to improve understanding.
Methods
We developed a simulation tool using a discrete cellular automaton process, modeling disease spread through a population grid where individuals can change states (susceptible, infected, vaccinated). Users can input parameters such as disease transmissibility, vaccination rates, and social distancing protocols to simulate scenarios across time. This model was tested as an educational supplement in an immunology class. Additionally, we developed a probabilistic multi-state cellular automaton model, incorporating stochastic elements to reflect randomness in disease transmission and individual behaviors. We applied the model to real-world data from COVID-19 databases to evaluate the effectiveness of herd immunity and social distancing in different communities.
Results
A survey of students using the discrete simulation found 83% reporting the software was intuitive, while 100% felt it increased understanding of herd immunity. The probabilistic cellular automaton model illustrated the positive impact of vaccination and social distancing on herd immunity, demonstrating vaccine effectiveness can be nearly 650 times more effective when social distancing is enforced. Additionally, the simulations revealed emerging patterns, such as regions without disease spread, possibly informing new metrics for evaluating public health responses.
Conclusion
Overall, this probabilistic simulation can serve as a valuable epidemiological tool to help characterize public health conditions. Furthermore, this simulation can be used as an educational tool for the public to better understand the mechanisms of herd immunity and the impact of their own behavior on disease spread. Future improvements to this model can include consideration of state transition adjustments, external system shocks, and additional considerations to initial conditions. The simulation tool's user-friendly interface and adaptable parameters make it feasible for widespread educational use, especially in unprecedented times. Its generalizability extends to various public health scenarios, promoting broader understanding of epidemiological strategies.

Characterizing Herd Immunity Through Cellular Automaton Models

Background: The hospital environment is a complex and unpredictable workplace where different providers share the responsibility of patient care. Differences in opinions, values, and experiences between resident physicians and other care team members may trigger conflicts that affect the safety and quality of patient care. Thus, developing conflict competencies may help to negotiate the complexities of different conflict situations and resolve these conflicts. However, the extent of the knowledge and perception of conflict competence among resident physicians remains to be determined.

Methods: A survey and qualitative semi-structured interviews of resident physicians were conducted. Participants were recruited voluntarily. Survey results were analyzed using SPSS 21, and MAXQDA 24 was used to evaluate the interview transcripts with thematic analysis.

Results: Sixty-five resident physicians completed the survey, and fifteen resident physicians were interviewed. 61.5% of the survey respondents identified as female, 76.9% were Caucasian, 35.4% of the respondents were from surgical specialties, and
43.1% of the residents were in their second year of training.
53.8% of the participants reported witnessing or experiencing conflicts weekly, with 44.6% reporting resident physician-nurse conflicts. 63.1% of the conflicts were reported as unresolved, with 16.9% reporting that the conflict affected future working relationships, 25.5% of the conflicts were due to failure of communication, 75.4%residents did not have any form of prior training on conflict management, and 83.1% of them reported interest in conflict competence training. Conflicts mainly affected the quality of care (87.3%) compared to patient safety concerns (12.3%). Participants with prior training in conflict competence were more likely to resolve their reported conflict (p= .047). The interviews highlighted five main themes: sources of conflict, awareness of conflict resolution styles, addressing conflict and outcomes, and the effect on patient care. Sources of conflict included hierarchy and different priorities. 52.2% of the respondents did not know any style of conflict resolution.
Addressing conflict included collaboration, avoidance, competition, and prevention. Avoidance was the most common style used by interviewees, followed by collaboration. While most felt that the conflicts affected the quality of patient care, one interviewee reported severe adverse events on the patient.
Conclusion
Conflicts are rife in the hospital environment and can affect patient care when unresolved. Resident physicians' knowledge of conflict competence is low and does not reflect the complexity of their working environment. Future training in conflict competence and resolution is warranted.

Keywords: conflict, conflict competence, resident physicians, hospitals


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