American Board Of Surgery In-Training Examination Research Articles

Flipping the Classroom in Residency Didactics Leads to Higher American Board of Surgery in-Training Examination Scores

Didactic education in General Surgery (GS) residency typically follows a nationally standardized curriculum; however, instructional format varies by institution. In recent years, GS residents at our institution expressed discontentment with weekly didactics and were not meeting their goals on the American Board of Surgery In-Training Examination (ABSITE). We sought to develop improvements in our didactic curriculum to increase resident satisfaction and ABSITE scores of GS junior residents (Jrs). In a quality improvement project, we changed the weekly didactic curriculum format from hour-long lectures in the 2018 to 2019 academic year (AY) to a partially-flipped classroom in the 2019 to 2020 AY, involving a 30-minute faculty-led presentation followed by 30 minutes of resident-led practice questions. The outcomes measured were ABSITE scores taken in 2019 and 2020 and resident opinions via an anonymous survey. This study was conducted at the University of Minnesota (Minneapolis, MN). The cohort for this study included all GS Jrs in our GS residency program, including postgraduate year (PGY) 1 nondesignated preliminary, PGY1 to 3 categorical GS residents, and residents in their lab time. Senior residents attended a separate didactics session. After curriculum changes, the ABSITE percentile scores for GS Jrs rose from 52% ± 5% to 66% ± 4% (p = 0.03). No categorical GS Jr scored <30% in 2020, compared to 20% (6/30) of categorical General Surgery residents in 2019. All residents preferred the new format overall and reported greater engagement in and preparation for didactics. After changing didactic education from hour-long lectures in the 2018 to 2019 AY to a flipped classroom model in the 2019 to 2020 AY including 30 minutes of faculty-led lecture followed by 30 minutes of resident-led practice questions, ABSITE scores and resident satisfaction at the University of Minnesota General Surgery Program improved.

Structured Textbook Review and Individualized Learning Plans Successfully Remediate Underperforming Residents and Improve General Surgery Program Performance on the ABSITE.

We endeavored to create an evidence-based curriculum to improve general surgery resident fund of knowledge. Global and resident-specific interventions were employed to this end. These interventions were monitored via multiple choice question results on a weekly basis and American Board of Surgery In-Training Examination (ABSITE) performance. This study was performed in a prospective manner over a 2-year period. A structured textbook review with testing was implemented for all residents. A focused textbook question-writing assignment and a Surgical Council on Resident Education (SCORE)-based individualized learning plan (ILP) were implemented for residents scoring below the 35th percentile on the ABSITE. Curriculum implementation resulted in a statistically significant reduction in the number of residents scoring below the 35th percentile, from 50% to 30.8% (P = .023). One hundred percent of residents initially scoring below the 35th percentile were successfully remediated over the study period. Average overall program ABSITE percentile scores increased from 38.5% to 51.4% over a 2-year period. Structured textbook review and testing combined with a question-writing assignment and a SCORE-focused ILP successfully remediated residents scoring below the 35th percentile and improved general surgery residency ABSITE performance.

Preliminary Development of a Program ABSITE Dashboard (PAD) to Guide Curriculum Innovation

Medical Knowledge for general surgery residents' is assessed by the American Board of Surgery In- Training Examination (ABSITE). ASBITE score reports contain many metrics residency directors can utilize to assess resident progress and perform program evaluation. The purpose of this study was to develop a framework to evaluate program effectiveness in teaching specific subtest and subtopic areas of the ABSITE, using ABSITE score reports as an indicator. The aim is to demonstrate the identification of topic areas of weakness in program-wide performance on the ABSITE to guide proposed modification of the general surgery residency program curriculum, and to initiate development of a data visualizing dashboard to communicate these metrics. A single institution retrospective study was performed utilizing ABSITE score reports from general surgery residents at a large academic training program from 2017 to 2020. ABSITE performance metrics from 320 unique records were entered into a database; statistical analysis for linear trends and variance were conducted for standard scores, subtest standard scores, and incorrect subtest topics. Deviation from national average scores were calculated by subtracting the national average score from each subtest score for each trainee. Data were displayed as medians or proportions and are displayed to optimize visualization as a proof-of-concept for the development of a program dashboard. Trends and variance in general surgery program and cohort performance on various elements of the ABSITE were visualized using figures and tables that represent a prototype for a program dashboard. Figure A1 demonstrates one example, in which a heatmap displays the median deviation from national average scores for each subtest by program year. Boxplots show the distribution of the deviation from national average, range for national average scores, and the recorded scores for each subtest by program year. Trends in median deviation from the national average scores are displayed for each program year paneled by subtest or for each exam year paneled by cohort. Median change in overall test scores from one program year to another in a cohort is visualized as a table. Bar graphs show the most often missed topics across all program years and heatmaps were generated showing the proportion of times each topic was missed for each subtest and exam year. We demonstrate use of ABSITE reports to identify specific thematic areas of opportunities for curriculum modification and innovation as an element of program evaluation. In this study we demonstrate, through data analysis and visualization, feasibility for the creation of a Program ABSITE Dashboard (PAD) that enhances the use of ABSITE reports for formative program evaluation and can guide modifications to surgery program curriculum and educational practices.

National ABSITE Preparation Practices: A Survey of General Surgery Residency Program Directors

The American Board of Surgery In-Training Examination (ABSITE) was designed as a low-stakes, medical knowledge examination for US general surgery residency programs. However, in practice, this exam has been utilized for higher stakes purposes, such as resident promotion or remediation, and fellowship selection. Several studies have demonstrated the efficacy of ABSITE preparation resources, but best practices for ABSITE preparation and national preparatory habits are currently unknown. The aim of this work was to determine current residency programs' strategies for ABSITE preparation. We distributed an electronic survey to program directors or program coordinators of US general surgery programs asking them to anonymously report program ABSITE educational practices and ABSITE scores. We analyzed the proportion of responses using descriptive statistics and compared the effect of various strategies using the Mann-Whitney testing for nonparametric data. An average ABSITE percentile score was calculated for each residency based on program self-reported scores. Association of Program Directors (APDS) Listserv PARTICIPANTS: General surgery residency programs participating at the time of distribution (278). Response rate was 24% (66/278); 41 programs (62.1%) identified as university-affiliated, and 25 (37.9%) were community-based. Median intern class size was 8 (range: 3-14), including preliminary interns. Average ABSITE percentile score was 52.8% (range 36.9%-67.6%). There were no significant differences in ABSITE scores based on affiliation or program size. Educational resources utilized for ABSITE preparation included SCORE (89.3%), Q-banks (50%), and surgical textbooks (25.8%). The majority (56.1%) of programs reported using a year-long curriculum for ABSITE preparation, and 66.6% used a time-limited curriculum completed in the months immediately prior to ABSITE. Most programs reported that ABSITE scores were a low priority (63.6%) or not a priority (13.6%). The existence of a year-long curriculum for ABSITE was positively correlated with score as compared to programs without a year-long curricula (53.9% vs 48.5%, p <0.01). Programs using a time-limited curriculum demonstrated lower scores as compared to programs without time-limited curricula (51.3% v 56.1%, p < 0.01). General surgery programs use a variety of strategies to prepare residents for the ABSITE. Despite reporting that they utilize ABSITE scores for a variety of high stakes purposes including evaluation for promotion and as a predictor of the preparedness for the ABS QE, many programs reported that they consider ABSITE scores as a low priority. A year-long focused curriculum was the only strategy correlated with increased scores, which may reflect the value of encouraging consistent studying and spaced repetition. Additional work is needed to guide programs in optimal utilization of ABSITE scores for remediation and resident evaluation, as well as understanding how ABSITE preparatory strategies correlate with clinical performance.

The Program Director Perspective: Perceptions of PGY5 Residents' Operative Self-Efficacy and Entrustment.

A 2020 survey of post-graduate year 5 (PGY5) general surgery residents linked to the American Board of Surgery In-Training Examination (ABSITE) revealed significant deficits in self-efficacy (SE), or personal judgment of one's ability to complete a task, for 10 commonly performed operations. Identifying whether this deficit is similarly perceived by program directors (PDs) has not been well established. We hypothesized that PDs would perceive higher levels of operative SE compared to PGY5s. A survey was distributed through the Association of Program Directors in Surgery listserv; PDs were queried about their PGY5 residents' ability to perform the same 10 operations independently and their accuracy of patient assessments and operative plans for components of several core entrustable professional activities (EPAs). Results of this survey were compared to PGY5 residents' perception of their SE and entrustment based on the 2020 post-ABSITE survey. Chi-squared tests were used for statistical analysis. 108 responses were received, representing ∼32% (108/342) of general surgery programs. Perceptions from PDs of PGY5 residents' operative SE were highly concordant with resident perceptions; no significant differences were observed for 9 of 10 procedures. Both PGY5 residents and PDs perceived adequate levels of entrustment; no significant differences were observed for 6 of 8 EPA components. These findings show concordance between PDs and PGY5 residents in their perceptions of operative SE and entrustment. Though both groups perceive adequate levels of entrustment, PDs corroborate the previously described operative SE deficit, illustrating the importance of improved preparation for independent practice.

Assessing Resident Well-Being After the ABSITE: A Bad Time to Ask?

An annual survey evaluating surgical resident well-being is administered following the American Board of Surgery In-Training Examination (ABSITE). One concern about administering a survey after the ABSITE is that stress from the exam may influence their responses. A survey was administered to all general surgery residents following the 2018 ABSITE assessing positive and negative emotions (scales range from 0 to 12), as well as burnout, suicidality over the past 12 months, and mistreatment (discrimination, sexual harassment verbal/emotional or physical abuse) in the past academic year. Multivariable hierarchical regressions assessed the associations of exam performance and emotions with burnout, suicidality, and mistreatment. Residents from 262 programs provided complete responses (N = 6987, 93.6% response rate). Residents reported high mean positive emotion (M = 7.54, SD = 2.35) and low mean negative emotion (M = 5.33, SD = 2.43). While residents in the bottom ABSITE score quartile reported lower positive and higher negative emotion than residents in the top 2 and 3 quartiles, respectively (P < 0.005), exam performance was not associated with the reported likelihood of burnout, suicidality, or mistreatment. Residents' emotions after the ABSITE are largely positive. Although poor exam performance may be associated with lower positive and higher negative emotion, it does not seem to be associated with the likelihood of reporting burnout, suicidality, or mistreatment. After adjusting for exam performance and emotions, mistreatment remained independently associated with burnout and suicidality. These findings support existing evidence demonstrating that burnout and suicidality are stable constructs that are robust to transient stress and/or emotions.

National Comparison of Program Director Perceptions vs. Resident Reports of the Learning Environment and Well-Being

Our research objectives were to (1) assess the correlation between PD perceptions and their residents' reported experiences and (2) identify PD and program characteristics associated with alignment between PD perceptions and their residents' reports. A survey was administered to US general surgery residents following the 2019 American Board of Surgery In-Training Examination (ABSITE) to study wellness (burnout, thoughts of attrition, and suicidality) and mistreatment (gender discrimination, sexual harassment, racial/ethnic/religious discrimination, bullying). General surgery program directors (PDs) were surveyed about the degree to which they perceived mistreatment and wellness within their programs. Concordance between PDs' perceptions and their residents' reports was assessed using Spearman correlations. Multivariable logistic regression models examined factors associated with alignment between PDs and residents. Of 6,126 residents training at SECOND Trial-enrolled programs, 5,240 (85.5%) responded to the ABSITE survey. All 212 PDs of programs enrolled in the SECOND Trial (100%) responded to the PD survey. Nationally, the proportion of PDs perceiving wellness issues was similar to the proportion of residents reporting them (e.g., 54.9% of PDs perceive that burnout is a problem vs. 40.1% of residents experience at least one burnout symptom weekly); however, the proportion of PDs perceiving mistreatment vastly underestimated the proportion of residents reporting it (e.g., 9.3% of all PDs perceive vs. 65.9% of all residents report bullying). Correlations between PDs' perceptions of problems within their program and their residents' reports were weak for racial/ethnic/religious discrimination (r = 0.176, p = 0.019), sexual harassment (r = 0.180, p = 0.019), burnout (r = 0.198, p = 0.007), and thoughts of attrition (r = 0.193, p = 0.007), and non-existent for gender discrimination, bullying, or suicidality. Multivariable regression models did not identify any program or PD characteristics that were consistently associated with improved resident-program director alignment. Resident and PD perceptions were generally disparate regarding mistreatment, burnout, thoughts of attrition, and suicidality. Reconciling this discrepancy is critical to enacting meaningful change to improve the learning environment and resident well-being.

The fundamentals of laparoscopic surgery in general surgery residency: fundamental for junior residents' self-efficacy.

Implementation of the Fundamentals of Laparoscopic Surgery (FLS) by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has served a need for educational structure for laparoscopic skill within General Surgery training since 2004. This study looks at how FLS affects resident self-efficacy (SE) with laparoscopic procedures. We conducted a national survey, linked to the 2020 American Board of Surgery In-Training Examination (ABSITE), in which 9275 residents from 325 US General Surgery Training Programs participated. The online survey included multimodal questions that analyzed whether participants felt they could perform the most commonly-logged laparoscopic operationsamong residents [Laparoscopic Appendectomy (LA), Laparoscopic Cholecystectomy (LC), Laparoscopic Right Hemicolectomy (LRH), Diagnostic Laparoscopy (DL)] without faculty assistance. This used a 5-point scaled assessment, ranging from "not able to" to "definitely able to." Multivariate analyses determined if completion of FLS made a difference for resident self-efficacy, stratified by post-graduate year (PGY). At the time of the survey, 2300 reported completion of FLS. The percentage of FLS completion increased from PGY1 to PGY5 (4.2% n = 59 vs 85.8% n = 893). PGY1 residents who completed FLS, from 48 diverse institutions, demonstrated the most significant increases in SE (p < 0.05) with significantly higher perceived self-efficacy in LA (p = 0.001) and LRH (p = 0.012). PGY2 and PGY3 residents indicated increased SE in DL (p = 0.037, p = 0.015, respectively), based on FLS completion. These FLS effects were less evident in the more senior classes. Completion of FLS arguably has the greatest benefits for more junior residents, as it establishes a foundation of laparoscopic knowledge and skill, upon which further residency training can build. Successful completion of the curriculum and assessment offered by the Fundamentals of Laparoscopic Surgery leads to greater sense of ability in early trainees.

Bridging the Gap: How to Get Osteopathic Residents Into Fellowships.

IntroductionThe fellowship match process is convoluted, with each specialty having its match on its timeline- with some programs having a Post Graduate Year (PGY) 4th-year or 5th-year match.This study aims to identify tangible recommendations for osteopathic surgery residents to use to improve their applications and, ultimately, the success rate for matching into post-graduate fellowship training.MethodsIn October 2021, as a part of the American College of Osteopathic Surgeons (ACOS) Strategic Planning efforts, the ACOS Resident Student Section sent a questionnaire to the listed email contact for each surgical fellowship program. Fellowship coordinators and program directors were included in the survey. The programs that were included in the study were vascular, thoracic (which included cardiothoracic), surgical critical care, endocrine, hepatobiliary, transplant, pediatric, surgical oncology, breast, minimally invasive, and colorectal surgery.ResultsOf the 108 programs that answered the survey, 36% of them reported they currently had an osteopathic fellow, and another 29% said they had an osteopathic fellow in the past. 35% of the programs listed that they had never had an osteopathic fellow in their program.In regards to how residents can improve their application for fellowship matches the most common answer was research in the field, they were trying to match into. They wanted to see high scores on the United States Medical Licensing Examination (USMLE) and American Board of Surgery In-Training Examination (ABSITE) exams. They also noted that they wanted candidates from more well know residency programs, where they knew the residents would have gotten good training.ConclusionWe recommend that any potential fellowship applicant focus on the following three areas increase competitiveness for matching into fellowship training: publication in the desired field, increased overall scholarly activity, and increased ABSITE scores.

Simulation as Soothsayer: Simulated Surgical Skills MMIs During Residency Interviews are Associated With First Year Residency Performance

The main consideration during residency recruitment is identifying applicants who will succeed during residency. However, few studies have identified applicant characteristics that are associated with competency development during residency, such as the Accreditation Council for Graduate Medical Education milestones. As mini multiple interviews (MMIs) can be used to assess various competencies, we aimed to determine if simulated surgical skills MMI scores during a general surgery residency interview were associated with Accreditation Council for Graduate Medical Education milestone ratings at the conclusion of intern year. Retrospective cohort study. Interns' Step 1 and 2 clinical knowledge (CK) scores, interview day simulated surgical skills MMI overall score, traditional faculty interview scores, average overall milestone ratings in the spring of residency, and intern American Board of Surgery In-Training Examination (ABSITE) percentile scores were gathered. Two multiple linear regression were performed analyzing the association between Step 1, Step 2 CK, MMI, and traditional faculty interview scores with (1) average overall milestone rating and (2) ABSITE percentile scores, controlling for categorical/preliminary intern classification. One academic medical center PARTICIPANTS: General surgery interns matriculating in 2020-2021 RESULTS: Nineteen interns were included. Multiple linear regression revealed that higher overall simulated surgical skills MMI score was associated with higher average milestone ratings (β = .45, p = 0.03) and higher ABSITE score (β = .43, p = 0.02) while neither Step 1, Step 2 CK, nor faculty interview scores were significantly associated with average milestone ratings. Surgical residency programs invest a tremendous amount of effort into training residents, thus metrics for predicting applicants that will succeed are needed. Higher scores on a simulated surgical skills MMIs are associated with higher milestone ratings 1 year into residency and higher intern ABSITE percentiles. These results indicate a noteworthy method, simulated surgical skills MMIs, as an additional metric that may select residents that will have early success in residency.

United States medical licensing examination Step 1 scores are a quantifiably better predictor of American Board of Surgery In-Training Examination success compared to Step 2 scores

BackgroundUnited States Medical Licensing Examination Step 1 (STEP 1) and Step 2 (STEP 2) scores are used in the selection of surgery residents. The American Board of Surgery In-Training Examination (ABSITE) is employed to assess resident knowledge. We sought to determine whether both STEP 1 and/or STEP 2 were predictive of ABSITE performance. MethodsWe performed a 10-year retrospective analysis of all PGY levels comparing STEP 1 and 2 scores with raw ABSITE scores and percentile rank. Additionally, we analyzed STEP 1 and 2 scores for the likelihood of scoring above the 20th percentile on the ABSITE. ResultsWhen STEP 1 and STEP 2 scores were evaluated separately, both were independent predictors of ABSITE performance. However, when STEP 1 and STEP 2 scores were evaluated together, only STEP 1 scores were predictive of ABSITE performance. Finally, only STEP 1 scores were predictive of scoring above the 20th percentile. ConclusionSTEP 1 scores are a better predictor of ABSITE performance than STEP 2.

Prospective Factors that Predict American Board of Surgery In-Training Examination Performance: A Systematic Review.

American Board of Surgery In-Training Examination (ABSITE) performance has become an important factor when monitoring resident progress. Understanding which prospective factors predict performance can help identify residents at risk. A literature search was conducted searching PubMed, EMBASE, and JAMA Network from June 2011 to June 2021, in accordance with the PRISMA guidelines. Searches were performed for the terms "ABSITE" and "American Board of Surgery In-Training Examination." Prospective factors such as prior examination performance, clinical evaluations, and demographics were evaluated. A final 35 studies were included. The prospective factor most consistently found to predict ABSITE performance is performance on prior knowledge-based examinations such as the USMLE step exams. The ACGME Medical Knowledge 1 milestone evaluation also appears to correlate to ABSITE performance, although clinical evaluations, in general, do not. Demographics have no significant correlation to ABSITE performance. Using performance on prior knowledge-based examinations programs may be able to identify residents at risk for failing ABSITE. It may be possible to initiate early intervention before rather than only remediation after poor performance.

American Board of Surgery Entrustable Professional Activities (EPAs): Assessing Graduating Residents’ Perception of Preoperative Entrustment

To determine if graduating surgical residents are achieving entrustment of surgical entrustable professional activities (EPAs). We hypothesize that postgraduate year 5 (PGY5) residents are achieving evaluation and management entrustment in the selected EPAs. In January 2020, surgical residents completed a survey following the American Board of Surgery In-Training Examination (ABSITE) to measure their levels of entrustment in 4 of the 5 ABS-selected EPAs. A Resident Entrustability Index (REI) score was developed to ascertain PGY5 residents' levels of entrustment (range 1-5). Residents indicated how often their assessments and operative plans were modified in the prior 6 months for each EPA (1=Always, 2=Frequently, 3=Occasionally, 4=Rarely, 5=Never). An independent clinical decision-making score (ICDM) was developed with subsequent evaluation of its relationships to intrinsic, resident-related and extrinsic, program-dependent factors. A national post-ABSITE survey. All general surgery residents participating in ABSITE were invited to participate. Of the 1367 PGY5 residents that completed the survey, 1049 residents (76.7%) responded to the surgical EPA items. Residents achieved an average REI of 4, indicating rare modification of assessments and operative plans for the 4 EPAs assessed. Complete entrustment was reported for inguinal hernias and penetrating abdominal trauma (Median REI = 5, IQR 4, 5) indicating assessments and operative plans were never modified. Lack of entrustment (REI ≤3) was reported by a minority of residents (ranging from 8.6% for operative plan of right lower quadrant pathology to 12.8% for operative plan of blunt abdominal trauma). Significant resident-related and program-dependent factors associated with achievement of expected ICDM was socializing with a co-resident (p = 0.001), while training in one's hometown (p < 0.001) and policies that mandate attendings be scrubbed in (p = 0.022) were associated with decreased achievement of expected ICDM. Overall, 89.2% and 90.3% of PGY5 residents are attaining appropriate levels of entrustment and ICDM abilities, respectively, within 6 months of graduating. Of the EPAs evaluated, PGY5 residents are achieving appropriate levels of entrustment in evaluation and management. Although this is the case for a vast majority of PGY5 residents, there is still work to be done to ensure that all PGY5 residents are attaining entrustment prior to graduation. Our study also provides content validity for the surgical EPAs in assessing levels of entrustment in PGY5 residents.

National Evaluation of the Association Between Resident Labor Union Participation and Surgical Resident Well-being

Labor unions are purported to improve working conditions; however, little evidence exists regarding the effect of resident physician unions. To evaluate the association of resident unions with well-being, educational environment, salary, and benefits among surgical residents in the US. This national cross-sectional survey study was based on a survey administered in January 2019 after the American Board of Surgery In-Training Examination (ABSITE). Clinically active residents at all nonmilitary US general surgery residency programs accredited by the American Council of Graduate Medical Education who completed the 2019 ABSITE were eligible for participation. Data were analyzed from December 5, 2020, to March 16, 2021. Presence of a general surgery resident labor union. Rates of labor union coverage among non-health care employees within a region were used as an instrumental variable (IV) for the presence of a labor union at a residency program. The primary outcome was burnout, which was assessed using a modified version of the abbreviated Maslach Burnout Inventory and was defined as experiencing any symptom of depersonalization or emotional exhaustion at least weekly. Secondary outcomes included suicidality, measures of job satisfaction, duty hour violations, mistreatment, educational environment, salary, and benefits. A total of 5701 residents at 285 programs completed the pertinent survey questions (response rate, 85.6%), of whom 3219 (56.5%) were male, 3779 (66.3%) were White individuals, 449 (7.9%) were of Hispanic ethnicity, 4239 (74.4%) were married or in a relationship, and 1304 (22.9%) had or were expecting children. Among respondents, 690 residents were from 30 unionized programs (10.5% of programs). There was no difference in burnout for residents at unionized vs nonunionized programs (297 [43.0%] vs 2175 [43.4%]; odds ratio [OR], 0.92 [95% CI, 0.75-1.13]; IV difference in probability, 0.15 [95% CI, -0.11 to 0.42]). There were no significant differences in suicidality, job satisfaction, duty hour violations, mistreatment, educational environment, salary, or benefits except that unionized programs more frequently offered 4 weeks instead of 2 to 3 weeks of vacation (27 [93.1%] vs 52 [30.6%]; OR, 19.18 [95% CI, 3.92-93.81]; IV difference in probability, 0.77 [95% CI, 0.09-1.45]) and more frequently offered housing stipends (10 [38.5%] vs 9 [16.1%]; OR, 2.15 [95% CI, 0.58-7.95]; IV difference in probability, 0.62 [95% CI 0.04-1.20]). In this evaluation of surgical residency programs in the US, unionized programs offered improved vacation and housing stipend benefits, but resident unions were not associated with improved burnout, suicidality, job satisfaction, duty hour violations, mistreatment, educational environment, or salary.

How to Prepare for the American Board of Surgery In-Training Examination (ABSITE): A Systematic Review

Performance on ABSITE is an important factor when monitoring resident progress. It predicts future performance and has lasting effects. Understanding the highest-yield preparation strategies can help residents in their study efforts and optimize performance. A literature search was conducted searching PubMed, EMBASE and JAMA Network in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Searches were performed for the terms "ABSITE" and "American Board of Surgery In-Training Examination". Only studies discussing individual study habits from May 2011 to May 2021 were included. 19 studies were included in qualitative synthesis. Year-round clinical study failed to show significant correlation to ABSITE performance although year-round ABSITE review was more consistently correlated. During a dedicated study period, increased time and increased total practice questions completed are associated with improved performance. The correlation of individual resources such as ABSITE review books, textbooks, audio podcasts and ABSITE preparatory courses to improved ABSITE performance was not proven. Residents should optimize study strategies based on methods that have consistently shown to improve performance. Recommendations for best preparation strategies are provided.

Trainee Utilization of the SCORE Curriculum is Associated With Improved ABSITE Performance: A Multi-institutional Study

The Surgical Council on Resident Education's (SCORE) structured educational curriculum for general surgery residents uses a 2-year repeating cycle of modules and quizzes called "This Week in SCORE" (TWIS) to organize and sequence the curricular content on the SCORE portal. The purpose of this study was to evaluate the impact of using the SCORE content and TWIS curriculum on American Board of Surgery In-Training Examination (ABSITE) performance. To date, no multi-institutional studies have examined this effect. Eight residency programs participated, including university and community-based programs. SCORE usage overall, TWIS usage, and ABSITE percentile scores (adjusted for post-graduate year [PGY]) were analyzed for the academic years 2017 to 2020. SCORE usage was defined as number of SCORE logins annually per resident with "low usage" ≤10 times and "high usage" >10 times. TWIS usage was defined as "low usage" (no TWIS quizzes done) or "high usage" (≥1 TWIS quiz per year). Four hundred and twenty-eight trainees were evaluated. Trainees with high SCORE and TWIS usage consistently achieved a higher ABSITE percentile score. This difference was maintained in subgroup analysis by PGY with the greatest impact in PGY-1 and PGY-2 levels. Utilization of multiple aspects of SCORE content appears to have a significant positive impact on ABSITE performance across all levels of postgraduate training. This multi-institutional study of a large number of users is the first to demonstrate that increased usage of SCORE content appears to be a predictor of ABSITE performance success.

Experiences of Gender Discrimination and Sexual Harassment Among Residents in General Surgery Programs Across the US

Mistreatment is a common experience among surgical residents and is associated with burnout. Women have been found to experience mistreatment at higher rates than men. Further characterization of surgical residents' experiences with gender discrimination and sexual harassment may inform solutions. To describe the types, sources, and factors associated with (1) discrimination based on gender, gender identity, or sexual orientation and (2) sexual harassment experienced by residents in general surgery programs across the US. This cross-sectional national survey study was conducted after the 2019 American Board of Surgery In-Training Examination (ABSITE). The survey asked respondents about their experiences with gender discrimination and sexual harassment during the academic year starting July 1, 2018, through the testing date in January 2019. All clinical residents enrolled in general surgery programs accredited by the Accreditation Council for Graduate Medical Education were eligible. Specific types, sources, and factors associated with gender-based discrimination and sexual harassment. Primary outcome was the prevalence of gender discrimination and sexual harassment. Secondary outcomes included sources of discrimination and harassment and associated individual- and program-level factors using gender-stratified multivariable logistic regression models. The survey was administered to 8129 eligible residents; 6956 responded (85.6% response rate)from 301 general surgery programs. Of those, 6764 residents had gender data available (3968 [58.7%] were male and 2796 [41.3%] were female individuals). In total, 1878 of 2352 female residents (79.8%) vs 562 of 3288 male residents (17.1%) reported experiencing gender discrimination (P < .001), and 1026 of 2415 female residents (42.5%) vs 721 of 3360 male residents (21.5%) reported experiencing sexual harassment (P < .001). The most common type of gender discrimination was being mistaken for a nonphysician (1943 of 5640 residents [34.5%] overall; 1813 of 2352 female residents [77.1%]; 130 of 3288 male residents [4.0%]), with patients and/or families as the most frequent source. The most common form of sexual harassment was crude, demeaning, or explicit comments (1557 of 5775 residents [27.0%] overall; 901 of 2415 female residents [37.3%]; 656 of 3360 male residents [19.5%]); among female residents, the most common source of this harassment was patients and/or families, and among male residents, the most common source was coresidents and/or fellows. Among female residents, gender discrimination was associated with pregnancy (odds ratio [OR], 1.93; 95% CI, 1.03-3.62) and higher ABSITE scores (highest vs lowest quartile: OR, 1.67; 95% CI, 1.14-2.43); among male residents, gender discrimination was associated with parenthood (OR, 1.72; 95% CI, 1.31-2.27) and lower ABSITE scores (highest vs lowest quartile: OR, 0.57; 95% CI, 0.43-0.76). Senior residents were more likely to report experiencing sexual harassment than interns (postgraduate years 4 and 5 vs postgraduate year 1: OR, 1.77 [95% CI, 1.40-2.24] among female residents; 1.31 [95% CI, 1.01-1.70] among male residents). In this study, gender discrimination and sexual harassment were common experiences among surgical residents and were frequently reported by women. These phenomena warrant multifaceted context-specific strategies for improvement.

Burnout Phenotypes Among U.S. General Surgery Residents

Although well-established metrics exist to measure workplace burnout, researchers disagree about how to categorize individuals based on assessed symptoms. Using a person-centered approach, this study identifies classes of burnout symptomatology in a large sample of general surgery residents in the United States. A survey was administered following the 2018 American Board of Surgery In-Training Examination (ABSITE) to study wellness among U.S. general surgery residents. Latent class models identified distinct classes of residents based on their responses to the emotional exhaustion and depersonalization questions of the modified abbreviated Maslach Burnout Inventory (aMBI). Classes were assigned representative names, and the characteristics of their members and residency programs were compared. The survey was completed by 7415 surgery residents from 263 residency programs nationwide (99.3% response rate). Five burnout classes were found: Burned Out (unfavorable score on all six items, 9.8% of total), Fully Engaged (favorable score on all six items, 23.1%), Fatigued (favorable on all items except frequent fatigue, 32.2%), Overextended (frequent fatigue and burnout from work, 16.7%), and Disengaged (weekly symptoms of fatigue and callousness, 18.1%). Within the more symptomatic classes (Burned Out, Overextended, and Disengaged), men manifested more depersonalization symptoms, whereas women reported more emotional exhaustion symptoms. Burned Out residents were characterized by reports of mistreatment (abuse, sexual harassment, and gender-, racial-, or pregnancy and/or childcare-based discrimination), duty hour violations, dissatisfaction with duty hour regulations or time for rest, and low ABSITE scores. Burnout is multifaceted, with complex and variable presentations. Latent class modeling categorizes general surgery residents based on their burnout symptomatology. Organizations should tailor their efforts to address the unique manifestations of each class as well as shared drivers.

SCORE-Based Simulated ABSITE Exam Performance as a Predictor of Performance on the ABSITE

The American Board of Surgery In-Training Examination (ABSITE) is a crucial, objective assessment of surgical knowledge during training. In 2014, the American Board of Surgery (ABS) announced the alignment of the ABSITE to the SCORE® (Surgical Council on Resident Education) Curriculum Outline for General Surgery Residency. We hypothesized that implementing a pre-ABSITE SCORE-based exam would help identify underperforming residents and provide early guidance to improve performance on the ABSITE. In October 2014, our university-based surgical residency program began administering a yearly comprehensive pre-ABSITE SCORE-based exam consisting of 225 to 250 multiple-choice questions selected from the SCORE question bank to all our general surgery residents, preliminary and categorical. The 4-hour exam addresses both clinical management (80%) and applied sciences (20%). Residents receive reports with their scores (percentage correct). Residents performing at less than 60% meet with the Program Director for discussion and formulation of a study plan. Correlational analysis was performed between resident ABSITE scores, pre-ABSITE SCORE-based exam scores, gender, resident status (preliminary vs. categorical), postgraduate year (PGY), and the United States Medical Licensing Examination (USMLE) Step 1 and Step 2 scores. A total of 244 exam scores (122 pre-ABSITE SCORE-based exams and 122 matched ABSITE) were completed by 51 residents at different PGY levels (32 PGY1, 32 PGY2, 20 PGY3, 19 PGY4, and 18 PGY5). Fifty-seven percent were males, 62% were categorical residents, and 38% were preliminary residents. October pre-ABSITE SCORE-based exam scores were compared to the subsequent January ABSITE scores. Categorical residents completed 101 (83%) of the January exams, while preliminary residents completed 21 (17%) of these paired exams. We found strong correlations between the correct percentage on ABSITE and pre-ABSITE SCORE-based scores (r = 0.637, p < 0.001), between the correct percentage on ABSITE and PGY (r = 0.688, p < 0.001), and between ABSITE and resident status (r = 0.462, p < 0.001). Additionally, there was a weak to negligible correlation between the correct percentage on ABSITE and resident gender (r = 0.274, p = 0.001), USMLE-2 (r = 0.12, p = 0.16), and USMLE-1 (r = 0.04, p = 0.653). Multiple regression analysis, with all predictors, was performed to predict the percentage score on the ABSITE and produced R2 0.58, with an adjusted R2 of 0.57, with a large size effect, p < 0.001. After controlling for the other variables, three factors reached statistical significance (p < 0.05): pre-ABSITE SCORE-based exam scores, PGY, and resident gender. We found a strong correlation between performance on the pre-ABSITE SCORE-based exam and performance on the ABSITE exam. Surgery residents are encouraged to start studying earlier and to utilize SCORE contents as outlined by the ABS in their study plan.

Learning to Read: Successful Program-Based Remediation Using the Surgical Council on Resident Education (SCORE) Curriculum

The Surgical Council on Resident Education (SCORE) curriculum is aligned with the American Board of Surgery (ABS) objectives. Our program adopted the SCORE curriculum in 2015 after poor ABS In-Training Examination (ABSITE) performance and lowest quartile ABS Certifying Exam (CE) and Qualifying Exam (QE) first-time pass rates. We examined the association of SCORE use with ABSITE performance and ABS board exam first-time pass rate. At a single institution, a retrospective review of surgery residents' SCORE metrics and ABSITE percentile was conducted for academic years 2015 to 2019. Metrics analyzed on the SCORE web portal were mean total minutes and total visits per resident for all residents using SCORE that year. First-time pass rates of the ABS QE and CE were examined from 2013 to 2019. Chi-square and linear regression analysis were performed, and a 95% level of confidence was assumed (alpha= 0.05). Yearly data from categorical general surgery residents showed a significant increase in total minutes, total visits, and ABSITE percentile. Combined first time pass rates for the ABS QE and CE significant increased from 70.8% in 2013 to 2015 to 93.9% in 2016 to 2019 (p= 0.018). Increased longitudinal use of the SCORE curriculum was associated with programmatic improvements in ABSITE performance and ABS board exam first-time pass rate.