General Surgical Residency Programs Research Articles

Right Case, Right Time: Which Procedures Best Differentiate General Surgery Trainees’ Operative Performance?

Assessing surgical trainee operative performance is time- and resource-intensive. To maximize the utility of each assessment, it is important to understand which assessment activities provide the most information about a trainee's performance. The objective of this study is to identify the procedures that best differentiate performance for each general surgery postgraduate year (PGY)-level, leading to recommendations for targeted assessment. The Society for Improving Medical Professional Learning (SIMPL) operative performance ratings were modeled using a multilevel Rasch model which identified the highest and lowest performing trainees for each PGY-level. For each procedure within each PGY-level, a procedural performance discrimination index was calculated by subtracting the proportion of "practice-ready" ratings of the lowest performing trainees from the proportion of "practice-ready" ratings of the highest performing trainees. Four-quadrant plots were created using the median procedure volume and median discrimination index for each PGY-level. All procedures within the upper right quadrant were considered "highly differentiating, high volume" procedures. This study was conducted across 70 general surgical residency programs who are members of the SIMPL collaborative. A total of 54,790 operative performance evaluations of categorical general surgery trainees were collected between 2015 and 2021. Trainees who had at least 1 procedure in common were included. Procedures with less than 25 evaluations per training year were excluded. The total number of evaluations per procedure ranged from 25 to 2,131. Discrimination values were generated for 51 (PGY1), 54 (PGY2), 92 (PGY3), 105 (PGY4), and 103 (PGY5) procedures. Using the above criteria, a total of 12 (PGY1), 15 (PGY2), 22 (PGY3), 21 (PGY4), and 28 (PGY5) procedures were identified as highly differentiating, high volume procedures. Our study draws on national data to identify procedures which are most useful in differentiating trainee operative performance at each PGY-level. This list of procedures can be used to guide targeted assessment and improve assessment efficiency.

Availability of Operative Surgical Experience and Supervision for Competency-Based Education: A Review of A General Surgery Program at A Tertiary Care Teaching Hospital in Pakistan.

In view of importance for competency-based education (CBE), we undertook a self-study to elicit the available operative surgical workload and supervision for residents in the general surgical residency program at the teaching hospital in Karachi. This was a cross-sectional study spanning a 5-year period between January 2015 and December 2019. The numbers of surgical residents during this period were identified. Five procedures were selected as core general surgical procedures: incision and drainage of superficial abscess, laparoscopic appendectomy, laparoscopic cholecystectomy, open inguinal hernia repair, and perianal procedures. Trends of the number of residents per year and the numbers of procedures per year were determined. The mean number of core procedures per eligible resident during their entire training was calculated to represent potential operative surgical experience and were benchmarked. The ratio of the average number of residents rotating in general surgery per year to the number of attending surgeons was determined as a measure of available supervision. The mean total number of general surgical residents per year was 31.2 (range 28-35). The numbers of core general surgical procedures were consistent over the years of study. Potential exposure of eligible residents to each core procedure during their entire training was: 19.5 cases for incision and drainage of superficial abscess; 89 cases for laparoscopic appendectomy; 113.6 for inguinal hernia repair, 267.5 for laparoscopic cholecystectomy and 64.5 for perianal procedures. The average yearly residents to full-time attending surgeons' ratio was 2.5. The workload of core general surgical procedures at AKUH was higher than the Accreditation Council for Graduate Medical Education (ACGME) recommended volumes for operative surgical experience for residents in the US. This method of assessing the potential of a surgical program for transitioning to CBE appears practical and can be generalized.

Acceptability and perceived effectiveness of a single-session mindfulness intervention for medical residents

Introduction: Medical residents report high levels of stress, with many work-related demands contributing to their experience of heightened stress. Mindfulness training has been suggested as a beneficial strategy for stress management with residents; however, many mindfulness programs are time-consuming, and compliance with conventional mindfulness training programs becomes challenging given the intense, competing time commitments of residency. The present study sought to evaluate the acceptability and perceived effectiveness of a single-session, mindfulness-based stress management workshop for medical residents.Methods: Residents (n = 142) from family medicine, internal medicine and general surgical residency programs participated in a 1.5-hour mindfulness workshop in 2016 and completed: a measure of workshop satisfaction immediately post-workshop; a measure of adherence to suggested strategies 4–6 weeks post-workshop; and measures of stress, mindfulness and positive and negative affect immediately post-workshop and 4–6 weeks post-workshop.Results: Results revealed high levels of satisfaction with the workshop. Participants who used the recommended strategies over the 4 to 6-week post-workshop period reported significant increases in mindfulness and significant decreases in stress at follow-up.Conclusions: Results suggest single-session mindfulness training can be beneficial for residents who use the strategies effectively; however, ensuring strategy use following training is challenging. Future research is needed to investigate facilitators and barriers to strategy use.

Can Better Selection Tools Help Us Achieve Our Diversity Goals in Postgraduate Medical Education? Comparing Use of USMLE Step 1 Scores and Situational Judgment Tests at 7 Surgical Residencies.

Use of the United States Medical Licensing Examination (USMLE) for residency selection has been criticized for its inability to predict clinical performance and potential bias against underrepresented minorities (URMs). This study explored the impact of altering traditional USMLE cutoffs and adopting more evidence-based applicant screening tools on inclusion of URMs in the surgical residency selection process. Multimethod job analyses were conducted at 7 U.S. general surgical residency programs during the 2018-2019 application cycle to gather validity evidence for developing selection assessments. Unique situational judgment tests (SJTs) and scoring algorithms were created to assess applicant competencies and fit. Programs lowered their traditional USMLE Step 1 cutoffs and invited candidates to take their unique SJT. URM status (woman, racial/ethnic minority) of candidates who would have been considered for interview using traditional USMLE Step 1 cutoffs was compared with the candidate pool considered based on SJT performance. A total of 2,742 general surgery applicants were invited to take an online SJT by at least 1 of the 7 programs. Approximately 35% of applicants who were invited to take the SJT would not have met traditional USMLE Step 1 cutoffs. Comparison of USMLE-driven versus SJT-driven assessment results demonstrated statistically different percentages of URMs recommended, and including the SJT allowed an average of 8% more URMs offered an interview invitation (P < .01). Reliance on USMLE Step 1 as a primary screening tool precludes URMs from being considered for residency positions at higher rate than non-URMs. Developing screening tools to measure a wider array of candidate competencies can help create a more equitable surgical workforce.

Using Audience Response Systems for Real-Time Learning Assessments During Surgical Morbidity and Mortality Conference

Morbidity and mortality (M&M) conference is a mainstay of surgical education. However, its effectiveness is poorly described. The purpose of this study was to demonstrate the feasibility of a real-time audience response system for learner assessment during M&M. We integrated a web-based audience response system into weekly M&M conference. First, this platform collected qualitative responses about the role of M&M. Then, we used the platform to direct questions to attendees in real time. Questions focused on surgical risk estimation and classifying root causes. Responses were grouped by training and compared to a validated risk tool's prediction. Root cause assignment concordance was statistically compared using Cohen's kappa between the pluralities of faculty responses to that of trainees. General surgical residency program based at a tertiary academic medical center. Affiliated categorical residents, preliminary residents, and clinical fellows. We enrolled 110 participants (38 faculty, 31 senior trainees, and 41 trainees). The majority of respondents (75.9%) cited education as the purpose of M&M, and all of respondents stated education as their personal motivation. Audience response questions were integrated into 34 unique case presentations. Mean absolute differences between predicted complication rates and attendees' predictions were highest for faculty (-9.4%, p = 0.009) and lowest for junior residents (-1.8%, p = 0.385). When assigning root cause of each morbidity, concordance between faculty and trainees was low to moderate (K = 0.41). Assessment of learning during M&M can be performed in real time with discrimination observed by learner experience level. These data support development of this response platform to trend learner performance over time and to monitor targeted educational interventions at future M&Ms.

Teaching speed in the operative theatre: Should case duration benchmark efficiency in general surgical residency programs?

BackgroundTraining surgical residents remains an important mission of academic medical centers. Today, financial pressures guide improved operating room (OR) efficiency and theoretically may affect surgical education. There is no current benchmark with regards to operative time and surgical cases involving General Surgical Residents. Study design971 laparoscopic surgical cases were reviewed for total operative time, closing time, length of stay and 30-day readmission rates. T-test of means and regression analyses were done involving surgical times and point in time during the academic year of the surgical program to gauge whether efficiency improvements exist in the program. Regressions were also done comparing surgical times (total operative and closing time to outcome measures: length of stay, 30-day readmission, and log cost). ResultsResidents had significantly longer procedure times compared to the year prior to commencement of the program where attending surgeons operated without residents by mean t-test (p<0.05). Length of stay increased as total operative time increased in 4 of the 6 category cohort of cases that general surgical residents were involved (p<0.05). There was no improvement in closing time among residents throughout the academic year of their program nor when comparing successive program years.There were strong and statistically significant correlations between total operative time and cost. ConclusionResident participation contributes to increased procedure time and cost for common laparoscopic general surgical procedures. There is also a link between outcomes as measured by length of stay and total operative time. Consequently teaching and/or maintaining efficiency standards may be paramount to maintaining better outcomes. General surgical residency programs may consider benchmarking operative and/or closing times in guiding efficiency in their programs.

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.

The Effect of a New Surgery Residency Program on Case Volume and Case Complexity in a Sub-Saharan African Hospital

Improved access to surgical care could prevent a significant burden of disease and disability-adjusted life years, and workforce shortages are the biggest obstacle to surgical care. To address this shortage, a 5-year surgical residency program was established at Kamuzu Central Hospital (KCH) in July 2009. As the residency enters its fourth year, we hypothesized that the initiation of a general surgical residency program would result in an increase in the overall case volume and complexity at KCH. We conducted a retrospective analysis of operated cases at KCH during the 3 years before and the third year after the implementation of the KCH surgical residency program, from July 2006 to July 2009 and the calendar year 2012, respectively. During the 3 years before the initiation of the surgical residency, an average of 2317 operations were performed per year, whereas in 2012, 2773 operations were performed, representing a 20% increase. Before residency, an average of 1191 major operations per year were performed, and in 2012, 1501 major operations were performed, representing a 26% increase. Our study demonstrates that operative case volume and complexity increase following the initiation of a surgical residency program in a sub-Saharan tertiary hospital. We believe that by building on established partnerships and emphasizing education, research, and clinical care, we can start to tackle the issues of surgical access and care.

The Unmet Need for a National Surgical Quality Improvement Curriculum: A Systematic Review

The Accreditation Council for Graduate Medical Education Next Accreditation System will require general surgery training programs to demonstrate outstanding clinical outcomes and education in quality improvement (QI). The American College of Surgeons-National Surgical Quality Improvement Project Quality In-Training Initiative reports the results of a systematic review of the literature investigating the availability of a QI curriculum. Using defined search terms, a systematic review was conducted in Embase, PubMed, and Google Scholar (January 2000-March 2013) to identify a surgical QI curriculum. Bibliographies from selected articles and other relevant materials were also hand searched. Curriculum was defined as an organized program of learning complete with content, instruction, and assessment for use in general surgical residency programs. Two independent observers graded surgical articles on quality of curriculum presented. Overall, 50 of 1155 references had information regarding QI in graduate medical education. Most (n = 24, 48%) described QI education efforts in nonsurgical fields. A total of 31 curricular blueprints were identified; 6 (19.4%) were specific to surgery. Targeted learners were most often post graduate year-2 residents (29.0%); only 6 curricula (19.4%) outlined a course for all residents within their respective programs. Plan, Do, Study, Act (n = 10, 32.3%), and Root Cause Analysis (n = 5, 16.1%) were the most common QI content presented, the majority of instruction was via lecture/didactics (n = 26, 83.9%), and only 7 (22.6%) curricula used validated tool kits for assessment. Elements of QI curriculum for surgical education exist; however, comprehensive content is lacking. The American College of Surgeons-National Surgical Quality Improvement Project Quality In-Training Initiative will build on the high-quality components identified in our review and develop data-centered QI content to generate a comprehensive national QI curriculum for use in graduate surgical education.

Surgeons' Attitude Toward a Competency-Based Training and Assessment Program: Results of a Multicenter Survey

Currently, most surgical training programs are focused on the development and evaluation of professional competencies. Also in the Netherlands, competency-based training and assessment programs were introduced to restructure postgraduate medical training. The current surgical residency program is based on the Canadian Medical Education Directives for Specialists (CanMEDS) competencies and uses assessment tools to evaluate residents' competence progression. In this study, we examined the attitude of surgical residents and attending surgeons toward a competency-based training and assessment program used to restructure general surgical training in the Netherlands in 2009. In 2011, all residents (n = 51) and attending surgeons (n = 108) in 1 training region, consisting of 7 hospitals, were surveyed. Participants were asked to rate the importance of the CanMEDS competencies and the suitability of the adopted assessment tools. Items were rated on a 5-point Likert scale and considered relevant when at least 80% of the respondents rated an item with a score of 4 or 5 (indicating a positive attitude). Reliability was evaluated by calculating the Cronbach's α, and the Mann-Whitney test was applied to assess differences between groups. The response rate was 88% (n = 140). The CanMEDS framework demonstrated good reliability (Cronbach's α = 0.87). However, the importance of the competencies 'Manager' (78%) and 'Health Advocate' (70%) was undervalued. The assessment tools failed to achieve an acceptable reliability (Cronbach's α = 0.55), and individual tools were predominantly considered unsuitable for assessment. Exceptions were the tools 'in-training evaluation report' (91%) and 'objective structured assessment of technical skill' (82%). No significant differences were found between the residents and the attending surgeons. This study has demonstrated that, 2 years after the reform of the general surgical residency program, residents and attending surgeons in a large training region in the Netherlands do not acknowledge the importance of all CanMEDS competencies and consider the assessment tools generally unsuitable for competence evaluation.

Attitudes and Practices of Surgery Residency Program Directors Toward the Use of Social Networking Profiles to Select Residency Candidates: A Nationwide Survey Analysis

To determine whether residency program directors (PDs) of general surgery and surgical subspecialties review social networking (SN) websites during resident selection. A 16-question survey was distributed via e-mail (Survey Monkey, Palo Alto, California) to 641 PDs of general surgery and surgical subspecialty residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME). Institutions with ACGME-accredited general surgery and surgical subspecialty residency programs. PDs of ACGME-accredited general surgery and surgical subspecialty residency programs. Two hundred fifty (39%) PDs completed the survey. Seventeen percent (n = 43) of respondents reported visiting SN websites to gain more information about an applicant during the selection process, leading 14 PDs (33.3%) to rank an applicant lower after a review of their SN profile. PDs who use SN websites currently are likely to continue (69%), whereas those who do not use SN currently might do so in the future (yes 5.4%, undecided 44.6%). Online profiles displayed on SN websites provide surgery PDs with an additional avenue with which to evaluate highly competitive residency applicants. Applicants should be aware of the expansion of social media into the professional arena and the increasing use of these tools by PDs. SN profiles should reflect the professional standards to which physicians are held while highlighting an applicant's strengths and academic achievements.

Service or Education

To elicit and compare surgical resident and program director (PD) perspectives on service and education in surgical training and the conditions that influence these opinions. Cross-sectional, multi-institutional national study conducted through an online survey. General surgical residency programs in the United States. General surgical residents and PDs. Resident and PD perspectives on the circumstances, conditions, and context in which activities are perceived as service vs education. Respondents scored 24 resident activities on 5-point Likert scales and commented on conditions that influenced these scores. From 17 residency programs, 105 of 218 PDs (48.4%) responded, and 407 of 645 residents (63.1%) responded. Compared with residents, PDs rated 21 of 24 activities (87.5%) as more educational than service (P ≤ .05). In more than half these activities, notable minorities (≥ 25%) of residents stated that these activities were service and educational, depending on factors that included the particular attending physician, case complexity, and experience with the activity. Postgraduate year seniority correlated with service and educational perceptions in 12 activities (P < .05). Attending physician teaching and learning environment correlated positively (P < .05) with perception as educational in 8 and 5 activities, respectively. This study demonstrated significant differences in service and education definitions for PDs and residents. The implication that these activities are mutually exclusive may devalue residents' perceptions of the importance of patient care as an essential component of surgical competency. In an era of diminished work hours and continuity of care, educators must teach residents to appreciate the educational value in providing care for all patients and develop a sense of patient ownership in both faculty and residents.

Medical Student Mentorship in a University Setting as a Strategy for a Career in Surgery

Gender balance in surgery is a respectable and necessary goal. At the University of Louisville (UL) School of Medicine, we have compared percentages of UL medical student applicants to general surgery or surgical subspecialty residency programs, surgical residents, and surgical faculty with the rest of the nation. Although UL has at times paralleled or exceeded the nation in many of these categories, there is room for improvement and the comparison data allow for strategic planning initiatives. To promote gender balance among future generations of surgeons at UL, we recently implemented a mentoring program that pairs medical students with residents and faculty in surgery. We plan to track the success over time and correct any shortcomings of this program. Virginia Commonwealth University's commitment to gender balance in surgery is exemplary. As part of a more comprehensive vision to create a mentorship program for female medical students at the UL School of Medicine, we have recently recruited female surgical residents and faculty, whom we hope will provide the type of inspiration and guidance that will increase the number of women from UL who decide to train in general surgery and the surgical specialties. To understand why women across the nation are not generally at numerical parity in these fields, it is important to consider the length and intensity of the surgical residency programs in the context of the other goals and objectives that a woman might have for her future. This article does not address this broad topic but provides a perspective of how a medical school can evaluate and perhaps intervene to mentor medical students more effectively about the satisfaction derived from a career in surgery. As part of this project, we have evaluated each step of the path through medical school and a surgical residency by comparing data for our students, residency programs, and faculty with national data.

Integrating Population Health Into a General Surgical Residency Curriculum

Abstract The once disparate fields of public health and medicine are slowly converging and reintegrating. Public health principles of community interventions and partnerships to effect better population health are included in the curricula of more medical schools. For graduate medical education, the specialties of internal medicine, family medicine, and preventive medicine are intuitively obvious population health partners, whereas surgeons have been relatively silent in this area. Despite the fact that many common surgical diseases are directly attributable to preventable causes, including cancer, trauma, and obesity, surgical residents receive little formal population health education. However, surgeons have always been and are increasingly active within the public health sphere. Examples of surgical population health initiatives include trauma systems development and improvement, research on disparities, and global health initiatives, including disaster relief. This article describes a single institution experience utilizing modest curriculum changes, increased global health opportunities, and direct service learning to help integrate population health principles into a general surgical residency program.

The Impact Of Vascular And Endovascular Simulation On Perception And Interest Level Of Junior Level Residents

Introduction: To study the impact of a vascular and endovascular simulation curriculum on attitudes and interest level of junior level trainees of a general surgical residency program. Methods: Twenty-three junior residents from the Hospital of the University of Pennsylvania undergoing surgical simulation for the vascular and endovascular surgery block were evaluated. The session consisted of both didactic as well as practicum components. The residents were taken through the conduct of vascular anastomoses, endovascular stent graft deployment and endovascular intervention.

Surgery in the Horn of Africa

To describe the 1-year experience of a unique postgraduate medical education program set in Eritrea, a recently war-torn country. The Partnership for Eritrea, a cooperative between The George Washington University Medical Center, Physicians for Peace, and the Eritrean Ministry of Health, formed a surgical residency program, launched January 2, 2008, in Asmara, Eritrea, to train native Eritrean surgeons. No prior residency program (to our knowledge) had existed in Eritrea. Eritrea, a country in the Horn of Africa. Five Eritrean physicians participated in the surgical residency. The number of operations performed, length of stay, antibiotic use, and intravenous fluid use. The number of operations increased and resource use decreased because of improved and standardized clinical management. The Partnership for Eritrea established a general surgical residency program that improved clinical care in a resource-poor country that previously had lacked postgraduate training. The program experience suggests a model that can be reproduced in other developing countries.

Are General Surgery Residency Programs Likely to Prepare Future Rural Surgeons?

Too few surgeons practice in small rural areas of the United States. Many newly graduating surgeons choose not to practice rurally because they feel unprepared for rural practice. Family medicine residencies have a track record of placing graduates in rural settings. Their experience shows that having a stated interest in training rural physicians, a rural-focused curriculum, and rural practice exposure opportunities are successful elements for graduating physicians who practice rurally. To describe the extent to which general surgery residency training is likely to prepare future rural surgeons using criteria cited in reviews of rural family medicine residency programs. Three criteria were used to assess whether general surgery residency programs are positioned to produce rural surgeons: rural location, rural-focused curriculum, and self-identified interest in rural training. Several search strategies were employed to identify residency programs that meet the criteria. Additionally, data extracted from the American Medical Association's Physician Masterfile was used to determine demographic characteristics of residency programs that have trained surgeons who currently practice rurally. Overall, 25 general surgery residency programs meet at least 1 of the 3 criteria. This finding represents approximately 10% of all residency programs in the United States. Residency programs located in the Midwest and the South have generally been more successful in graduating surgeons who are practicing rurally than those situated in the Northeast and West. Although a few general surgery residency programs have been successful in graduating surgeons who practice rurally, there has not been a coordinated effort among programs to accomplish this goal. Our findings suggest a need for organization and coordination among those programs committed to training surgeons for rural practice. The creation of a consortium of general surgical residency programs with an interest in training rural surgeons could be a useful first step in this process.

Hepato-pancreato-biliary training in general surgery residency: is it enough for the real world?

Background Advanced training in hepato-pancreato-biliary (HPB) surgery is available at select centers. No approved fellowships have yet been established. Objective To determine the level of training in HPB surgery during general surgery residency and to assess the need for additional training. Method All general surgical residency programs in the United States were surveyed. Resident Review Committee (RRC) and International Hepato-Pancreato-Biliary Association (IHPBA) requirements were compared to Accreditation Council of Graduate Medical Education (ACGME) data. Results Eighty of 250 general surgical residency programs (32%) responded to the survey. Eighty percent felt their graduating residents had sufficient HPB training. The average number of pancreatic cases per graduating resident was 10.2 ± 7.3. The average number of hepatic resections was 8.6 ± 5.1, and for complex biliary cases, 5.3 ± 1.3. Conclusions A significant portion of HPB surgery is performed at transplant centers or by HPB surgeons. Guidelines must be established to assure adequate training. When HPB surgery is the main focus of the future practice, residents should seek additional training.

Motivation to Pursue Surgical Subspecialty Training: Is There a Gender Difference?

Few studies have examined whether women and men identify the same factors as important in choosing their specialty. We sought to evaluate whether the factors influencing residents' choice of surgical specialty differed by gender. A 32-item Web survey, designed to elucidate which factors motivated residents to seek fellowship training, was sent to 99 graduates of a university general surgery program, all of whom matriculated between 1985 and 2006. A total of 74 (75%) respondents replied (16 women, 58 men). There was a higher proportion of men who pursued fellowship training than women (69% versus 38%, p=0.04), but there was no significant difference in those who were currently in academic practice (men, 46% versus women, 27%, p=0.2). Both genders were equally likely to respond that interest in and intellectual appeal of their field, clinical opportunities in that field, and having an influential mentor during residency were important in choosing their future specialty. But significantly more women listed lifestyle as an important factor in choosing their future careers (69% versus 43%, p=0.03). When respondents' data from the most recent decade were analyzed, there was no difference between genders in completion of fellowship training or in those in academic practice. But lifestyle continued to be more important to women. Both genders were influenced by many similar factors when deciding to pursue subspecialty training, but women were more likely than men to be influenced by their perception of the lifestyle associated with their career choice. These findings suggest that general surgical residency programs might improve efforts to recruit women by addressing the perception of the lifestyle associated with choosing a surgical career.

P119: When is it enough? A survey of academic surgeons about end-of- life care

Introduction: Little is known about surgeon’s experience, attitudes and beliefs about advance directives and end of life care. Methods: We developed a 4- page survey designed to understand attitudes and practices of discussing withdrawing or withholding therapy, advance directives, and do not resuscitate orders in surgical patients. We also examined the impact of ICU staffing models and resident education in end-of-life care. We surveyed surgeons affiliated with accredited general surgical residency programs in New England.