Surgical Attendings Research Articles

Opioid Prescribing Behaviors Among Surgical Intensive Care Unit Attending Physicians.

More than 5 million Americans misuse opioids. Six percent of patients who receive opioids for acute pain progress to chronic use; this increases with higher doses and longer prescriptions. Prescribing variation exists within trauma centers and after emergency surgery but has not been demonstrated among intensivists. Milligram morphine equivalents (MME) per patient-ICU-day provided by eleven surgical intensivists were analyzed. The patients were separated into 2 groups based on their percentage of time intubated in the surgical ICU. Both study groups were compared using demographics and comorbidity scores. The attendings were divided into high- and low-prescribing groups based on their MME/pt-ICU-day for intubated patients, and bivariate statistical analyses were performed. A similar analysis compared surgery vs anesthesia intensivists. The analysis included 257 patients in the "long-vent group" (LVG) and 668 patients in the "short-vent group" (SVG). The average MME/pt-ICU-day for the LVG was 222. Despite no significant differences in age, sex, or Elixhauser Comorbidity Index, there was a 45% difference between the high- and low-prescribing physicians in the LVG (253.7 vs 175.4 MME/pt-ICU-day; P = .008). This difference was not observed for patients in the SVG (74.3 vs 93.1 MME/pt-ICU-day; P = .141) nor based on intensivist specialty (LVG: 217.9 vs 209.5 MME/pt-ICU-day; P = .8) (SVG: 79.0 vs 93.3 MME/pt-ICU-day; P = .288).

Attitudes about use of preoperative risk assessment tools: a survey of surgeons and surgical residents in an academic health system

BackgroundFormal surgical risk assessment tools have been developed to predict risk of adverse postoperative patient outcomes. Such tools accurately predict common postoperative complications, inform patients and providers of likely perioperative outcomes, guide decision making, and improve patient care. However, these are underutilized. We studied the attitudes towards and techniques of how surgeons preoperatively assess risk.MethodsSurgeons at a large academic tertiary referral hospital and affiliate community hospitals were emailed a 16-question survey via REDCap (Research Electronic Data Capture) between 8/2019-6/2020. Reminder emails were sent once weekly for three weeks. All completed surveys by surgical residents and attendings were included; incomplete surveys were excluded. Surveys were analyzed using descriptive statistics (frequency distributions and percentages for categorical variables, means, and standard deviations for continuous variables), and Fisher’s exact test and unpaired t-tests comparing responses by surgical attendings vs. residents.ResultsA total of 108 surgical faculty, 95 surgical residents, and 58 affiliate surgeons were emailed the survey. Overall response rates were 50.0% for faculty surgeons, 47.4% for residents, and 36.2% for affiliate surgeons. Only 20.8% of surgeons used risk calculators most or all of the time. Attending surgeons were more likely to use prior experience and current literature while residents used risk calculators more frequently. Risk assessment tools were more likely to be used when predicting major complications and death in older patients with significant risk factors. Greatest barriers for use of risk assessment tools included time, inaccessibility, and trust in accuracy.ConclusionsA small percentage of surgeons use surgical risk calculators as part of their routine practice. Time, inaccessibility, and trust in accuracy were the most significant barriers to use.

Optimizing surgical teaching through the lens of sociocultural learning theory

BackgroundThe objective of this study was to identify intraoperative instructional strategies that embody the ways that learning occurs in the social contexts of surgery. MethodsWe performed a qualitative review of examples of intraoperative teaching from transcripts of ten videotaped surgeries, coupled with interviews with surgical attendings and residents. We coded the examples according to the key tenets of sociocultural learning theories and used these codes to develop instructional strategies aimed at improving resident surgical autonomy. ResultsThe sociocultural learning theories prompted six intraoperative teaching strategies (Assess Learner Needs, Inquire, Coach, Permit, Entrust, and Debrief) to address residents' learning needs in specific surgical tasks. The six strategies involve identifying procedure-specific learning needs; discussing interventions based on strategies successful with other learners; providing in-the-moment, interactive coaching; allowing the resident to struggle; increasing the resident's graduated responsibility; debriefing about successes and struggles. ConclusionsWe argue that these six strategies should improve the quality of intraoperative teaching, and therefore, enhance progression to autonomous practice.

Video Coaching: A National Survey of Surgical Residency Program Directors

Video coaching has been demonstrated to improve resident and attending skills and is overwhelmingly well received by the participants. However, misperceptions about its utility among those who do not use video coaching may be a barrier to widespread implementation. Cross-sectional web-based survey SETTING: National survey PARTICIPANTS: Surgical program director members of the Association of Program Directors of Surgery STUDY DESIGN: The survey was developed via a deductive approach after a literature review and was piloted with surgical attendings and residents. All Likert scale were averaged and comparisons between groups was performed via independent t-tests. There were 52 responses from PDs. 27/52(51.9%) PDs reported their program supported video coaching of residents. PDs from residences with video coaching programs were more likely to believe that video coaching was useful in identifying their own strengths and weakness (p = 0.005), was a useful adjunct for resident feedback (p = 0.024), and a personal library of video recordings would be helpful (p = 0.015) when compared to PDs from residencies without video coaching. Programs without video coaching were more likely to believe barriers to implementation included it being ineffective (p = 0.024) and that the technology was unavailable (p = 0.006). Over 50% of respondents from both groups believed expense, difficulty with set up, time required, and patient privacy were "Very" or "Extremely" likely to be barriers to implementation. This is the first national survey of PDs regarding the use of video coaching. Residency programs without video coaching may underestimate the utility of video coaching in training surgical residents.

Effect of Surgical Team Communication on Adherence to Opioid Discharge Guidelines in Post-Operative Inpatients

Current opioid prescribing guidelines state that post-operative inpatients who do not receive opioids in the 24 hours preceding discharge do not require an opioid prescription on discharge. This study was designed to assess providers' understanding of opioid discharge guidelines and explore drivers of adherence. An electronic survey was released which assessed knowledge of opioid discharge guidelines and probed surgical team communication. Kruskal-Wallis tests were used to determine differences between provider types. Spearman's correlation evaluated relationships between estimated and observed adherence to guidelines. Yale New-Haven Hospital, (tertiary, university-based) PARTICIPANTS: Surgical residents, advanced practice providers (APPs) and attendings who discharged inpatients with opioids between November 2017-August 2019 RESULTS: The response rate was 36% (90/253), including 36% (49/136) of residents, 23% (13/56) of APPs, and 46% (28/61) of attendings. Seventy eight percent of participants believed patients who met the guideline should "never" or "sometimes" receive opioids on discharge. There was a significant difference between attending preferences and what residents (H22 = 202.7, p = 0.0001) and APPs (H22 = 24.6, p = 0.003) believed were the attending's preferences. Eleven percent of attendings preferred their patients to "most of the time" or "always" receive opioids on discharge, while 45% of residents and 54% of APPs reported the same. Overall, 57% of attendings reported they "most of the time" or "always" communicated their discharge preferences while 12% of residents (H22 = -20.4, p = 0.0003) and 8% of APPs (H22 = -23.5, p = 0.003) reported the same. There was no correlation between all groups' estimated adherence to the guidelines and observed adherence (rs = 0.135, p = 0.206). This study demonstrates that surgical residents, APPs, and attendings are aware of the guideline but breakdowns in communication between the attending and the surgical team may contribute to deviation from this guideline. Improving communication may lead to improved adherence to post-operative opioid discharge prescribing guidelines.

Perceptions of Gender Disparities Among Women in Cardiothoracic Anesthesiology

In this study of women in cardiothoracic anesthesiology, the authors aimed to characterize demographics, roles in leadership, and perceived professional challenges. A prospective cross-sectional survey of female cardiothoracic anesthesiologists in the United States. An internet-based survey of 43 questions was sent to women in cardiothoracic anesthesiology. The survey included questions on demographics, leadership, and perceptions of professional challenges including career advancement, compensation, promotion, harassment, and intimidation. A database of women in cardiothoracic anesthesiology was created via personal contacts and snowball sampling. None. A total of 153 responses were analyzed, for a response rate of 65.1%. Most respondents were at the Clinical Instructor or Assistant Professor rank. Many women perceived that compensation, promotion, authorship, and career advancement were affected by gender. Furthermore, 67% of respondents identified having children as having a negative impact on career advancement. Many women reported experiencing derogatory comments (55.6%), intimidation (57.8%), microaggression (69.6%), sexual harassment (25.2%), verbal harassment (45.2%), and unwanted physical or sexual advances (24.4%). These behaviors were most often from a surgical attending, anesthesia attending, or patient. This survey study of women in cardiothoracic anesthesiology found that many women perceived inequities in financial compensation, authorship opportunities, and promotion; in addition, many felt that their career advancement was impacted negatively by having children. A striking finding was that the majority of women have experienced intimidation, derogatory comments, and microaggressions in the workplace.

Credentialing and Patient Safety in Robotic Gynecologic Surgery: Changes over the Last Nine Years

<h3>Study Objective</h3> To assess how credentialing standards and perceptions of safe use of robotic surgery in gynecology have changed over time. <h3>Design</h3> Two anonymous online surveys conducted in 2012 and 2021. <h3>Setting</h3> ACGME approved residency programs. <h3>Patients or Participants</h3> Trainees (residents and fellows) and attending physicians. <h3>Interventions</h3> Survey. <h3>Measurements and Main Results</h3> A total of 367 physicians responded to the survey; 265 in 2012 and 102 in 2021. Distributions of responses were compared using the Fisher exact test and percentage-based statistics. 89% of 2021 respondents compared to 30% of 2012 respondents reported having the robot at their institution for >5 years. The average number of robotic cases performed increased over time, with only 19% performing >5 cases monthly in 2012 compared to 35% in 2021. 100% of attending respondents in 2021 reported having formalized credentialing processes for robotic surgery compared to 70% in 2012. The percentage of attendings performing bedside assisting prior to console work increased from 46% to 79%. Attendings report of institutional minimum case number requirements to maintain robotic credentials increased from 27% to 90%, with the majority (76%) reporting 10-20 cases needed annually. When asked about beliefs about the number of cases needed for surgical independence, trainees and attendings reported higher numbers in 2021; the percentage reporting >20 cases were required for independence increased from 58% to 93% and 29% to 70%, respectively. Trainees and attendings increased their rate of reporting that attendings are always fully independent and competent (52% to 69% and 51% to 68%, respectively) and decreased their rate of reporting that those doing robotic cases lacked the skills to do so safely (54% to 6% and 30% to 21%, respectively). Notably, nearly a quarter of attending surgeons still reported they had colleagues who lacked skills to consistently perform safe robotic surgery in 2021. <h3>Conclusion</h3> Expansion of credentialing processes over time correlated with improved confidence in surgeon skills.

Assessing learner engagement with virtual educational events: Development of the Virtual In-Class Engagement Measure (VIEM)

BackgroundThe COVID-19 pandemic has necessitated virtual education, but effects on learner engagement are unknown. We developed a virtual in-class engagement measure (VIEM) to assess learner engagement in online surgical education events. MethodsUsing the STROBE, an observer collected tool to document student engagement, as a template an ASE committee workgroup developed the VIEM. The VIEM had two parts: observer assessment and learner self-assessment of engagement. Trained observers collected engagement data from two institutions using the VIEM. Surgical attendings, fellows and residents were observed during virtual learning events. Educator attitudes towards online teaching were also assessed via survey. Results22 events with 839 learners were observed. VIEM distinguished between sessions with low and high engagement. 20% of learners pretended to participate. Half of instructors were comfortable with virtual teaching, but only 1/3 believed was as effective as in-person. 2/3 of teachers believed video learners were more engaged than audio learners. ConclusionsVirtual platforms do not automatically translate into increased engagement. Standard tools such as VIEM may help with assessment of engagement during virtual education.

The surgical debrief: Just another checklist or an instrument to drive cultural change?

IntroductionPost-procedural debrief is recommended to improve patient safety. We examined operating room (OR) clinicians’ perceptions of the impact of a multi-disciplinary debrief on OR culture. MethodsA survey was administered to 182 OR clinicians at a major academic medical center. Attitudes toward the surgical debrief and its effect on patient safety and OR culture were evaluated. ResultsMajority of clinicians (58.2%) believed creating a culture of safety in the OR was a shared care team responsibility, however, surgical attendings and trainees were more likely to assign this responsibility to the surgical attending. Few circulating nurses and trainees felt comfortable initiating a surgical debrief. Overall clinicians agreed that a debrief would impact both patient safety outcomes and OR culture. ConclusionsClinicians felt implementation of a surgical debrief would positively affect the OR culture of safety by improving interdisciplinary communication and influencing the power hierarchy that exists in many ORs.

Colonic displacement as a marker of endoscopic skill: development of a novel tool for endoscopy training.

Colonoscopy is a technically challenging procedure. The colonoscope is prone to forming loops in the colon, which can lead patient discomfort and even perforation. We hypothesized that expert endoscopists use techniques to avoid loop formation, identify and straighten loops earlier, and thus exert less force. Using a commercially available physical colon simulator model (Kyoto Kagaku), electromagnetic tracking markers (NDI Medical) were placed along the mobile segments of the colon (sigmoid, transverse) to measure the degree of displacement of the colon as the scope was advanced to the cecum. The colon model was set for each participant to simulate a redundant alpha loop in the sigmoid colon. Gastroenterology and surgical trainees and attendings were assessed. Demographic data were collected for each participant. Seventy-five participants were enrolled in the study. There were 17 (22.7%) attending physicians, and 58 (77.3%) trainees. Attending physicians advanced the scope to the cecum faster. The mean time required for procedure completion was 360.5s compared to 178.4s for the trainee and attending groups respectively (mean difference: 182.1s, 95% CI: 93.0, 269.7; p = 0.0002). Attending physicians exerted significantly lower mean colonic displacement than trainees. The mean colonic displacement was 79.8mm for the trainee group and 57.9mm for the attending group (mean difference: 21.9mm, 95% CI: 2.6, 41.2; p = 0.04). Those who used torque steering caused lower maximum colonic displacement than those who used knob steering. Attending physicians advance the scope during colonoscopy in a manner that results in significantly less colonic displacement than resident trainees. Although prior studies have shown a difference in force application between endoscopists and inexperienced students, ours is the first to differentiate across varying degrees of endoscopic skill. Future studies will define metrics for incorporation into endoscopic training curricula, focusing on techniques that encourage safety and comfort for patients.

How I Do It a Surgical Palliative Care Rotation for Residents

To address the need for increased exposure to the essential components of Palliative Care in our residency, we created a 4 week rotation in Surgical Palliative Care for all of our categorical interns. The rotation includes time on an interdisciplinary inpatient consultative palliative care service as well as time in the outpatient clinic and in the operating room with the Surgical Palliative Care attending. Most patients who are seen and evaluated have surgical issues, allowing exposure to the fundamental aspects of palliative care as they pertain to surgical practice across the continuum of healthcare settings. Communication around serious illness, complicated decision making, complex pain and symptom management, withdrawal of life-sustaining treatment, and end-of-life care are all integral parts of the rotation. The rotation has been very favorably received by the residents, and the impact on the culture of the department has been tremendous as well. The structured approach provided, including goals and objectives and the weekly schedule, make this rotation easily replicable in other residency programs.

The Resident-Run Minor Surgery Clinic: A Four-Year Analysis of Patient Outcomes, Satisfaction, and Resident Education

A resident-run minor surgery clinic was developed to increase resident procedural autonomy. We evaluated whether 1) there was a significant difference between complications and patient satisfaction when procedures were independently performed by surgical residents vs. a surgical attending and 2) if participation was associated with an increase in resident procedural confidence. Third year general surgery residents participated in a weekly procedure clinic from 2014-2018. Post-procedure complications and patient satisfaction were compared between patients operated on by residents vs. the staff surgeon. Residents were surveyed regarding their confidence in independently performing a variety of clinic-based patient care tasks. Massachusetts General Hospital General in Boston, MA; an academic tertiary care general surgery residency program. Post-graduate year three general surgery residents that ran the clinic as part of a general surgery rotation. 1230 patients underwent 1592 procedures (612 in resident clinic, 980 in attending clinic). There was no significant difference in the 30-day complication rate between patients operated on by the resident vs. attending (2.5% vs. 1.9%, p = 0.49). 459 patient satisfaction surveys were administered with a 79.1% response rate. There was no significant difference in the overall quality of care rating between residents and the attending surgeon (87.5% top-box rating vs. 93.1%, p = 0.15). Twenty-one residents completed both a pre- and post-rotation survey (77.8% response rate). The proportion of residents indicating that they could independently perform a variety of patient care tasks significantly increased across the rotation (all p < 0.05). Mid-level general surgery residents can independently perform office-based procedures without detriment to safety or patient satisfaction. The resident-run procedure clinic serves as an environment for residents to grow in confidence in both technical and non-technical skills. Given the high rate at which patients provide resident feedback, future work may investigate how to best incorporate patient derived evaluations into resident assessment.

Semantically Ambiguous Language in the Teaching Operating Room

Teaching and training surgeons work hard in the OR to understand each other, yet miscommunication is an important cause of preventable adverse events in surgery. Our objective was to perform a formal semantic analysis of language in authentic teaching surgical cases, identify the prevalence and typology of ambiguous or potentially ambiguous language, and describe their potential for miscommunication. In this secondary analysis of qualitative data, we collaborated with a semanticist, categorizing linguistic phenomena often associated with miscommunication. We defined an ambiguous phenomenon as a string of language that could be reasonably interpreted in more than one way. We analyzed transcripts of 319 minutes of surgery, coding for 14 linguistic categories.Cohen's kappa was calculated.We determined the prevalence and rate of each linguistic category and chose illustrative examples. Six surgical attendings, four fellows, and six residents, ranging from PGY1 to PGY4, at the University of Pittsburgh Medical Center, a tertiary medical center in Pittsburgh, Pennsylvania. We found 3912 examples of potentially ambiguous language, 12.3 per minute. Percentage agreement between two expert raters was 76.3%. The most common phenomena were deixis (3.1 per minute), directional (2.6), anaphora (1.3), implicit instruction (1.3), and degree modifiers (0.7). Restatements/reframing occurred 1.4 times per minute. We identified 131 near misses associated with potentially ambiguous language. Cohen's kappa was 0.70 among expert semanticists. Potentially ambiguous language is common and has the potential to jeopardize safe teaching surgery. We postulate that the high amount of potentially ambiguous language use in the operating room places a burden on the training surgeon to comprehend surgical instruction.

Rapid Adoption of an Interdisciplinary Care Team Model for Surgical Residents Managing Coronavirus Disease-19.

Introduction: Patients infected with SARS-Cov-2, the causative virus behind the coronavirus disease-19 (COVID-19) pandemic, have been increasing rapidly in New York City. New York City has the highest incidence in the United States and fully 45% of all deaths from COVID-19. Our medical center is located within a high-density region of cases in south Brooklyn and, in fact, three of our neighborhood zip codes are in the top seven in New York in incidence. As a result, our center has experienced a dramatic increase in hospitalizations, particularly respiratory distress secondary to COVID-19, which rapidly exceeded the capacity of our internal medicine service. This necessitated the formation of new COVID-19 units throughout the hospital, replacing all former service lines. These units employed management teams composed of residents from many medical and surgical disciplines, including general surgery residents. Methods: Our general surgery residency program established a surgical COVID-19 (SCOVID) management team. Initially, 4 surgical residents (2 senior and 2 junior), 1 attending surgeon, and 1 attending internal medicine physician were allocated to the initial SCOVID team. On day 3 of implementation, to achieve more rapid competence in the complex management of these patients, a senior medicine resident with direct experience in the care of COVID-19 patients was added in an advisory capacity. Results: The addition of an experienced senior medical resident and attending allowed for the quick adoption of uniform management protocols by surgical residents and attendings. Discussion: We describe a protocol for the establishment of COVID-19 management teams staffed with general surgical residents, as well as a strategy for the achievement of rapid increases in competency. The addition of a senior internal medicine resident and attending to our SCOVID team allowed for rapid achievement of competency in the care of COVID-19 patients in our large institution at the epicenter of the COVID-19 pandemic.

Transition Services for Paediatric Inflammatory Bowel Disease: A Multicentre Study of Practice in the United Kingdom.

Patients with paediatric inflammatory bowel disease (IBD) constitute one of the largest cohorts requiring transition from paediatric to adult services. Standardised transition care improves short and long-term patient outcomes. This study aimed to detail the current state of transition services for IBD in the United Kingdom (UK). We performed a nationwide study to ascertain current practice, facilities and resources for children and young people with IBD. Specialist paediatric IBD centres were invited to contribute data on: timing of transition/transfer of care; transition resources available including clinics, staff and patient information; planning for future improvement. Twenty of 21 (95%) of invited centres responded. Over 90% of centres began the transition process below 16 years of age and all had completed transfer to adult care at 18 years of age. The proportion of patients in the transition process at individual centres varied from 10% to 50%.Joint clinics were held in every centre, with a mean of 12.9 clinics per year. Adult and paediatric gastroenterologists attended at all sites. Availability of additional team members was patchy across the UK, with dietetic, psychological and surgical attendance available in <50% centres. A structured transition tool was used in 75% of centres. Sexual health, contraception and pregnancy were discussed by <60% of teams. This study provides real-world clinical data on UK-wide transition services. These data can be used to develop a national strategy to complement current transition guidelines, focused on standardising services whilst allowing for local implementation.

Curtailing Unnecessary Waste Among Operating Room Personnel: Evaluating the Cost Awareness of Commonly Used Surgical Items.

Operating rooms (ORs) generate 70% of hospital waste, leading to increased costs for the hospital, patient, and the environment. The lack of cost awareness among physicians has been well documented; however, there is little information on anesthesiologists or ancillary OR staff. This study aimed to evaluate the cost awareness of commonly used items at an academic medical center among OR personnel. Anonymous surveys were distributed to OR personnel (nurses, surgical technicians (STs), nurse anesthetists, anesthesiologists, surgeons, and residents), asking for the estimated costs of ten commonly used items. These costs were then compared against actual costs to evaluate the accuracy of participants' estimates. Responders were clustered by job, highest level of education, and years of experience for comparison. 167 surveys were collected, and overall only 16.4% of estimates were accurate within 50% of actual price. No significant differences in accuracy between groups were identified overall (P = .2), but both surgical and anesthesia attendings had significantly higher rates of correct responses than their respective residents. No difference was seen in accuracy when all attendings (surgeons and anesthesiologists) were compared with either nurses or STs. Linear regression demonstrated no correlation between number of years at current position or years at institution and number of correct responses (R2 = .0025 and R2 = .005, respectively). Addressing the knowledge deficit around item costs via global education of all OR personnel (surgeons, anesthesia providers, and ancillary staff) could be a viable pathway to reduce waste, and thus cost, for our healthcare system.

Implementation of the ACS/ APDS Resident Skills Curriculum reveals a need for rater training: An analysis using generalizability theory

BackgroundThe American College of Surgeons (ACS)/Association of Program Directors in Surgery (APDS) Resident Skills Curriculum includes validated task-specific checklists and global rating scales (GRS) for Objective Structured Assessment of Technical Skills (OSATS). However, it does not include instructions on use of these assessment tools. Since consistency of ratings is a key feature of assessment, we explored rater reliability for two skills. MethodsSurgical faculty assessed hand-sewn bowel and vascular anastomoses in real-time using the OSATS GRS. OSATS were video-taped and independently evaluated by a research resident and surgical attending. Rating consistency was estimated using intraclass correlation coefficients (ICC) and generalizability analysis. ResultsThree-rater ICC coefficients across 24 videos ranged from 0.12 to 0.75. Generalizability reliability coefficients ranged from 0.55 to 0.8. Percent variance attributable to raters ranged from 2.7% to 32.1%. Pairwise agreement showed considerable inconsistency for both tasks. ConclusionsVariability of ratings for these two skills indicate the need for rater training to increase scoring agreement and decrease rater variability for technical skill assessments.

Risk of Infectious Endophthalmitis From a Resident-Performed Intravitreal Injection

This work assesses the safety of resident-performed intravitreal injections by comparing the incidence of postinjection endophthalmitis associated with residents vs surgical retina attendings. In this retrospective noninferiority cohort study, the Current Procedural Technology code for an intravitreal injection was used to identify patients from July 1, 2015, to October 31, 2018, at a single-center Veterans Affairs hospital where patients receive intravitreal injections from attending vitreoretinal surgeons and residents. The medical record for each injection was reviewed for the training level of the proceduralist, indication, medication, and laterality. The main outcome was the incidence of postinjection endophthalmitis occurring within 30 days of an intravitreal injection, which was confirmed by at least 2 medical-record reviewers. In this cohort of 593 patients, most were male (97.0%), and the average age was 70.3 years (±10.8 years). Of the 6934 injections given, 3877 (55.9%) were performed by residents and 3057 (44.1%) by attendings. Of the 5 cases of endophthalmitis identified, 3 were associated with a resident-performed injection in his or her fourth year of postgraduate training. The difference (0.012%; 95% CI, -0.168% to 0.169%) in the incidence of postinjection endophthalmitis between residents (0.077%) and attendings (0.065%) did not cross the predetermined noninferiority limit (0.200%). At our teaching clinic, resident-performed injections were not associated with an elevated risk of endophthalmitis when compared with attending-performed injections. Under varying levels of supervision, residents appeared to demonstrate appropriate sterile injection technique.

Impact of Robotic Single and Dual Console Systems in the Training of Minimally Invasive Gynecology Surgery (MIGS) Fellows

Study Objective To evaluate fellow console time, surgical steps performed, and surgical takeovers between attending and fellow using a dual versus (vs) single console robotic systems. Design Quality improvement project evaluating use of dual consoles in robotic surgical education. Setting MIGS fellowship program in an academic institution's tertiary care center. Patients or Participants Two MIGS fellows and 5 subspecialty trained gynecologic surgeons. Interventions Variables were prospectively collected for 62 robotic surgeries and included: dual vs single console, trainee console time, trainee, attending, surgical takeovers, docking time, type of surgery, steps performed by trainee, complications, total case time, specimen weight and estimated blood loss. Demographic patient data were also collected. Variables were compared using the Wilcoxon Rank Sum test (continuous), and the Pearson Chi-square test (categorical). Measurements and Main Results Fellows spent more time at the console in dual console operations compared to single (56 vs. 36 min, P=0.002). There were 11 (31%) single console procedures where the fellow had no control compared to dual console where the fellow assumed control every time (P=0.001). Median number of surgical takeovers was higher in dual console operations (3 vs. 1, P Conclusion Dual console robotic training provide fellows the opportunity for more hands on experience and more interaction between the fellow and surgical attending, with an increased number of surgical takeovers. This opportunity presents itself at the cost of a longer case time but with similar complication rates. ned IUDs. Knowledge of the alignment of the IUD to the longitudinal axis of the uterus and the degree of embedment, or perforation, allows for employing the most appropriate technique. Although removal can often be achieved in the office, deeply embedded IUDs or IUD fragments may require the operating room setting for safe extraction.

Experiences from the epicenter: an observational report on converting a post anesthesia care unit to a COVID-19 intensive care unit

Experiences from the epicenter: an observational report on converting a post anesthesia care unit to a COVID-19 intensive care unit