General Surgery Residency Training Research Articles

The learning curve of laparoscopic holecystectomy in general surgery resident training: old age of the patient may be a risk factor?

A well-designed learning curve is essential for the acquisition of laparoscopic skills: but, are there risk factors that can derail the surgical method? From a review of the current literature on the learning curve in laparoscopic surgery, we identified learning curve components in video laparoscopic cholecystectomy; we suggest a learning curve model that can be applied to assess the progress of general surgical residents as they learn and master the stages of video laparoscopic cholecystectomy regardless of type of patient.Electronic databases were interrogated to better define the terms “surgeon”, “specialized surgeon”, and “specialist surgeon”; we surveyed the literature on surgical residency programs outside Italy to identify learning curve components, influential factors, the importance of tutoring, and the role of reference centers in residency education in surgery. From the definition of acceptable error, self-efficacy, and error classification, we devised a learning curve model that may be applied to training surgical residents in video laparoscopic cholecystectomy.Based on the criteria culled from the literature, the three surgeon categories (general, specialized, and specialist) are distinguished by years of experience, case volume, and error rate; the patients were distinguished for years and characteristics. The training model was constructed as a series of key learning steps in video laparoscopic cholecystectomy. Potential errors were identified and the difficulty of each step was graded using operation-specific characteristics. On completion of each procedure, error checklist scores on procedure-specific performance are tallied to track the learning curve and obtain performance indices of measurement that chart the trainee’s progress.Conclusions. The concept of the learning curve in general surgery is disputed. The use of learning steps may enable the resident surgical trainee to acquire video laparoscopic cholecystectomy skills proportional to the instructor’s ability, the trainee’s own skills, and the safety of the surgical environment. There were no patient characteristics that can derail the methods. With this training scheme, resident trainees may be provided the opportunity to develop their intrinsic capabilities without the loss of basic technical skills.

Senior Surgical Resident Confidence in Performing Flexible Endoscopy: What Can We Do Differently?

The American Board of Surgery endoscopy requirements for general surgery training are evolving. In 2006, the Residency Review Committee in Surgery increased the total number of endoscopy cases required before completion of general surgery residency training. This requirement is set to change further, given the new Flexible Endoscopic Curriculum that would be a requirement for applicants graduating surgical training during or after the 2017 to 2018 academic year. Given these changes, our goal was to evaluate the confidence of senior surgical residents performing flexible endoscopy. A survey was developed and sent to general surgery residents nationally, querying them regarding demographics and program-specific characteristics; additionally they were asked to rate their confidence level in performing flexible upper endoscopy and colonoscopy on a Likert scale of 1 to 5. We then compared those residents who indicated confidence (Likert scale 4-5) to those who did not (Likert scale 1-3). For the purpose of this study, only senior (postgraduate year 4 and 5) general surgery residents were assessed. We received 1176 responses from senior surgical residents: 56% of these were postgraduate year 5 residents, 65% male, 68% from University Programs, and 56% from programs associated with a Veteran's Affairs Hospital; 33% were from programs in the Northeast, 29% in the South, 24% in the Midwest, and 14% in the West; 75% were going on to additional fellowship training after the completion of residency; 42% indicated that they would go into academic practice and 32% into private practice; 66.7% reported confidence performing upper endoscopy and 52.7% reported confidence performing colonoscopy. Male gender, overall operative volume, and graduating from a medium-sized program or program in the South were associated with increased confidence performing flexible endoscopy. A large percentage of senior residents do not report confidence in performing flexible endoscopy. Although increasing the number of cases required for graduation has likely helped improve the training of residents in endoscopy, additional improvements in training are required. The Flexible Endoscopic Curriculum helps standardize the curriculum and demonstrate that the graduating resident has the fundamental knowledge and skills required in the performance of endoscopy. Simulation training and dedicated endoscopic rotations during the course of residency training could help improve endoscopy training and proficiency for future graduating residents.

Endoscopy services and training: a national survey of general surgeons.

Delivering high-quality endoscopy services depends largely on the competence of endoscopists. General surgery residency training in endoscopy and the associated quality of endoscopy services being delivered by general surgeons have been the subject of considerable controversy. In conjunction with the Canadian Association of General Surgeons (CAGS) executive board, we formulated a survey to evaluate the general state of endoscopy practice and training among general surgeons in Canada. The study was designed as a cross-sectional survey. General surgeons who are members of CAGS were selected to participate in the study and were emailed a link to the online questionnaire regarding the importance of endoscopy. They were asked to compare their training to resident training today. Sixty-nine surveys were completed. The majority of general surgeons (95.7%) indicated that endoscopy was an important skill to possess, and more than 85.5% used endoscopy in their own practices. However, nearly half (46.4%) felt that general surgery endoscopy training in Canada is currently inadequate to produce competent endoscopists. The main qualitative themes emerging from the survey were the inadequacy of current postgraduate endoscopy training (37.5%) and the absence of standardization in training (25.0%). Endoscopy is considered integral to academic and community general surgeons' practices; however, the adequacy of training seems to be questioned. Postgraduate training in endoscopy needs to be formalized and standardized, with a greater emphasis placed on teaching endoscopy.

Endoscopy training in Canadian general surgery residency programs.

Currently, general surgeons provide about 50% of endoscopy services across Canada and an even greater proportion outside large urban centres. It is essential that endoscopy remain a core component of general surgery practice and a core competency of general surgery residency training. The Canadian Association of General Surgeons Residents Committee supports the position that quality endoscopy training for all Canadian general surgery residents is in the best interest of the Canadian public. However, the means by which quality endoscopy training is achieved has not been defined at a national level. Endoscopy training in Canadian general surgery residency programs requires standardization across the country and improved measurement to ensure that competency and basic credentialing requirements are met.

Issues With “Issues in General Surgery Residency Training—2012”

Minimally Invasive Bariatric and Advanced Laparoscopy Fellowship, Department of General and Vascular Surgery, Gundersen Health System, La Crosse, WI, [email protected] Department of Bariatric Surgery, Hamilton Medical Center, Dalton, GA, Memorial Hospital, Chattanooga, TN Disclosure: Dr Kothari serves as a preceptor for Torax Medical Inc (Shoreview, MN). Dr Ponce serves as a consultant for Allergan Inc (Irvine, CA), Vibrynt Inc (Redwood City, CA), and ReShape Medical (San Clemente, CA).

Dr. James w. Fleshman and dr. Warren e. Lichliter.

Dr. James W. Fleshman is the Helen Buchanan and Stanley Joseph Seeger Endowed Professor and Chairman—Department of Surgery, Baylor University Medical Center, and Chief of Surgery at Baylor University Medical Center, Dallas, Texas. James was born in New Orleans, Louisiana, and received an MD degree from Washington University School of Medicine, St. Louis, MO. His general surgery training, which included a year of research, was conducted at The Jewish Hospital of St. Louis, Washington University School of Medicine, St. Louis, MO. He then performed a fellowship in Colon and Rectal Surgery at the University of Toronto, Toronto, Canada. In 1987, he joined the colorectal staff at Washington University School of Medicine, St. Louis, MO, and eventually became professor and section head of the division of colon and rectal surgery. In 2012, he moved to Dallas, TX, to assume his current position. Dr. Fleshman is a major force in colorectal research. In addition to being honored with the American Society of Colon and Rectal Surgeon's Young Researcher's Award in 1992, he served as the President of the American Society of Colon and Rectal Surgeons Research Foundation. He has been involved in most of the major multicenter colorectal trials including the COST (Clinical Outcomes of Surgical Therapy) trial and remains an active researcher. Dr. Fleshman is a member of and held leadership positions in multiple national surgical and colorectal societies. He has served as the president of the ASCRS (American Society of Colon and Rectal Surgeons) and the American Board of Colorectal Surgery, and is a senior member of the American Board of Surgery. Dr. Fleshman has served on the Editorial Board of Diseases of the Colon and Rectum and Annals of Surgery as well as eight other journals. He has had a long interest in cancer and has published over 161 peer-reviewed articles, 34 non–peer-reviewed articles, and 60 book chapters on this and other colorectal subjects. He has edited four textbooks, including the first edition of the ASCRS Textbook of Colon and Rectal Surgery. Dr. Fleshman maintains a very busy clinical practice in which the management of rectal cancer plays a major role. He educates medical students and surgical and colorectal residents on a daily basis. James and his wife, Linda, live in Dallas, Texas. When not working, Jim enjoys golf, reading, and spending time with his family, especially his four grandchildren. In summary, Dr. Fleshman is one of the major leaders and academic surgeons in colorectal surgery. It is an honor to know him and consider him a friend. Dr. Warren E. Lichliter is the Chief of the Department of Colon and Rectal Surgery and Colorectal Surgery Residency Director at Baylor University Medical Center, Dallas, Texas. Warren was born in Murphysbort, Illinois and did his undergraduate training at the University of Tennessee. He attended medical school at the University of Texas Medical Branch at Galveston. His general surgery residency and colorectal surgery training was performed at Baylor University Medical Center, Dallas, Texas. Following his colorectal surgery training, Dr. Lichliter joined the staff at the Baylor University and progressed to the positions listed above. Dr. Lichliter educates medical students and general surgery and colorectal residents on a daily basis and mentors trainees and junior faculty as well as conducting research. His publications include nine peer reviewed articles and he has made multiple presentations at regional and national forums. Dr. Lichliter is a fellow of the American College of Surgeons and the American Society of Colon and Rectal Surgeons (ASCRS). He has served on several important committees and as President of the North Texas Chapter of the American College of Surgeons. He is also Board Certified in General Surgery and Colon and Rectal Surgery and is listed in Best Doctors in America Warren has four children and lives with his wife in Dallas, Texas. On behalf of the readers and staff of Clinics of Colon and Rectal Surgery, I thank Dr. Fleshman and Lichliter for serving as Guest Editors and for providing us with a comprehensive update and state-of-the-art review of rectal cancer management.

Bariatric surgery and the changing current scope of general surgery practice: implications for general surgery residency training.

The scope of general surgery practice has evolved tremendously in the last 20 years. However, clinical experience in general surgery residency training has undergone relatively little change. To evaluate the current scope of academic general surgery and its implications on surgical residency. The University HealthSystem Consortium and Association of American Medical Colleges established the Faculty Practice Solution Center (FPSC) to characterize physician productivity. The FPSC is a benchmarking tool for academic medical centers created from revenue data collected from more than 90,000 physicians who practice at 95 institutions across the United States. The FPSC database was queried to evaluate the annual mean procedure frequency per surgeon (PFS) in each calendar year from 2006 through 2011. The associated work relative value units (wRVUs) were also examined to measure physician effort and skill. During the 6-year period, 146 distinct Current Procedural Terminology codes were among the top 100 procedures, and 16 of these procedures ranked in the top 10 procedures in at least 1 year. The top 10 procedures accounted for more than half (range, 52.5%-57.2%) of the total 100 PFS evaluated for each year. Laparoscopic Roux-en-Y gastric bypass was consistently among the top 10 procedures in each year (PFS, 18.2-24.6). The other most frequently performed procedures included laparoscopic cholecystectomy (PFS, 30.3-43.5), upper gastrointestinal tract endoscopy (PFS, 26.5-34.3), mastectomy (PFS, 16.5-35.0), inguinal hernia repair (PFS, 15.5-22.1), and abdominal wall hernia repair (PFS, 21.6-26.1). In all years, laparoscopic Roux-en-Y gastric bypass generated the highest number of wRVUs (wRVUs, 491.0-618.2), and laparoscopic cholecystectomy was regularly the next highest (wRVUs, 335.8-498.7). A significant proportion of academic general surgery is composed of bariatric surgery, yet surgical training does not sufficiently emphasize the necessary exposure to technical expertise and clinical management of the patient undergoing bariatric surgery. As the scope of general surgery practice continues to evolve, general surgery residency training will need to better integrate the exposure to bariatric surgery.

A national review of the frequency of minimally invasive surgery among general surgery residents: assessment of ACGME case logs during 2 decades of general surgery resident training.

Minimally invasive surgery (MIS) has created a shift in how many surgical diseases are treated. Examining the effect on resident operative experience provides valuable insight into trends that may be useful for restructuring the requirements of resident training. To evaluate changes in general surgery resident operative experience regarding MIS. Retrospective review of the frequency of MIS relative to open operations among general surgery residents using the Accreditation Council for Graduate Medical Education case logs for academic years 1993-1994 through 2011-2012. General surgery residency training among accredited programs in the United States. We analyzed the difference in the mean number of MIS techniques and corresponding open procedures across training periods using 2-tailed t tests with statistical significance set at P < .05. Of 6,467,708 operations with the option of MIS, 2,393,030 (37.0%) were performed with the MIS approach. Of all MIS operations performed, the 5 most common were cholecystectomy (48.5%), appendectomy (16.2%), groin hernia repair (10.0%), abdominal exploration (nontrauma) (4.4%), and antireflux procedures (3.6%). During the study period, there was a transition from a predominantly open to MIS approach for appendectomy, antireflux procedures, thoracic wedge resection, and partial gastric resection. Cholecystectomy is the only procedure for which MIS was more common than the open technique throughout the study period (P < .001). The open approach is more common for all other procedures, including splenectomy (0.7% MIS), common bile duct exploration (24.9% MIS), gastrostomy (25.9% MIS), abdominal exploration (33.1% MIS), hernia (20.3% MIS), lung resection (22.3% MIS), partial or total colectomy (39.1%), enterolysis (19.0% MIS), ileostomy (9.0% MIS), enterectomy (5.2% MIS), vagotomy (1.8% MIS), and pediatric antireflux procedures (35.9% MIS); P < .001. Minimally invasive surgery has an increasingly prominent role in contemporary surgical therapy for many common diseases. The open approach, however, still predominates in all but 5 procedures. Residents today must become efficient at performing multiple techniques for a single procedure, which demands a broader skill set than in the past.

Construct validation: simulation of thoracoscopic intrathoracic anastomosis.

Background and Objectives:We sought to develop a simulation model that accurately replicates the challenges of the thoracoscopic intrathoracic anastomosis. This model is intended to serve as a teaching tool during the introduction to, and development of, the skills required to perform a thoracoscopic intrathoracic anastomosis during an Ivor Lewis minimally invasive esophagectomy.Methods:The simulation model uses porcine tissue placed within an artificial hemithorax and covered with a synthetic skin. The model is draped to simulate a realistic operative setting, and ports are placed in standard surgical fashion. Dissection of the esophagus from the mediastinum is then performed, followed by the creation of an esophagogastric anastomosis. The effectiveness of the training model was evaluated using volunteer general and thoracic surgery residents at varying stages of surgical training. The quality of the anastomoses created were evaluated using both objective and subjective criteria, and successful anastomoses were tested for leaks using hydrostatic pressure.Results:Objective evaluation showed that successful completion of the anastomosis task increased with the number of attempts, with 100% of participants successfully completing an anastomosis by the final attempt. The time to completion of a successful anastomosis also improved across successive attempts. Moreover, objective measures also showed improvement over time based on the graded quality of the completed anastomosis.Conclusion:As surgical techniques continue to evolve, so must the means by which they are taught. This simulation model shows effectiveness in the training of general and thoracic surgery residents performing thoracoscopic intrathoracic anastomosis during the Ivor Lewis minimally invasive esophagectomy.

Board #305 - Technology Innovation TITUS (Thoracic Intervention Training Unit Simulator)

Introduction Procedural competency is a vital component of emergency medicine (EM) and general surgery residency training and is a dedicated focus in the ACGME Milestone Project. Chest tube thoracostomy can be an emergent lifesaving procedure that all graduating EM and general surgery residents should be competent in performing. Practicing emergent lifesaving procedures through the use of simulation affords the learner the opportunity to learn and perform these crucial actions prior to performing an invasive procedure on a live patient. Simulation manikins and devices for chest tube thoracostomy are commercially available and described in the literature, however, financial constraints and anatomical inconsistencies are potential barriers to trainees experiencing an optimal simulation experience. Educational Objectives: TITUS (Thoracic Intervention Training Unit Simulator) was developed to create a chest tube thoracostomy model that is basic to assemble, provides a lifelike experience to the learner, and is portable, affordable, and easily reusable. The aim of TITUS is to be an effective education device capable of multiple uses in a timely manner to promote proficiency in chest tube thoracostomy. Description TITUS is comprised of a plastic clothing manikin torso, supplies obtainable at a local hardware store, and basic power tools. The manikin is divided in half and attached to a stable base. A rectangular section of the manikin from the axilla/lateral chest wall is removed. A bracket assembly is attached to the inside of the manikin. When in use, a segment of porcine ribs (available at a local grocer) is placed from inside the manikin to cover the open section of the chest wall and tightly secured with the metal brackets. The materials for a TITUS cost approximately $50 (not including power tools). A single person can assemble a TITUS in two hours or less. TITUS follows anatomical landmarks given the presence of an axilla and pectoral region (simulating the “triangle of safety”) and the installed bracket assembly within TITUS allows for easy and secure loading of porcine ribs which provide realistic tactile feedback. Conclusion TITUS has been successfully used in training sessions for providers at various levels of practice. The unique design of TITUS allows for multiple providers to perform a tube thoracostomy in uncompromised tissue despite the short time allotment between groups of trainees. TITUS is easy to build and inexpensive, making it ideal for training locally and in resource-limited settings. Feedback from trainees and instructors regarding their experience with TITUS has been consistently positive. Disclosures None

Eric K. Johnson, MD, FACS, FASCRS.

Dr. Eric K. Johnson is a staff colon and rectal surgeon at Madigan Army Medical Center, Fort Lewis, WA. Eric was born in Baumholder, Germany. He received bachelor of science in biology from the University of Maryland, College Park, Maryland, and MD from the University of Maryland, Baltimore, MD. He did his General Surgery Residency training at Eisenhower Army Medical Center in Augusta, Georgia. He then completed a Colon and Rectal Residency at the Georgia Colon and Rectal Surgical Clinic in Atlanta, GA. Eric then served as Chief of Colorectal Surgery at Eisenhower Army Medical Center for 6 years. In 2011, he joined the staff at Madigan Army Medical Center. During his Army career, Dr. Johnson spent multiple deployments as a staff surgeon in Iraq and Afghanistan. He has been promoted to the rank of Colonel and he has been awarded several military decorations including the Meritorious Service Medal and the Bronze Star. Dr. Johnson is an associate professor of surgery at the Uniformed Services University of the Health Sciences in Bethesda, MD, and a clinical assistant professor of surgery at the University of Washington School of Medicine in Seattle, WA. He is board certified in General and Colon and Rectal Surgery. He teaches military surgical residents and medical students on a daily basis and is an active participant in multiple surgical societies. His contributions to the medical literature include 48 peer-reviewed publications and 7 book chapters. He has also made multiple presentations at national meetings. Eric, his wife, Amy; and his three daughters, Emily, Abigail, and Molly, live in Gig Harbor, WA. When not working, he participates in sky diving and mountain climbing. As a retired USAF surgeon, I can appreciate the dedication and sacrifices of the dedicated individuals in our armed services. We owe our freedoms and societal options to all of those who have served our country. Dr. Johnson and several of his colleagues, who remain on active duty, have contributed to this issue. Their service and contributions merit our acknowledgment and gratitude. On behalf of the readers and staff of Clinics of Colon and Rectal Surgery, I sincerely thank Dr. Eric K. Johnson for serving as a guest editor and for providing us with a superb issue on biologicals in colon and rectal surgery.

Putting Residents in the Office: An Effective Method to Teach the Systems-Based Practice Competency

Systems-based practice (SBP) was 1 of 6 core competencies established by the Accreditation Council for Graduate Medical Education and has proven to be one of the most difficult to effectively implement. This pilot study presents an immersion workshop as an effective tool to teach the SBP competency in a way that could easily be integrated into a residency curriculum. In 2006, 16 surgical residents rotated through 3 stations for 30 minutes each: coding and billing, scheduling operations and return appointments, and patient check-in. Participants were administered a pretest and posttest questionnaire evaluating their knowledge of SBP, and were asked to evaluate the workshop. Outpatient clinic at MedStar Georgetown University Hospital, Washington, DC. Residents in the general surgery residency training program at MedStar Georgetown University Hospital. Most residents (62.5%) improved their score after the workshop, whereas 31.25% showed no change and 6.25% demonstrated a decrease in score. Overall within their training levels, all groups demonstrated an increase in mean test score. Postgraduate year-2 residents demonstrated the greatest change in mean score (20%), whereas postgraduate year-4 residents demonstrated the smallest change in mean score (3.3%). An immersion workshop where general surgery residents gained direct exposure to SBP concepts in situ was an effective and practical method of integrating this core competency into the residency curriculum. Such a workshop could complement more formal didactic teaching and be easily incorporated into the curriculum. For example, this workshop could be integrated into the ambulatory care requirement that each resident must fulfill as part of their clinical training.

Global Standardization of Surgical Training.

Global Standardization of Surgical Training.

J. Marcus Downs, MD

Dr. J. Marcus Downs is a colon and rectal surgeon and program director of the Colon and Rectal Surgery Residency at the Parkland and Presbyterian Hospitals, Dallas, TX. Marcus was born in East St. Louis, IL, and received a bachelor of science in biology from the Washington University in St. Louis and a MD degree from the University of Missouri, Columbia. He did 3 years of General Surgery Residency training at the University of Missouri, Columbia, then completed his residency at Wilford Hall USAF Medical Center, San Antonio, TX. Marcus then completed a Colon and Rectal Residency at the Presbyterian and Parkland Hospitals, Dallas, TX. After finishing his training, he served as a deputy chair in the Department of Surgery, USAF Medical Center Scott, at Scott AFB, IL. In 1993, Dr. Downs left the USAF and joined the staff at the Texas Health Presbyterian Hospital in Dallas, TX. He has been a member of the teaching faculty since returning to Dallas and has been program director of the Residency Program in Colon and Rectal Surgery since 2007. Dr. Downs is an assistant clinical professor of surgery at the University of Texas Southwestern Medical School, Dallas, TX, and is board certified in General and Colon and Rectal Surgery. He teaches surgical residents and medical students on a daily basis and is an active participant in multiple surgical societies. He is the former president of the Texas Society of Colon and Rectal Surgeons. His contributions to the medical literature include two peer-reviewed publications and several presentations at regional and national meetings. In 1994, he and his associates formed Texas Colon and Rectal Surgeons had a single specialty group, which now includes 13 surgeons. Marcus, his wife Carol Lee, and children, Colleen (27 years old) and Brian (24 years old), live in Dallas, TX. When not working, Marcus enjoys swimming with Dallas Aquatic Masters, and playing polo with Dallas Water Polo Club. On behalf of the readers and staff of Clinics of Colon and Rectal Surgery, I sincerely thank Dr. Downs for serving as a guest editor and for providing us with a superb issue on fecal incontinence.

Research Productivity of Residents and Surgeons With Formal Research Training

The spectrum of the surgeon-scientist ranges from a clinician who participates in the occasional research collaboration to the predominantly academic scientist with no involvement in clinical work. Training surgeon-scientists can involve resource-intense and lengthy training programs, including Masters and PhD degrees. Despite high enrollment rates in such programs, limited data exist regarding their outcome. The aim of the study was to investigate the scientific productivity of general surgeons who completed Masters or PhD graduate training compared with those who completed clinical residency training only. A retrospective cohort study of graduates of general surgery residency was conducted over 2 decades. Data regarding graduation year, dedicated research training type, as well as publication volume, authorship role, and publication impact of surgeons during and after training, were analyzed. The study was conducted in 2 general surgery residency training programs in Canada (University of Alberta and University of Toronto). A cohort of 323 surgeons who completed general surgery residency between 1998 and 2012. Overall, 25% of surgeons obtained graduate-level research degrees. Surgeons with graduate degrees were proportionately more likely to participate in research publications both during training (100% of PhD, 82% of Masters, and 38% of clinical-only graduates, p < 0.05) and after training (91% of PhD, 81% of Masters, and 44% of clinical-only graduates, p < 0.05). Among surgeons involved in publication, the individual publication volume and impact of publication were highest among those with PhD degrees, as compared with clinical-only or Masters training. The volume and impact of research publication of PhD-trained surgeon-scientists are significantly higher than those having clinical-only and Masters training. The additional 1 or 2 years of training to obtain a PhD over a Masters degree significantly nurtures trainees to hone research skills within a supervised environment and should be encouraged for research-inclined residents.

Accreditation Council for Graduate Medical Education Case Log: General Surgery Resident Thoracic Surgery Experience

General surgery resident training has changed dramatically over the past 2 decades, with likely impact on specialty exposure. We sought to assess trends in general surgery resident exposure to thoracic surgery using the Accreditation Council for Graduate Medical Education (ACGME) case logs over time. The ACGME case logs for graduating general surgery residents were reviewed from academic year (AY) 1989-1990 to 2011-2012 for defined thoracic surgery cases. Data were divided into 5 eras of training for comparison: I, AY89 to 93; II, AY93 to 98; III, AY98 to 03; IV, AY03 to 08; V, AY08 to 12. We analyzed quantity and types of cases per time period. Student t tests compared averages among the time periods with significance at a pvalues less than 0.05. A total of 21,803,843 general surgery cases were reviewed over the 23-year period. Residents averaged 33.6thoracic cases each in period I and 39.7 in period V. Thoracic cases accounted for nearly 4% of total cases performed annually (period I 3.7% [134,550 of 3,598,574]; period V 4.1% [167,957 of 4,077,939]). For the 3 most frequently performed procedures there was a statistically significant increase in thoracoscopic approach from period II to period V. General surgery trainees today have the same volume of thoracic surgery exposure as their counterparts over the last 2 decades. This maintenance in caseload has occurred in spite of work-hour restrictions. However, general surgery graduates have a different thoracic surgery skill set at the end of their training, due to the predominance of minimally invasive techniques. Thoracic surgery educators should take into account these differences when training future cardiothoracic surgeons.

The impact of an acute care surgery team on general surgery residency

BackgroundAcute care surgical teams (ACSTs) have limited data in residency. We sought to determine the impact of an ACST on the depth and breadth of general surgery resident training. MethodsOne year prior to and after implementation of an ACST, Accreditation Council for Graduate Medical Education case logs spanning multiple postgraduate year levels were compared for numbers, case types, and complexity. ResultsWe identified 6,009 cases, including 2,783 after ACST implementation. ACSTs accounted for 752 cases (27%), with 39.2% performed laparoscopically. ACST cases included biliary (19.4%), skin/soft tissue (10%), hernia (9.8%), and appendix (6.5%). Second-year residents performed a lower percentage of laparoscopic cases after the creation of the ACST (20.4% vs 26.3%; P = .003), while chief residents performed a higher percentage (42.1 vs 37.4; P = .04). Case numbers and complexity following ACST development were unchanged within all year groups (P > .1). ConclusionACST in a residency program does not sacrifice resident case complexity, diversity, or volume.

James Yoo, MD, FACS, FASCRS.

Dr. James Yoo is a colon and rectal surgeon and Chief of Division of Colon and Rectal Surgery, Tuffs Medical Center, Boston, MA. Dr. James Yoo received bachelor of science in biology from Brown University, Providence, RI, and MD from Mount Sinai School of Medicine in New York, NY. He did his General Surgery Residency training at Beth Israel Deaconess Medical Center, Boston, MA, which included 2 years of research at Harvard University in Boston and the University of Cincinnati in Cincinnati, OH. Following residency, he did a laparoscopic colon and rectal fellowship at Weill Cornell Medical College, New York, NY, followed by a clinical residency in colon and rectal surgery at New York-Presbyterian Hospital in New York, NY. Following his training, Dr. Yoo joined the UCLA School of Medicine in California as an assistant professor and advanced to be Chief, Section of Colon and Rectal Surgery in the UCLA Department of Surgery. In 2014, he moved to Tufts Medical Center and assumed his current position. Dr. Yoo is an associate professor of surgery at Tufts University and is board certified in general and colon and rectal surgery. He teaches fellows, residents, and medical students on a daily basis and is an active participant in multiple surgical societies. He currently serves as chairman of the American Society of Colon and Rectal Surgery (ASCRS) Awards committee. Dr. Yoo is an active researcher and has received NIH KO8 Mentored Clinical Scientist Research Career Development Award. He serves on the editorial board of the Journal of Surgical Research and the American Journal of Digestive Disease. His contributions to the medical literature include 19 peer-reviewed publications, 5 review articles, 3 book chapters, and multiple presentations at national meetings. Dr. Yoo and his wife, Shirley Y. Huang, MD, live in Boston. Academic activities and research play an increasing role in colon and rectal surgery. On behalf of the readers and staff of Clinics of Colon and Rectal Surgery, I sincerely thank Dr. Yoo for serving as a guest editor and for providing us with a superb issue on developing a career in colon and rectal surgery.

Does Intentional Support of Degree Programs in General Surgery Residency Affect Research Productivity or Pursuit of Academic Surgery?

Many residents supplement general surgery training with years of dedicated research, and an increasing number at our institution pursue additional degrees. We sought to determine whether it was worth the financial cost for residency programs to support degrees. We reviewed graduating chief residents (n = 69) in general surgery at Vanderbilt University from 2001 to 2010 and collected the data including research time and additional degrees obtained. We then compared this information with the following parameters: (1) total papers, (2) first-author papers, (3) Journal Citation Reports impact factors of journals in which papers were published, and (4) first job after residency or fellowship training. The general surgery resident training program at Vanderbilt University is an academic program, approved to finish training 7 chief residents yearly during the time period studied. Chief residents in general surgery at Vanderbilt who finished their training 2001 through 2010. We found that completion of a degree during residency was significantly associated with more total and first-author publications as compared with those by residents with only dedicated research time (p = 0.001 and p = 0.017). Residents completing a degree also produced publications of a higher caliber and level of authorship as determined by an adjusted resident impact factor score as compared with those by residents with laboratory research time only (p = 0.005). Degree completion also was significantly correlated with a first job in academia if compared to those with dedicated research time only (p = 0.046). Our data support the utility of degree completion when economically feasible and use of dedicated research time as an effective way to significantly increase research productivity and retain graduates in academic surgery. Aggregating data from other academic surgery programs would allow us to further determine association of funding of additional degrees as a means to encourage academic productivity and retention.

Jeffery M. Nelson, MD, FACS, FASCRS

Dr. Jeffery Nelson is a colon and rectal surgeon and chief of surgery at Walter Reed National Military Medical Center, Bethesda, MD. Jeffery was born in Ogden, UT, and received a bachelor of science in chemistry and a MD degree from the University of Utah in Salt Lake City, UT. He did his General Surgery Residency training at Tripler Army Medical Center in Hawaii. He then served for 2 years as a staff general surgeon at Landstuhl Regional Medical Center, Landstuhl, Germany. Following this service, Jeffery completed a Colon and Rectal Residency at the Northwest Colon and Rectal Clinic, Seattle, WA. Dr. Nelson then joined the staff at Walter Reed Army Medical Center in 2001, as chief of colon and rectal surgery and progressed to become chief of surgery. During his Army career, Jeffery spent multiple deployments as a staff surgeon in Iraq and other overseas locations. He has been promoted to the rank of colonel and he has been awarded several military decorations including three Meritorious Service Medals and the Bronze Star. Dr. Nelson is an associate professor of surgery at the Uniformed Services University of the Health Sciences in Bethesda, MD, and is board certified in General and Colon and Rectal Surgery. He teaches military surgical residents and medical students on a daily basis and is an active participant in multiple surgical societies. His contributions to the medical literature include 13 peer-reviewed publications and he has made multiple presentations at national meetings. Jeffery, his wife, LTC Sarah J. Krajnik (who also serves in the Army National Guard), and his two children Ariana (8 years old) and Emily (5 years old) live in Laurel, MD. When not working, Jeffery is active in Crossfit (pretty much every day) and long-distance running. He also likes to read on American history and enjoys cooking. As a retired USAF surgeon, I can appreciate the dedication and sacrifices of the dedicated individuals in our armed services. We owe our freedoms and societal options to all of those who have served our country. Jeffery and several of his colleagues, who remain on active duty, have contributed to this issue. Their service and contributions merit our acknowledgment and gratitude. On behalf of the readers and staff of Clinics of Colon and Rectal Surgery, I sincerely thank Dr. Nelson for serving as a guest editor and for providing us with a superb issue on Quality in Colon and Rectal Surgery.