General Surgery Programs Research Articles

Current trends in the practice of endoscopy among surgeons in the USA.

The diagnostic and therapeutic roles for endoscopic intervention are expanding. To continue emphasis on endoscopy in surgical training, The Society of American Gastrointestinal and Endoscopic Surgeons has developed the Fundamentals of Endoscopic Surgery (FES) course to standardize and assess endoscopy training. However, little demographic information exists about the current practice of endoscopy by general surgeons and how to best integrate endoscopic skills into surgical training. A survey to collect data regarding the current practice patterns of endoscopy was sent to surgeons with a valid email address in the American Medical Association masterfile. Information regarding the type of training (academic vs. community general surgery residency) and current practice environment (academic medical center vs. community hospital) was collected. The respondents' current practice volume of upper endoscopy and colonoscopy over the prior year was stratified into three groups: rare (<1 per month), moderate (1-10 per month), and frequent (>10 per month). Pearson's Chi-squared test was used to analyze the data. The survey was sent to 9902 general surgeons. There were 767 who provided answers regarding their current practice of endoscopy. Mean time in practice was 18±10years, 87% were male, and 83% practiced in a metropolitan area. Respondents who trained at academic general surgery programs were less likely than those at community programs to frequently perform colonoscopy (17.3 vs. 27.9%, p<0.05) and upper endoscopy (11.8 vs. 17.1%, p<0.05). Those who currently practice in academic medical centers were also less likely to be frequent performers of colonoscopy (5.6 vs. 24.7%, p<0.05) and upper endoscopy (9.8 vs. 14.8%, p<0.05) than those who practice at community hospitals. The type of residency training and current practice setting of general surgeons has a significant influence on the volume of endoscopic procedures performed. This study identifies areas where more emphasis on endoscopic skills training is needed, such as FES.

Can a virtual reality assessment of fine motor skill predict successful central line insertion?

BackgroundDue to the increased use of peripherally inserted central catheter lines, central lines are not performed as frequently. The aim of this study is to evaluate whether a virtual reality (VR)–based assessment of fine motor skills can be used as a valid and objective assessment of central line skills. MethodsSurgical residents (N = 43) from 7 general surgery programs performed a subclavian central line in a simulated setting. Then, they participated in a force discrimination task in a VR environment. Hand movements from the subclavian central line simulation were tracked by electromagnetic sensors. Gross movements as monitored by the electromagnetic sensors were compared with the fine motor metrics calculated from the force discrimination tasks in the VR environment. ResultsLong periods of inactivity (idle time) during needle insertion and lack of smooth movements, as detected by the electromagnetic sensors, showed a significant correlation with poor force discrimination in the VR environment. Also, long periods of needle insertion time correlated to the poor performance in force discrimination in the VR environment. ConclusionsThis study shows that force discrimination in a defined VR environment correlates to needle insertion time, idle time, and hand smoothness when performing subclavian central line placement. Fine motor force discrimination may serve as a valid and objective assessment of the skills required for successful needle insertion when placing central lines.

The Burden of the Fellowship Interview Process on General Surgery Residents and Programs

This study evaluated the effect of the fellowship interview process in a cohort of general surgery residents. We hypothesized that the interview process would be associated with significant clinical time lost, monetary expenses, and increased need for shift coverage. An online anonymous survey link was sent via e-mail to general surgery program directors in June 2014. Program directors distributed an additional survey link to current residents in their program who had completed the fellowship interview process. United States allopathic general surgery programs. Overall, 50 general surgery program directors; 72 general surgery residents. Program directors reported a fellowship application rate of 74.4%. Residents most frequently attended 8 to 12 interviews (35.2%). Most (57.7%) of residents reported missing 7 or more days of clinical training to attend interviews; these shifts were largely covered by other residents. Most residents (62.3%) spent over $4000 on the interview process. Program directors rated fellowship burden as an average of 6.7 on a 1 to 10 scale of disruption, with 10 being a significant disruption. Most of the residents (57.3%) were in favor of change in the interview process. We identified potential areas for improvement including options for coordinated interviews and improved content on program websites. The surgical fellowship match is relatively burdensome to residents and programs alike, and merits critical assessment for potential improvement.

2016 Trauma Association of Canada Annual Scientific Meeting Abstracts.

2016 Trauma Association of Canada Annual Scientific Meeting Abstracts.

National Survey of Burnout among US General Surgery Residents

Burnout is a complex syndrome of emotional distress that can disproportionately affect individuals who work in health care professions. For a national survey of burnout in US general surgery residents, we asked all ACGME-accredited general surgery program directors to email their general surgery residents an invitation to complete an anonymous, online survey. Burnout was assessed with the Maslach Burnout Inventory; total scores for Emotional Exhaustion (EE), Depersonalization (DP), and Personal Accomplishment (PA) subscales were calculated. Burnout was defined as having a score in the highest tertile for EE or DP or lowest tertile for PA. Chi-square tests and one-way ANOVA were used to test associations between burnout tertiles for each subscale and various resident and training-program characteristics as appropriate. From April to December 2014, six hundred and sixty-five residents actively engaged in clinical training had data for analysis; 69% met the criterion for burnout on at least one subscale. Higher burnout on each subscale was reported by residents planning private practice careers compared with academic careers. A greater proportion of women than men reported burnout on EE and PA. Higher burnout on EE and DP was associated with greater work hours per week. Having a structured mentoring program was associated with lower burnout on each subscale. The high rates of burnout among general surgery residents are concerning, given the potential impact of burnout on the quality of patient care. Efforts to identify at-risk populations and to design targeted interventions to mitigate burnout in surgical trainees are warranted.

Learning by (video) example: a randomized study of communication skills training for end-of-life and error disclosure family care conferences

BackgroundTeaching residents to lead end of life (EOL) and error disclosure (ED) conferences is important. MethodsWe developed and tested an intervention using videotapes of EOL and error disclosure encounters from previous Objective Structured Clinical Exams. Residents (n = 72) from general and orthopedic surgery programs at 2 sites were enrolled. Using a prospective, pre-post, block group design with stratified randomization, we hypothesized the treatment group would outperform the control on EOL and ED cases. We also hypothesized that online course usage would correlate positively with post-test scores. ResultsAll residents improved (pre-post). At the group level, treatment effects were insignificant, and post-test performance was unrelated to course usage. At the subgroup level for EOL, low performers assigned to treatment scored higher than controls at post-test; and within the treatment group, post graduate year 3 residents outperformed post graduate year ​1 residents. ConclusionsTo be effective, online curricula illustrating communication behaviors need face-to-face interaction, individual role play with feedback and discussion.

Program Director Perceptions of Surgical Resident Training and Patient Care under Flexible Duty Hour Requirements

The Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial was a national, cluster-randomized, pragmatic, noninferiority trial of 117 general surgery programs, comparing standard ACGME resident duty hour requirements ("Standard Policy") to flexible, less-restrictive policies ("Flexible Policy"). Participating program directors (PDs) were surveyed to assess their perceptions of patient care, resident education, and resident well-being during the study period. A survey was sent to all PDs of the general surgery residency programs participating in the FIRST trial (N= 117 [100% response rate]) in June and July 2015. The survey compared PDs' perceptions of the duty hour requirements in their arm of the FIRST trial during the study period from July 1, 2014 to June 30,2015. One hundred percent of PDs in the Flexible Policy arm indicated that residents used their additional flexibility in duty hours to complete operations they started or to stabilize a critically ill patient. Compared with the Standard Policy arm, PDs in the Flexible Policy arm perceived a more positive effect of duty hours on the safety of patient care (68.9% vs 0%; p < 0.001), continuity of care (98.3% vs 0%; p < 0.001), and resident ability to attend educational activities (74.1% vs 3.4%; p < 0.001). Most PDs in both arms reported that safety of patient care (71.8%), continuity of care (94.0%), quality of resident education (83.8%), and resident well-being (55.6%) would be improved with a hypothetical permanent adoption of more flexible duty hours. Program directors involved in the FIRST trial perceived improvements in patient safety, continuity of care, and multiple aspects of resident education and well-being with flexible duty hours.

Vascular Trauma Operative Experience is Inadequate in General Surgery Programs

Vascular injuries may be challenging, particularly for surgeons who have not received formal vascular surgery fellowship training. Lack of experience and improper technique can result in significant complications. The objective of this study was to examine changes in resident experience with operative vascular trauma over time. A retrospective review was performed using Accreditation Council for Graduate Medical Education (ACGME) case logs of general surgery residents graduating between 2004 and 2014 at 2 academic, university-affiliated institutions associated with level 1 trauma centers. The primary outcome was number of reported vascular trauma operations, stratified by year of graduation and institution. A total of 112 residents graduated in the study period with a median 7 (interquartile range 4.5-13.5) vascular trauma cases per resident. Fasciotomy and exposure and/or repair of peripheral vessels constituted the bulk of the operative volume. Linear regression showed no significant trend in cases with respect to year of graduation (P=0.266). Residents from program A (n=53) reported a significantly higher number of vascular trauma cases when compared with program B (n=59): 12.0 vs. 5.0 cases, respectively (P<0.001). Level 1 trauma center verification does not guarantee sufficient exposure to vascular trauma. The operative exposure in program B is reflective of the national average of 4.0 cases per resident as reported by the ACGME, and this trend is unlikely to change in the near future. Fellowship training may be critical for surgeons who plan to work in a trauma setting, particularly in areas lacking vascular surgeons.

Systematic Review of Postgraduate Surgical Education in Low- and Middle-Income Countries.

Surgical care is recognized as an important component of public health, however, many low- and middle- income countries (LMICs) are faced with a shortage of trained personnel. In response to this unmet need, many countries have developed local postgraduate training programs in surgery. This study aims to characterize general surgery postgraduate education in LMICs. PubMed, EMBASE, and Global Index Medicus databases were searched for articles related to postgraduate general surgery education in LMICs. Studies in other surgical specialties and those published prior to 1990 were excluded. Data were collected on the characteristics of postgraduate training programs. Sixty-four articles discussed postgraduate surgical education in LMICs. Programs in 34 different countries and 6 different regions were represented. Nine countries were low-income, 12 were low-middle-income, and 13 were upper-middle-income countries. Sixty-four articles described aspects of the local postgraduate training program. Prior to postgraduate training, residents complete an undergraduate medical degree with 19 programs describing a pre-training experience such as internship. Surgical curricula were broad-based to prepare trainees to work in low-resource settings. At the completion of postgraduate training, examination formats varied including oral, written, and clinical exams. Postgraduate general surgery programs ranged from 2.5 to 7years. Postgraduate surgical education is one mechanism to increase surgical capacity in LMICs. Different strategies have been employed to improve surgical education in LMICs and learning from these programs can optimize surgical education across teaching sites.

Attributes of Candidates Passing the ABS Certifying Examination on the First Attempt—Program Directors׳ Perspective

The American Board of Surgery Certifying Examination (CE) is a pivotal event in a surgeon's career development, as it is the last challenge before achieving Board certification. First-time pass rate on the CE is one of the key metrics of surgery residency programs. The overall pass rate on the CE has declined significantly in recent years. The goal of this study was the identification of attributes of general surgery residents that are associated with passing the CE at the first attempt. The modified Delphi process was used to survey general surgery program directors. The study was conducted in 2 rounds in the interest of time available for surgical education research fellowship project. All 259 program directors were contacted in each round of surveys. In all, 49 (19%) responded to the first round and 54 (21%) responded to the second round of survey. The characteristics of a successful resident on CE include confidence, self-motivation, sound knowledge base, strong performance on the Board's training examination (American Board of Surgery In-Training Examination), and mock orals, and good communication skills. Postgraduate years 4 and 5 are the most likely resident levels at which failure could be predicted.

First 101 Robotic General Surgery Cases in a Community Hospital.

Background and Objectives:The general surgeon's robotic learning curve may improve if the experience is classified into categories based on the complexity of the procedures in a small community hospital. The intraoperative time should decrease and the incidence of complications should be comparable to conventional laparoscopy. The learning curve of a single robotic general surgeon in a small community hospital using the da Vinci S platform was analyzed.Methods:Measured parameters were operative time, console time, conversion rates, complications, surgical site infections (SSIs), surgical site occurrences (SSOs), length of stay, and patient demographics.Results:Between March 2014 and August 2015, 101 robotic general surgery cases were performed by a single surgeon in a 266-bed community hospital, including laparoscopic cholecystectomies, inguinal hernia repairs; ventral, incisional, and umbilical hernia repairs; and colorectal, foregut, bariatric, and miscellaneous procedures. Ninety-nine of the cases were completed robotically. Seven patients were readmitted within 30 days. There were 8 complications (7.92%). There were no mortalities and all complications were resolved with good outcomes. The mean operative time was 233.0 minutes. The mean console operative time was 117.6 minutes.Conclusion:A robotic general surgery program can be safely implemented in a small community hospital with extensive training of the surgical team through basic robotic skills courses as well as supplemental educational experiences. Although the use of the robotic platform in general surgery could be limited to complex procedures such as foregut and colorectal surgery, it can also be safely used in a large variety of operations with results similar to those of conventional laparoscopy.

INTERVENCIONES REALIZADAS POR RESIDENTES DE CIRUGÍA GENERAL

surgical procedures performed by general surgery residents introduction: The national Society of Surgery has defined the minimum number of surgical procedu - res that must be performed by general surgeons in trainee, however, there is no national data reporting this accomplishment. The aim of this study is to report on detail the surgical interventions performed by General Surgery Residents at the Pontificia Universidad Catolica de Chile (PUC) as lead surgeons. methods: Retros- pective analysis of surgical procedures performed by 26 Residents of the General Surgery Program (GSP) at PUC who graduated between the years 2012 and 2014. A total of 10.102 registered surgeries were reviewed and summarized. results: The mean number of interventions performed by surgery residents was 481 (20% of them on the first year). The most frequently performed procedures were (mean per resident) laparoscopic cholecystectomy (115;24%), open appendectomy (89;19%), classic hernioplasty (43;9%), laparoscopic appen - dectomy (34;7%) and open cholecystectomy (25;5%). Regarding complex/sub-specialty interventions, partial/ total colectomy (12;2%), thyroidectomy-parathyroidectomy (9;2%), vascular access (8;2%), thoracotomy- VATS-sternotomy (5;1%) and breast surgery (4;1%) were the most commonly performed. Fifty three percent of all procedures were done in an emergency setting. The proportion of emergency procedures increased through the GSP training (elective vs emergency: 62 vs 38% at first year and 34 vs 66% at third year, res - pectively; p < 0.002). Interventions were mainly performed in the capital city of Chile, Santiago (74%) and the remaining were done in other provinces. Regarding only abdominal interventions (mean per resident: 366), 42% was performed by laparoscopy. conclusions: Residents of the PUC-GSP execute a considerable large amount of interventions as resident surgeons throughout their 3-years-training program, exceeding the minimum recommendations established by the national Society of Surgery.

Predicting and enhancing American Board of Surgery In-Training Examination performance: does writing questions really help?

BackgroundThe generative learning model posits that individuals remember content they have generated better than materials created by others. The goals of this study were to evaluate question generation as a study method for the American Board of Surgery In-Training Examination (ABSITE) and determine whether practice test scores and other data predict ABSITE performance. MethodsResidents (n = 206) from 6 general surgery programs were randomly assigned to one of the two study conditions. One group wrote questions for practice examinations. All residents took 2 practice examinations. ResultsThere was not a significant effect of writing questions on ABSITE score. Practice test scores, United States Medical Licensing Examination Step 1 scores, and previous ABSITE scores were significantly correlated with ABSITE performance. ConclusionsThe generative learning model was not supported. Performance on practice tests and other data can be used for early identification of residents at risk of performing poorly on the ABSITE.

Sustained Increased Entry of Medical Students into Surgical Careers: A Student-Led Approach

To determine whether a surgical interest group run entirely by preclinical students can influence medical students to enter general surgery residency programs. Matriculation rates into general surgery and affiliated subspecialties from Columbia University College of Physicians and Surgeons residency match lists were compared to National Residency Match Program data for all U.S. senior students from 2006 to 2014. The Columbia University College of Physicians and Surgeons. After establishing the interest group, entrance rates into general surgery programs tripled from the early 2000s to more than 12% of 2006 Columbia University College of Physicians and Surgeons graduates. After 8 years, our data illustrate sustained results, with more than 8% of students entering surgical residencies, significantly higher than the National Residency Match Program's average (p < 0.025). Surgical interest groups spark early and lasting interest in surgery that may influence residency decisions. Moreover, these programs can be successfully run entirely by preclinical students and implemented in other institutions.

Investigating the Impact of the 2011 ACGME Resident Duty Hour Regulations on Surgical Residency Programs: The Program Director Perspective

The 2011 ACGME regulations required substantial changes to the structure of general surgery residency programs, due primarily to the 16-hour in-house rule for PGY1 residents. However, the scope of changes that programs have undertaken to meet these requirements, and the educational impact of those changes, are poorly understood. We performed in-depth qualitative interviews with general surgery program directors. Twenty program directors participated in the study; interviews were conducted until adequate thematic saturation was achieved. Participants were recruited from a stratified random sampling of residency programs in the United States to ensure a representative cohort. Interviews focused on changes in call schedule, interns' educational requirements, development, and satisfaction. Most programs used a month-long night float (NF) rotation (14 of 20 [75%]). A minority of programs (5 of 20 [25%]) used a weekly rotating schedule, in which interns worked 5 to 6 nights in a month. Multiple programs (65%) had an NF in place before 2011; these programs made changes to and expanded their existing schedule to accommodate the new regulations. Commonly cited challenges to instituting NF included weekend coverage (60%) and providing adequate days off during day-to-night transition. Interns spent as much as 3 months of the year on NF. Only 5 programs made explicit changes to teaching schedules or developed a curriculum for residents on NF. Seventy-five percent of programs excused interns, explicitly or implicitly, from didactic teaching when on NF. Common themes noted by program directors included delayed maturation of trainees, interns being isolated from the team culture, and a conflict between the professional behaviors of "following the rules" and "doing what is right."

Operative Experience with Fasciotomy is Inadequate in General Surgery Programs: Should Lab Simulation be the New Training Paradigm?

Introduction: Lower extremity fasciotomy is an important technical skill for the general surgeon. Improper technique can result in significant complications, and adequate resident training in the procedure is vital. The objective of our study is to study the changes in resident experiencewith fasciotomies over time. Methods: A retrospective review was done using ACGME case logs of general surgery residents graduating between 2004 and 2014 at two academic institutions associated with level 1 trauma centers. The primary outcome, total fasciotomies done,was stratifiedby year of graduationand institution. Results: One hundred twelve residents graduated in the study period with an average of 2.9 (±2.7) fasciotomy cases per resident. Neither program had simulation courses for fasciotomy.Linear regressionshowednosignificant trend incases with respect to year of graduation (p 1⁄40.54). Residents from program A (n 1⁄4 53) reported a significantly higher average of fasciotomies when compared with program B (n1⁄459): 4.5 (±2.5) vs. 1.4 (±1.8) cases, respectively (p<0.001). Conclusion: Association with a level 1 trauma center does not guarantee sufficient exposure to lower extremity fasciotomy. It is unlikely the number of cases per resident is adequate at most general surgery programs given the low average operative volume. Simulation courses with cadaver models should be employed to train future graduates this vital surgical procedure.

The Effects of the Addition of a Pediatric Surgery Fellow on the Operative Experience of the General Surgery Resident

Adding fellows to surgical departments with residency programs can affect resident education. Our specific aim was to evaluate the effect of adding a pediatric surgery (PS) fellow on the number of index PS cases logged by the general surgery (GS) residents. At a single institution with both PS and GS programs, we examined the number of logged cases for the fellows and residents over 10 years [5 years before (Time 1) and 5 years after (Time 2) the addition of a PS fellow]. Additionally, the procedure related relative value units (RVUs) recorded by the faculty were evaluated. The fellows averaged 752 and 703 cases during Times 1 and 2, respectively, decreasing by 49 (P = 0.2303). The residents averaged 172 and 161 cases annually during Time 1 and Time 2, respectively, decreasing by 11 (P = 0.7340). The total number of procedure related RVUs was 4627 and 6000 during Times 1 and 2, respectively. The number of cases logged by the PS fellows and GS residents decreased after the addition of a PS fellow; however, the decrease was not significant. Programs can reasonably add an additional PS fellow, but care should be taken especially in programs that are otherwise static in size.

Impact of advanced practice providers (nurse practitioners and physician assistants) on surgical residents' critical care experience

BackgroundTeaching hospitals often employ advanced practice providers (nurse practitioners and physician assistants or APPs) to counteract residents' work-hour restrictions. With increased utilization of APPs in labor-intense areas, such as intensive care units (ICUs), APPs may have an impact on resident education and experience. No studies have investigated the direct role an APP plays on the training experience of a surgical resident in the ICU. Materials and methodsAn institutional review board-approved survey was emailed to residents in Accreditation Council for Graduate Medical Education-accredited general surgery programs. Surveys asked about demographics, residency and/or ICU characteristics, and the effects of APPs on patient care, workflow, and educational experience. Regression analysis determined predictors of resident perception. ResultsA total of 354 of 1178 residents responded to the survey (30%). Some residents felt that nurses calling APPs preferentially for patient-care issues interfered with education (17%) and residents' ability to follow patients (12%) and was associated with overall detrimental effects to ICU experience on regression (odds ratio, 3.7; confidence interval, 1.5–9.1). Most residents reported positive effects of APPs, such as reduced resident workload (79.8%), teaching protocols and/or guidelines (60.3%), enhanced patient care (60.3%), and enhanced communication (50.5%). When asked how APPs affected their overall ICU experience, 48.4% reported positive effects, 20.6% reported “no effect,” and 31% reported detrimental effects. ConclusionsOnly a minority of residents perceived that APPs detract from training, particularly those who felt excluded when nurses preferentially contact APPs with patient-care issues. APPs have the potential to enhance training and ICU experience, as reflected in many of the responses. Strategies to maintain direct nurse and resident communication might preserve residents' perception of the educational value of APPs.

Global opportunities on 239 general surgery residency Web sites

BackgroundMany general surgical residency programs lack a formal international component. We hypothesized that most surgery programs do not have international training or do not provide the information to prospective applicants regarding electives or programs in an easily accessible manner via Web-based resources. Materials and methodsIndividual general surgery program Web sites and the American College of Surgeons residency tool were used to identify 239 residencies. The homepages were examined for specific mention of international or global health programs. Ease of access was also considered. Global surgery specific pages or centers were noted. Programs were assessed for length of rotation, presence of research component, and mention of benefits to residents and respective institution. ResultsOf 239 programs, 24 (10%) mentioned international experiences on their home page and 42 (18%) contained information about global surgery. Of those with information available, 69% were easily accessible. Academic programs were more likely than independent programs to have information about international opportunities on their home page (13.7% versus 4.0%, P = 0.006) and more likely to have a dedicated program or pathway Web site (18.8% versus 2.0%, P < 0.0001). Half of the residencies with global surgery information did not have length of rotation available. Research was only mentioned by 29% of the Web sites. Benefits to high-income country residents were discussed more than benefits to low- and middle-income country residents (57% versus 17%). ConclusionsGeneral surgery residency programs do not effectively communicate international opportunities for prospective residents through Web-based resources and should seriously consider integrating international options into their curriculum and better present them on department Web sites.

Accreditation Council for Graduate Medical Education Compliance and Resident Competence in Hepatopancreaticobiliary Surgery during General Surgery Residency: A Program Director Review

A survey of general surgery (GS) program directors (PD) was performed to determine how Accreditation Council for Graduate Medical Education (ACGME) hepatopancreatobiliary (HPB) requirements are met and compare the findings with previous national averages. The objectives were to establish whether GS residencies are in compliance with ACGME recommendations. Secondary objectives aimed to determine if fellowship affects residency training. A 30-question survey was sent out to GS PDs registered with Association of Program Directors in Surgery. Analysis of the responses was then completed using statistical software (GraphPad) and compared with the ACGME data. Although HPB training and exposure has changed, most programs continue to meet HPB requirements at their main institution (73%). Overall, 27% of PDs now send residents to outside facilities or have hired new HPB faculty to manage the shift in caseload. GS graduates have HPB numbers comparable to the national resident averages of 2010 to 2011, and many programs graduate residents exceeding ACGME HPB requirements. Although 69% of residents complete >50% of HPB cases, only 50% of PDs felt residents were competent. Altogether, 30% of programs had HPB fellowships; few PDs felt fellows positively affected residency training. PDs feel that residents achieve more than minimum required HPB numbers required by the ACGME but not all are competent. Fellows reduce resident exposure to HPB cases. More simulation and autonomy may improve HPB education in GS residency.