Surgical Graduate Medical Education Research Articles

747 Operative Objectives—A Pilot Study

INTRODUCTION: Surgical graduate medical education requires residents to learn a wide array of skills and apply them practically in a progressively independent manner, ultimately allowing them to practice independently. We devised "Operative-Objectives" as a tool to define the learning goals for each resident at a particular epoch of their training. This approach is operationalized, measurable, and consistently carried over time. METHODS: The Residents at a neurosurgical training program set their "Operative-Objectives" at the beginning of each 3-month rotation. These goals were then reviewed by the Program Director (PD) and faculty and appropriately tailored and finalized--forming a compact between residents and faculty whereby their commitment to the learning and teaching objectives are defined. The outcomes are reviewed with the PD following each rotation and scored. Residents and faculty were provided a pre-and post-implementation survey that sought to understand the impact of implementing "Operative-Objectives" on resident preparedness, objectives for improvement, resident satisfaction with, and objective improvement in resident's surgical skills. RESULTS: A total of eight residents and five faculty completed both a pre-and post-implementation survey. Residents reported significantly increased case preparedness (p = .048), ability to track improvement (p = .044), clear objectives for improvement (p = .021), and satisfaction with improvement in surgical skill (p = .044). The faculty reported a significant increase in resident preparedness for surgery (p = .049), ability to track improvement (p=.044), focus for improvement (p=.033), and goals for improvement (p = .033). CONCLUSIONS: "Operative Objectives" provide a focused delineation and tracking of a resident's surgical learning at the intersection of three vectors: level of training, location, and ability. The deliverables are measurable. They can be followed over time and allow for an organized and focused framework for improvement and feedback. As such, they can significantly improve the learning skills of the residents as well as the teaching abilities of the faculty.

General Surgery Trainee Cases Over Time: Postgraduate Year Matters.

Trainees and attending surgeons alike have concerns about resident and fellow operative volume/breadth, competency, and overall readiness for practice. This is an important topic within surgical graduate medical education. Our goal was to analyze the change in general surgery trainee operative experience over time by postgraduate year. Institutional operative records from two corresponding three-month time periods in 2009 and 2018 at the residency program's main hospital site were reviewed. Cases assisted on by general, vascular, or thoracic surgery trainees were included. The number of cases per level, combination of trainees in each case, and categories of cases were compared over time. There were 1940 cases in 2009 and 1967 cases in 2018 over the respective time periods. The distribution of trainees was different (P < .001), with a similar number of PGY-1 and fellow cases, a decrease in PGY-2 and PGY-5 cases, and an increase in PGY-3 and PGY-4 cases. The number of cases with two trainees, double scrubbed cases, increased from 19.6% to 26.8% (P < .001). In addition, there were differences in the resident years that double scrubbed cases together, an increase in robotic and endovascular surgery, and a decrease in open cases. This analysis of cases shows that resident operative volume over approximately a decade has been largely preserved, with some change in the distribution of cases based on trainee level, an increase in cases with more than one trainee, and a rise of minimally invasive surgery with a corresponding decrease in open cases.

Declining Military Surgical Cases and the Impact on Military Surgical Graduate Medical Education.

Several studies have indicated a decline in the number, types, and complexity of surgical procedures within military treatment facilities (MTFs). This study aims to determine what effect, if any, these downward trends have had on the relationship between the military health system (MHS) and surgical graduate medical education. Graduating chief resident final ACGME case logs from 4 of thirteen military general surgery programs were evaluated from 2015 to 2020. The proportion of total cases performed by residents at military institutions were compared on a year over year basis. The proportion of cases performed within the military hospitals declined 3.27% each year between 2015 and 2020 (P < .0001) in 4 MTFs. All individual hospitals had significant declines in case volume except one (William Beaumont Army Medical Center) which increased 6.05% with each year, but also increased the number of MTF partnerships within its program (P < .0001). There has been a statistically significant decline over time in the proportion of cases logged by residents within the studied military treatment facilities. Investment into military hospitals to increase case numbers, case diversity, and complexity and/or acceptance of this gradual decline with greater shifting of educational workload onto civilian hospitals is required.

Standardized Medical Coding Curriculum in Surgical Graduate Medical Education.

Despite the increasing importance of coding and billing in healthcare as a whole and calls from the Accreditation Council for Graduate Medical Education (ACGME) to emphasize systems-based practice, many surgical training programs have not prioritized coding and billing within their curricula. We aim to evaluate the performance of surgical residents and early career surgeons in coding and billing and to appraise interventions to improve coding and billing abilities within this group. A literature search from conception to March 15th, 2022 utilizing PubMed, Google Scholar, and EMBASE was conducted to search for studies that evaluate surgical resident coding practices and interventions to improve practice management and financial competency. Discrepancies in coding and billing ability are prominent between residents, surgeons, and professional coders. One study demonstrated coding accuracy of 76.5% for professional coders, 62.1% for surgical attendings, and 54.1% for surgical residents, whereas another study reported a 52.82% coding accuracy and residents. Resident performance in coding and billing was inferior to their more experienced surgical attending counterparts and professional coders. Surgical residents and fellows demonstrated significantly improved knowledge and confidence in coding following the administration of either individual or longitudinal educational interventions. Coding and billing discrepancies among students, residents, and surgeons persist due to a lack of formalized training. Integration of standardized and mandated medical coding curricula and interventions within residency programs has great potential to improve surgical coding practices and should be a mandatory component of graduate medical education.

Expansion of Surgical Graduate Medical Education Training Programs: A Return on Investment Analysis

BackgroundThe productivity of surgical departments is limited by the staffing of attending surgeons as well as surgical residents. Despite ongoing surgeon shortages, many health care organizations have been reluctant to expand training programs because of concerns about cost. We sought to determine the return on investment for the expansion of surgical training programs within our health system. MethodsThis study was completed as a retrospective review comparing two independent surgical departments at separate hospitals within a single integrated health system, including complete fiscal information from 2012 to 2019. Hospital A is a 594-bed hospital with large growth in its graduate surgical training programs over the study's period, whereas Hospital B is a 320-bed hospital where there was no expansion in surgical education initiatives. Case volumes, the number of full-time employees (FTE), and revenue data were obtained from our health systems business office. The number of surgical trainees, including general surgery residents and vascular surgery fellows, was provided by our office of Graduate Medical Education. The average yearly net revenue per surgeon was calculated for each training program and hospital location. ResultsOur results indicate a positive association between the number of surgical trainees and departmental net revenue, as well as the annual revenue generated per physician FTE. Each additional ancillary provider per physician FTE resulted in a positive impact of $112,552-$264,003 (R2 of 0.69 to 0.051). ConclusionsRegardless of hospital location or surgical specialty, our results demonstrate a positive association between the average net revenue generated per surgeon and the number of surgical trainees supporting the department. These findings are novel and provide evidence of a positive return on investment when surgical training programs are expanded.

Medical Student Involvement and Learning Objectives in Morbidity and Mortality Conferences: A National Survey of the Association for Surgical Education's Committee of Clerkship Directors

Despite implementation of Morbidity and Mortality (M&M) Conference across surgical graduate medical education, sparse literature exists regarding the attendance and involvement of medical students. We sought to examine student involvement and learning objectives for M&M on a national level. A survey was distributed through the Association for Surgical Education Committee of Clerkship Directors. Questions examined demographics, teaching practices regarding M&M, and student learning objectives. Forty-eight responses were collected reflecting practices of weekly M&M (96%) and required student attendance (93%). Students are observers in 61% of M&Ms, observer with questions in 37%, and presenter at 2%. Learning objectives for M&M highlighted exposing students to conference style (76%), reflective learning (63%), and highlighting medical error (78%). It is the national standard for medical students to attend weekly M&M. Student learning objectives reflect desires to improve exposure to this style of teaching conference and understanding the gravity of medical error.

Attrition Rate in Military General Surgery GME and Effect on Quality of Military Programs

The attrition rate in civilian general surgery Graduate Medical Education (GME) is estimated at 20%, while estimates of attrition in military general surgery (MGS) GME programs using the same methodology are nearly twice that. We sought to identify the true attrition rate in MGS GME, identify factors influencing attrition, and examine the relationship between attrition and quality of MGS GME. Deidentified data were collected on categorical general surgery residents matriculating from 2010 to 2013 from all 12 MGS residency programs. Information gathered included gender, medical degree, marital status, location of program, presence of a military-related interruption in training, and age at start of the categorical contract. For those who did not graduate, data on postgraduate year at time of attrition, reasons for attrition, and deficiencies in core competencies were solicited. To assess the effect of true attrition rate on graduate performance, we compared the published 5-year American Board of Surgery qualifying exam/certifying exam first time pass rates between military and civilian programs. One hundred eighty-four categorical residents matriculated from 2010 to 2013. Fifty six (31.5 %) were women, 151 (62.1%) were MD's, 103 (56%) were married, 172 (93.5%) were less than 35 years old, and 33 (17.9%) had a military-related interruption in training. Nineteen individuals left residency prior to graduation (15 resigned, 2 resigned in lieu of termination, 2 terminated) for an overall attrition rate of 10.3%. The most common year for attrition was PGY-3 (31.6%) and most common reason for resignation was changing to a different subspecialty (73.3%). Men and women had equal attrition rates (10.3%), and there was no meaningful difference between MD's and DO's (9.9% vs 12.1%, p = 0.71) or region of training (10.6% East vs 9.1% West, p = 0.73). However, those who were not married, had a militarily mandated interruption in training and started their categorical training over the age of 35 had higher attrition rates (married 5.6%, not married 15%, p = 0.04, interruption 16% vs no interruption 9%, p = 0.1; Age ≥ 35 33.3% vs age < 35 6.7%, p < 0.01). Comparison of American Board of Surgery (ABS) first time pass rates over a similar time period showed that military programs performed statistically discernibly better than civilian programs (82% ± 12 vs 75% ± 13, p = 0.047). Previous used methodology over estimates the attrition rate in MGS GME. The lower rate in MGS programs results in a high level of graduate performance as measured by ABS pass rates. Interruption in training and especially marital status and age ≥ 35 appear to be potential predictors of attrition. Components of MGS GME training and selection processes might inform efforts to reduce attrition and improve performance in civilian surgical GME.

The Value of Surgical Graduate Medical Education (GME) Programs Within An Integrated Health Care System

Surgical graduate medical education (GME) programs add both significant cost and complexity to the mission of teaching hospitals. While expenses tied directly to surgical training programs are well tracked, overall cost-benefit accounting has not been performed. In this study, we attempt to better define the costs and benefits of maintaining surgical GME programs within a large integrated health system. We examined the costs, in 2018 US dollars, associated with the surgical training programs within a single health system. Total health system expenses were calculated using actual and estimated direct GME expenses (salary, benefits, supplies, overhead, and teaching expenses) as well as indirect medical education (IME) expenses. IME expenses for each training program were estimated by using both Medicare percentages and the Medicare Payment Advisor Commission study. The projected cost to replace surgical trainees with advanced practitioners or hospitalists was obtained through interviews with program directors and administrators and was validated by our system's business office. A physician lead, integrated, rural health system consisting of 8 hospitals, a medical school and a health insurance company. GME surgical training programs within a single health system's department of surgery. Our health system's department of surgery supports 8 surgical GME programs (2 general surgery residencies along with residencies in otolaryngology, ophthalmology, oral-maxillofacial surgery, urology, pediatric dentistry, and vascular surgery), encompassing 89 trainees. Trainees work an average of 64.4 hours per week. Total health system cost per resident ranged from $249,657 to $516,783 based on specialty as well as method of calculating IME expenses. After averaging program costs and excluding IME and overhead expenses, we estimated the average annual cost per trainee to be $84,171. We projected that replacing our surgical trainees would require hiring 145 additional advanced practitioners at a cost of $166,500 each per year, or 97 hospitalists at a cost of $346,500 each per year. Excluding overhead, teaching and IME expenses, these replacements would cost the health system an estimated additional $16,651,281 or $26,119,281 per year, respectively. Surgical education is an integral part of our health system and ending surgical GME programs would require large expansion of human resources and significant additional fiscal capital.

AOA 2014-2015 Presidential Address: "Tipping points" in surgical education: AOA critical issues.

President Boden, Members of the AOA, Guests, Ladies, and Gentlemen, it is truly an honor to address you as the incoming president of this esteemed and historic organization. I would like to acknowledge any residents in the audience or those who may read future versions of this talk. For many of us in an academic orthopaedics, the residents are what our job is all about, and residents are what this talk is all about. We are in a time of tremendous change in health care, and surgical education is caught in the changes. Surgical education has been a focus throughout my career, and I have some thoughts on the challenges that we face in training the future generation of orthopaedic surgeons. I will concentrate on why and how surgical education has changed, is changing, and will change. Indeed, the concept of change is captured in the title. Surgical Graduate Medical Education (GME) is an important topic for AOA. Previous presidential addresses have focused on orthopaedic education. William Enneking and Michael Simon chose “The Education of Future Orthopaedists” as a title and spoke of the value of education over “training”1,2. Terry Peabody, in 2012, used teaching as his core theme3. The 2013 survey of AOA members rated resident education and the Council of Orthopaedic Residency Directors (CORD) among the top reasons for membership. GME is particularly important because, unlike the other changes in health care, the course of change can be altered. Organizations, and even individuals, can make a difference in GME. We can create change, and we can lead and guide change catalyzed by outside forces. Let us start by thinking about change. How does it occur? What causes it? What gets it started? In The Tipping Point: How Little Things Can Make a …

History of Simulation in Medicine

Medical and surgical graduate medical education has historically used a halstedian approach of "see one, do one, teach one." Increased public demand for safety, quality, and accountability in the setting of regulated resident work hours and limited resources is driving the development of innovative educational tools. The use of simulation in nonmedical, medical, and neurosurgical disciplines is reviewed in this article. Simulation has been validated as an educational tool in nonmedical fields such as aviation and the military. Across most medical and surgical subspecialties, simulation is recognized as a valuable tool that will shape the next era of medical education, postgraduate training, and maintenance of certification.

Surgical Resident Involvement Is Safe for Common Elective General Surgery Procedures

Outcomes of surgical resident training are under scrutiny with the changing milieu of surgical education. Few have investigated the effect of surgical resident involvement (SRI) on operative parameters. Examining 7 common general surgery procedures, we evaluated the effect of SRI on perioperative morbidity and mortality and operative time (OpT). The American College of Surgeons National Surgical Quality Improvement Program database (2005 to 2007) was used to identify 7 cases of nonemergent operations. Cases with simultaneous procedures were excluded. Logistic regression was performed across all procedures and within each procedure incorporating SRI, OpT, and risk-stratifying American College of Surgery National Surgical Quality Improvement Program morbidity and mortality probability scores, which incorporate multiple prognostic individual patient factors. Procedure-specific, SRI-stratified OpTs were compared using Wilcoxon rank-sum tests. A total of 71.3% of the 37,907 cases had SRI. Absolute 30-day morbidity for all cases with SRI and without SRI were 3.0% and 1.0%, respectively (p < 0.001); absolute 30-day mortality for all cases with SRI and without SRI were 0.1% and 0.08%, respectively (p < 0.001). After multivariate analysis by specific procedure, SRI was not associated with increased morbidity but was associated with decreased mortality during open right colectomy (odds ratio 0.32; p = 0.01). Across all procedures, SRI was associated with increased morbidity (odds ratio 1.14; p = 0.048) but decreased mortality (odds ratio 0.42; p < 0.001). Mean OpT for all procedures was consistently lower for cases without SRI. SRI has a measurable impact on both 30-day morbidity and mortality and OpT. These data have implications to the impact associated with surgical graduate medical education. Further studies to identify causes of patient morbidity and prevention strategies in surgical teaching environments are warranted.

Industry Support of Graduate Medical Education in Surgery

The role of pharmaceutical and medical device companies ("industry") in graduate medical education (GME) is under debate. We surveyed program directors in general surgery and surgical specialties to determine industry activities in surgical GME. We used an internet-based questionnaire regarding industry marketing and educational activities in surgical programs, and their effects on surgical education. We received 65 responses to 377 requests (17%). Nearly two-thirds reported industry-sponsored meals. Industry-supported travel was infrequent ("never" and "seldom" in 56% of device workshops, 69% of lectures, and 74% of conferences). More than one-half reported support for academic events: paid lecturers and exhibition fees (both 58%), and unrestricted grants (62%). More than one-half (54%) reported industry-sponsored research. One-fourth believed their programs to be dependent on industry for their educational missions. Most disagreed that industry support posed a problem, either in general (55%) or for their program (71%). One-fourth of respondents (25%) advocated profession-wide restrictions of industry involvement with GME. Equal numbers agreed (39%) and disagreed (35%) with the view that pharmaceutical and medical device industries have motivations that are in conflict with those of doctors and their patients. Industry activities are widespread in surgical residencies, with approval of many program directors.

Realistic Expectations and Leadership in the Era of Work Hour Reform 1

Work hour guidelines and core competencies were introduced to improve surgical education and are changing the landscape of surgical training. We sought to examine perceptions and attitudes regarding the impetus and impact associated with these changes. Anonymous surveys were distributed to faculty and surgeons-in-training in an Accreditation Council for Graduate Medical Education, university-based, training program. Faculty (F, n = 30) and trainees (T, n = 30) agree that lifestyle expectations and long work hours are the principal issues facing surgical education (F = 80%, T = 56%; P = 0.03). Implementation of ACGME guidelines is perceived as NOT improving patient care or clinical experience (F = 100%, T = 90%; P = 0.03) while reducing operative experience (F = 50%, T = 70%). More faculty (>80%) than trainees (33%) are concerned that ACGME guidelines will diminish patient care experiences. Although most (F = 77%, T = 83%; P = NS) agree that hiring additional providers will improve guideline compliance, many oppose ACGME guideline implementation fearing a loss of professionalism. Although both (F = 50%, T = 47%) admonish deficient interpersonal and communication skills as the major impediment to implementing ACGME guidelines, opinions regarding implementation differ. Most faculty (67%) believe ACGME-imposed deadlines are the most influential reason; however, trainees (57%) believe guidelines should be promptly implemented to address long-awaited changes in work environment and surgical graduate medical education. Although faculty and trainees' perception of the issues surrounding ACGME guidelines converge, perception of changes following implementation is quite divergent. For successful implementation, leadership must address prevailing attitudes and set realistic expectations. These trends have important implications for planning the future of surgical education, unifying multi-generational colleagues, and improving systems-based practice.

“Change in the wind”: report from the 2000 Thoracic Surgery Directors Association Retreat on Thoracic Surgery Graduate Medical Education

In October, 1999, the American Board of Thoracic Surgery (ABTS) resolved that “the ABTS change current policy regarding American Board of Surgery (ABS) certification so that at a point in the future, yet to be determined, ABS certification will become optional.” This position was taken by the ABTS after exhaustive study and debate of the relevant issues and of evolving data pertinent to Thoracic Surgery Graduate Medical Education (TSGME), a topic of three major conferences in the last decade 1 and of the addresses of seven thoracic societal presidents, four of them in the last 6 years. Among the most provocative points that were considered by the Board were: (1) The vast expansion of fundamental knowledge and of operative approaches to cardiothoracic diseases currently required to educate the TS resident in a time-frame essentially unchanged since formal education in TS began in 1928; (2) a total duration of medical school and of GME that obligates the thoracic surgeon entering practice to be older, as compared to peers in other professions, and to be constrained by greater indebtedness; (3) a disturbingly diminished pool of applicants to TS residencies, with fewer US medical graduates applying than residency positions to fill; and (4) diminishing funding for TSGME occurring concomitantly with increasing financial burdens on academic thoracic surgery programs. The specific intent of the ABTS was to facilitate change if change were to be the desire of thoracic surgery educators and of the other parties in organized thoracic surgery vested with interest in, and responsibility for, the process and product of TSGME.

The longitudinal study of surgical residents, 1994 to 1996

Background: The American College of Surgeons (ACS) has conducted a detailed annual survey of residents enrolled in surgical graduate medical education (GME) programs since 1982 and has regularly published the resulting data as the Longitudinal Study of Surgical Residents. This report documents surgical resident enrollment and graduation for the academic years 1994–95 and 1995–96. Study Design: The Medical Education Research and Information Database of the American Medical Association was supplemented by the existing ACS Resident Masterfile and by personal contact with program directors and their staffs to verify accuracy and completeness of reporting. Each resident was tracked individually through surgical GME. Results: The total number of surgical residents graduating from surgical GME in 1995 and 1996 has not changed since 1982. Most graduates of surgical residency programs are in obstetrics and gynecology, followed by general surgery; demographic analysis of the graduating cohort shows that most are Caucasian male graduates of US or Canadian medical schools, and that their age at graduation is 33 to 35 years. International medical graduates (IMG) make up 8.9% of entering surgical residents and 6% of graduates. Osteopathic medical school graduates account for 1.2% to 1.3% of entering and graduating surgical residents. Women represent 27% of entering and 23% to 24% of graduates of surgical GME. The largest number and proportion of women in surgical GME are enrolled in obstetrics and gynecology residency programs, where they make up the majority of entering and graduating classes. When all other surgical residency program enrollments are considered together, women make up 17% and 16% of entering residents in 1994 and 1995, respectively, and 13% and 14% of graduates in those years. Conclusions: Surgical GME enrollment and graduation is stable. Few women and ethnic minorities are enrolled in surgical residency programs. IMG enrollment and graduation in surgical GME is low.