57.13 Gender Distribution of Surgical Clerkship Directors in the Continental United States

Posted on January 26, 2017

S. Sprinkle1, B. Harris2, A. Wang1, H. Leraas1, J. Migaly1  1Duke University Medical Center,Department Of Surgery,Durham, NC, USA 2Temple University,School Of Medicine,Philadelpha, PA, USA

Introduction:
When choosing a specialty, mentorship is exceedingly important. This is especially true for female medical students contemplating a future in general surgery. Clerkship directors (CD) are important initial role models for medical students. However, no data currently exists on how many CDs are female surgeons.  We sought to determine the demographics of this important educational leadership role.

Methods:
A list of medical schools was obtained from the Liaison Council of Medical Education (LCME) and was current as of June 2016.  Forty percent of the institutions were selected by simple random sample. For those selected, institutional websites were evaluated for clerkship director’s gender, academic rank (assistant, associate, or professor), sub-specialty training, and year of residency graduation. Secondary internet searches were made if any data was missing. The 2014 gender distributions of surgical residents and faculty were obtained from publically available census reports. SAS 9.4 (Cary, NC) was used to perform chi-squared tests on categorical data and Mann-Whitney tests on skewed continuous data. Faculty rank was treated as an ordinal variable and modeled using an ordered logistic regression. As only publically available data was queried, this study was exempt from institutional review.  

Results:

Of 146 LCME medical schools, 57 (40%) were sampled, representing 22 different states.  Of this sample, 24.6% of CDs were women (14/57, p<0.0001).  The number of female CDs was not statistically different from the 2014 proportion of female faculty in general surgery (894/4455, 19.8%), p=0.4. However, the proportion of female CDs was statistically different from the 2014 proportion of female residents (2962/7890, 37.3%, p=0.04) and medical students (37196/78945, 47.1%), p<0.001.

The median year of graduation from residency for women was 2003 (range 1978-2013) compared to 2001 (1968-2012) for men (p=0.3). The majority of female CDs were assistant professors (50.0%, 7/14) with 28.7 % reaching the rank of associate (4/14) and 21.4% (3/14) full professors. Although the majority of male CDs held the rank of associate professor (35.1%, 20/43), there was no significant difference in the proportion of academic ranks by gender.  On logistic regression, gender was not a significant contributor to faculty rank (adjusted odds ratio [AOR] 0.84, 95% confidence interval [CI] 0.2-3.6).  However, years since residency graduation was a significant contributor to faculty rank (AOR 1.3, 95% CI 1.2-1.4, p<0.0001).

Conclusion:
In this random sample of medical schools, the proportion of female CDs does not vary significantly from the overall proportion of female faculty in general surgery.  Although women in academic medicine experience slower rates of advancement, this does not seem to be the case for CDs.  It is possible educational leadership positions mitigate discrepancies in faculty advancement, and future work should evaluate that possibility further.

57.11 Defining Mistreatment On Surgery Clerkships: A Medical Student-Generated Definition

Posted on January 26, 2017

E. Brandford1, D. Hoang1, B. Hasty1, E. Shipper1, S. Merrell1, D. Lin1, J. Lau1  1Stanford University,General Surgery,Palo Alto, CA, USA

Introduction:

Mistreatment has many negative effects on medical students including increased burnout, post-traumatic stress, depressive symptoms, drinking for escape, and decreased confidence in clinical skills. Mistreatment is reported at high rates during surgery clerkships, and may result in a decreased interest in pursuing a surgical residency. Despite the consensus that mistreatment is a problem that needs to be addressed, there exists no uniform definition of medical student mistreatment. Definitions used by medical institutions typically includes a small number of specific acts but are not necessarily based on medical student experiences. Without first defining mistreatment, we cannot develop interventions to prevent it. Our purpose was to characterize student generated definition(s) of mistreatment.

Methods:
An anonymous survey was distributed to medical students during both the first and last didactic session of their 8-week required surgery clerkship. Open ended survey questions asked students to define mistreatment generally, within the context of a surgery rotation, and to give examples of medical student mistreatment (real or hypothetical). Survey responses were qualitatively analyzed using content and thematic analysis to determine the components of mistreatment.

Results:
Between January 2014 and June 2016 a total of 219 medical students participated in the general surgery clerkship. 197 (90%) of students completed the pre-clerkship survey, and 183 (84%) completed the post clerkship survey, generating a total of 380 responses. Preliminary data analysis suggests that the features of mistreatment, as defined by medical students, can be described by four major categories: 1) perceived intent of the educator, 2) acts of mistreatment, 3) outcome of the action for the student and the educational environment, and 4) setting in which mistreatment takes place. The acts of mistreatment in the medical student generated definitions included examples not represented by traditional definitions of mistreatment, which are often limited to verbal abuse, physical abuse, discrimination and embarrassment. In addition, medical student definitions included subtler actions such as neglect and exclusion from learning.

Conclusion:
Our qualitative analysis demonstrates that a wide breadth of factors constitute mistreatment in surgical clerkships that is not captured by official definitions often used by medical institutions. While traditional acts of mistreatment were represented, student generated definitions also emphasized the context in which those actions took place, including the setting, the intent of the educator, and the final impact on the student. This delineation of mistreatment paves the way for the development of interventions to target the expanded range of actions, intents, and outcomes that students report as constituting mistreatment.
 

57.06 Perceptions of Inappropriate Behavior Among Surgeons and Students Influences Career Choice

Posted on January 26, 2017

J. L. Lazarus2, A. Gibson1, S. Campbell1  1Texas Tech Univeristy Health Science Center,Lubbock, TX, USA 2University Of Michigan,Ann Arbor, MI, USA

Introduction:
Demand for surgeons is increasing and expected to continue.  Though the number of general surgery residency positions has increased accordingly, the number of applicants has not proportionally increased.   Few have investigated the perceptions and behavioral dynamics of medical students and their mentors in regards to student career choice.  Increasing awareness regarding inappropriate behavior of physicians and trainees has led to professionalism included as a core competency in surgical training.  Since perceptions involve cultural and generational differences and are integral in interpersonal relationships, we hypothesize that perceptions of inappropriate behavior vary among medical students and attending surgeons subsequently directing students’ career paths.

Methods:
Medical students were given an evaluation twice during their surgery clerkship: at midpoint and rotation end. From a list, students were asked to select which behaviors they thought were appropriate or inappropriate.  Some behaviors included raising one’s voice, making sexual comments, and using foul language. Students were also asked if they had witnessed or experienced any of these behaviors at the end of the clerkship. Half of the participant’s evaluations were paired from mid to endpoint and specialty choice assessed. Seven attending surgeons participated in a separate survey and selected from a similar list of behaviors and rated them on appropriateness.

Results:
We first investigated whether the students and attending surgeons agreed on what they perceived as inappropriate behavior.  No behavior was completely agreed upon by either group. The following behavior had at least a 20% disparity among groups: use of foul language, ignoring someone, raising one's voice and making sexual comments. We then investigated any change in student’s perception of inappropriate behavior during the clerkship.   Interestingly, most students’ perceptions regarding at least one behavior changed from midpoint compared to the end of the rotation.  Of 41 students, 16 witnessed or experienced behavior they thought was inappropriate.  Three of these 16 students were considering surgery as a specialty at midpoint.  One of these three changed to a non-surgical specialty at the end of the rotation secondary these experiences. 

Conclusion:
Perception of inappropriate behavior varies among individuals, not only between students themselves, but between students and attending surgeons.  Since most students changed their perceptions during the rotation, we can conclude perceptions may be influenced by the interactions during the clerkship itself. Furthermore, witnessing or experiencing perceived inappropriate behavior leads to an undesirable learning environment.  Specific core professionalism training for both attending surgeons and medical students is necessary to ensure an inspiring learning environment fostering positive attitudes towards surgical careers.
 

57.05 Assessment of Desired and Actual Student Procedural Competence Over Time

Posted on January 26, 2017

C. Becker1, M. Meyers1  1University Of North Carolina At Chapel Hill,Surgery,Chapel Hill, NC, USA

Introduction:   Curriculum guidelines for medical students have changed in recent years associated with American Association of Medical Colleges guidelines published in 2014 deemphasizing procedural skill acquisition.  As such, the average student finishes their training with less procedural experience than in generations past.  We sought to examine whether student opinion has changed over time with regard to their desires for skill acquisition.     

Methods:   Under IRB approval, we conducted a survey of 4th year students over a six-year period (2011-2016) at a single medical school.  Experience, actual and desired levels of competence were measured for nine procedural skills (Table) using a 4-point Likert scale (1=unable to perform; 2= major assistance; 3= minor assistance; 4=independent). Data were compared by Student’s t test.

Results:  134 students (62 men/70 women) responded in 2011 (86% response rate(rr)) and 96 (59 men/37 women) in 2016 (56% response rate).  More students in 2011 were destined for a procedural specialty (57% vs. 28%; p=0.005).  For all skills, there was no difference in the students perceived level of actual competence between 2011 and 2016 except for arterial puncture. (Table) Similarly, for all skills except venipuncture, there was no difference in the desired level of competence between the two years. (Table) In both years, 2016, there was a significant difference between desired and actual competence for all skills (table).   

Conclusion:  No difference in either actual or desired competence was seen between 4th year students over a six year period of time for these nine skills, despite changes in recommendations from the AAMC minimizing expectations for graduating students.  Students in both years desired a significantly greater level of competence than they acquired.  Future recommendations should take into account student desires in evaluating curriculum changes.    

 

56.19 Is Resident-Protected Time Really Protected?

Posted on January 26, 2017

J. Legino1, M. Al-Kasspooles1, J. Ashcraft1, J. Valentino1, P. DiPasco1  1University Of Kansas Medical Center,Department Of Surgery,Kansas City, KS, USA

Introduction: Residency programs commonly integrate protected time into their workweek to allow didactic resident education without service related interruptions. Unfortunately, this respite is often willfully interrupted by clinical responsibilities or personal distractions, e.g., texting, that erode the sanctity of protected educational time. The aim of this study is to look at whether resident protected education time is truly protected in the face of unrelenting technological distractions such as pagers, cell phones, and computers.

Methods: This is an observational study of resident behavior during didactic lectures classified as protected learning time. Data was collected on the number of interruptions each resident experienced due to a technology-driven source. Each didactic lecture lasted approximately 1 hour in length.

Setting: Four Weekly Consecutive General Surgery Resident Education Conferences in an Academic Teaching Institution

Participants: General Surgery Residents

Results: In total, 15 residents were included in this study with training levels ranging from PGY1 to PGY5. A cumulative analysis combining the data from all 4 lectures showed that all residents experienced at least 4 interruptions over the course of the 4-lecture series. The maximum number of interruptions experienced by a single resident was 19. Over 4 cumulative sessions, the resident group experienced an average of 10.13 interruptions with 60% of the residents experiencing 8-19 interruptions.

Conclusion: The current model of protected resident education time is not an effective learning model due to the ubiquitous and seemingly irresistible nature of technological diversions. It is our recommendation based on these observations that more stringent measures should be taken to limit technological distractions during protected education time or that institutions abandon the practice of protected time all together. Further studies evaluating the most effective, distraction-free models for resident education are warranted.   
 

56.17 Use of an Online Curriculum Amongst Surgical Interns: Results of a Pilot Study

Posted on January 26, 2017

J. A. Taylor1, L. Spiguel1, A. Iqbal1  1University Of Florida,Department Of Surgery,Gainesville, FL, USA

Introduction:  The availability of material on the Internet influences how and what surgical residents use to study for assigned work, patient care, and for the annual in-service exam.  At the authors’ institution, the weekly teaching conference for the surgical interns incorporates online material, including that from the Surgical Council on Resident Education (SCORE) website, into the interns’ online curriculum.  We sought to investigate and define interns’ use of study material in various mediums, with the intent of using the results to assist in future curriculum development.  

Methods:  An IRB-approved survey inquiring about study material usage was administered to the interns at the end of the 2015 academic year.  It had been validated through a modified Delphi technique. Participation was voluntary.  Responses were de-identified prior to author analysis.  Descriptive statistics were performed on demographic data. Kruskal-Wallis and Mann-Whitney analyses were performed on Likert responses (α =0.05). 

Results: There was a 91.7% response rate (n=11). 45.4% were female. 54.5% were categorical interns.  No interns responded that they “always” used a textbook a study.  Similarly, no interns responded that they “usually” or “always” accessed the free surgical ebooks available through the university library.  9% used the Internet “always” to study; in total, 90.9% used SCORE (p<0.05).  Peer-reviewed journals and personal notes from sources such as clinic teaching were nearly universally not used for routine study material.  72.7% of interns were “somewhat satisfied” with the current study materials they used (p<0.05).  A majority of interns were either “somewhat satisfied” or “completely satisfied” with the assigned weekly curriculum material they accessed.  Regarding what would prompt them to use the online intern curriculum website more, 45.5% responded that they would use links to specific chapters in ebooks, if these were posted on the site.  36.4% wanted ability to download slides and handouts used by the faculty during the weekly conferences. 54.5% requested links to short video clips of operations.

Conclusion:  Although limited in group size, this survey study gave valuable insight regarding resources used, particularly as it related to material curated by surgery faculty for the interns.  The trend of the responses towards Internet use, specifically those with multimedia content, perhaps speaks to generational preferences, but also highlights the importance of knowing the learner audience.  The long term goal is to generate and continuously update an online curriculum that will improve comprehension of surgical issues, improve exam results, create an efficient learning environment, and stimulate greater intern satisfaction.

 

56.16 Examination of Surgeon Comfort with Complex Surgical Procedures in the Military Healthcare System

Posted on January 26, 2017

W. H. Ward2, L. M. Fluke1, C. S. McEvoy1, J. L. Fitch3, R. L. Ricca1  1Naval Medical Center Portsmouth,Department Of General Surgery,Portsmouth, VA, USA 2Fox Chase Cancer Center,Philadelphia, PA, USA 3University Of Texas Health Science Center At Houston,Houston, TX, USA

Introduction: Due to multiple factors, surgical residents may be exposed to fewer complex hepatobiliary cases affecting comfort levels.  Within the Military Healthcare System, surgeon training is variable with regard to exposure and volume. This investigation examines differences in training, volume, and operative comfort with complex general surgical procedures.

Methods: A total of 174 active duty Navy surgeons were surveyed concerning training, military station, current volume, and comfort level with complex general surgical procedures.  Forty-seven surveys were returned.   Board certified surgeons caring for adult patients were included.   Comparisons were made between surgeons at regional military treatment facilities versus those at smaller hospitals, surgeons trained within the military versus out-service residency training, and surgeons who had or had not completed a fellowship. 

Results:Males comprised 74%, median age was 42, and median time in practice was 5 years.  Twenty-one percent were civilian-trained surgeons and 60% completed a fellowship.  Sixteen (38%) surgeons were stationed at regional medical centers while the majority was assigned to smaller hospitals. There were no significant differences in procedure comfort based on fellowship training or residency training site.  Subjective level of comfort with procedures did not correlate with actual surgical volume. 

Conclusion:This review demonstrates that within the Military Health System, there is no subjective advantage to the completion of sub-specialty fellowship training.  Additionally, there appears to be no difference between military or civilian residency training with regard to the individual surgeon’s comfort with complex procedures.

 

56.13 “Speed Dating for Mentors”: A Novel Approach to Mentor/Mentee Pairing in Surgical Residency.

Posted on January 26, 2017

A. D. Caine1, A. Kunac1  1University Of Medicine And Dentistry Of New Jersey,General Surgery,Newark, NJ, USA

Introduction:  Mentoring has been established as a useful adjunct to resident support systems. Although not as extensively studied as attending-resident mentoring, resident-resident mentoring offers additional benefits. Previous works have shown that the quality of the mentorship pairing is important but techniques of pairing have seldom been described.  Herein we describe a system for mentor-mentee pairing that we call “Speed Dating for Mentors” (SDM).

Methods:  The SDM activity took place in an academic general surgery residency program in the Northeast consisting of 29 PGY 1-2 junior residents (JR) and 28 PGY 3-5+ senior residents (SR). SDM took place during academic protected time. JR were seated in our lecture auditorium while SR went in consecutive fashion from resident to resident in 90 second intervals. Upon completion of all interviews both JR and SR documented their 1st, 2nd and 3rd choices for mentors or mentees as well as rationale for their choices—this was used to create senior-junior resident pairings. A cross sectional written survey with Likert-type responses was conducted with univariate analysis of satisfaction with the SDM event and factors important to residents in choosing a mentor. 

Results: Forty-one surgical residents participated in SDM—23 junior residents participated and 19 senior residents participated resulting in 23 mentor-mentee pairings. Fourteen pairs were generated where both mentor and mentee were among top 3 choices, 7 pairings generated where either the mentor or mentee were a top 3 choice, and 2 pairings from the SDM session were assigned. The remaining 6 pairs were assigned for non-attendees. The most common rationale cited was “similar interests.”  A total of 36 surveys were completed—28 (78%) of respondents participated in SDM compared to 8 (22%) who did not. Of attendees, 82% of respondents were “satisfied” or “very satisfied” with the event. Eighty-five percent of respondents who attended were “satisfied” or “very satisfied” with their pairing compared to only 12% of non-attendees. Sixty-two percent of non-attendees were “neutral,” “dissatisfied” or “extremely dissatisfied” with their pairing and 2 non-attendees declined to answer. Race/ethnicity and gender were not found to be important and 86% of respondents thought having protected time for mentoring to be important.

Conclusion: “Speed Dating” is a novel approach to pairing surgical residents for the purpose of mentorship and allowed residents to identify potential mentors/mentees with similar interests. Residents who attended the event were satisfied with the event and with the outcome of their mentor/mentee pairing; SDM may also be a useful tool for faculty-resident mentorship pairings. Further investigations are warranted to determine what effects resident mentoring has on resident performance, stress levels, and morale.

 

56.09 Modern practice patterns of parathyroidectomy and implications for education.

Posted on January 26, 2017

A. Swearingen1, J. Jin1, J. J. Shin1, E. Berber1, A. Siperstein1, V. D. Krishnamurthy1  1Cleveland Clinic,Department Of Endocrine Surgery,Cleveland, OH, USA

Introduction:
Recent ACGME defined category operative requirements will require that graduates participate in a minimum of fifteen endocrine cases during general surgery residency, which is nearly double from the previous requirement of eight.  Parathyroid exploration is a common endocrine procedure and trainee exposure is variable.  We analyzed current practice patterns of parathyroid operations in the United States with respect to specialty and training.

Methods:
Centers Medicare and Medicaid Services datasets were used to identify surgeons who performed >10 parathyroid operations in 2014 on Medicare Part B beneficiaries (MCB).  Previous residency training was characterized as general surgery (GS) and otolaryngology (ENT).  Fellowship-trained (FT) surgeons were categorized as endocrine surgeons (ES), surgical oncologists (SO), and head and neck oncologists (H&N).  Surgeons who had entered practice in preceding decade were considered early-career.  Statistical analysis was performed with JPM Pro V12.

Results:
We identified 317 surgeons in 44 states who performed 6,560 parathyroid explorations on MCB 2014.  Median number of operations performed per surgeon was 17.  Residency training was GS for 76% (n=240) and ENT for 24% (n=75).  Overall, 41% were FT (n=128) and 59% were not-FT (N=187).  Of FT surgeons, 66% were ES (n=85), 20% were SO (n=25), and 15% were H&N (18).  Fifty percent practiced in non-academic settings (n=158).  The mean number of operations performed per surgeon was greater for GS-trained surgeons compared to ENT (21±1 vs. 18±1, p=0.037), FT surgeons compared to not (23±1 vs. 20±1, p=0.014), and academic compared to community surgeons (23±1 vs. 18±1, p=0.0001).  Early career surgeons who had completed fellowships performed more operations per surgeon when compared to their not-FT contemporaries (21±2 vs. 17±2, p=0.3).

Conclusion:
Most parathyroid surgery in the United States elderly population is performed by general surgeons, many of whom did not pursue an associated fellowship.  This supports the ACGME’s effort to strengthen education and experience with parathyroid surgery during residency. For programs who are challenged by the increased minimum of endocrine procedure requirements, residents can gain further experience through faculty recruitment of fellowship-trained surgeons or by proctorship with endocrine surgeons practicing in the community.
 

56.08 Research During General Surgery Residency: A Web-Based Review of Opportunities, Structure and Outputs

Posted on January 26, 2017

A. Brochu1, R. Aggarwal1  1McGill University,Faculty Of Medicine,Montreal, QC, Canada

Introduction:
Academic research is an integral part of residency training and several general surgery training programs offer opportunities for research experience. Despite standardization of surgical training requirements, there is perceived lack of structure and guidelines for residents who undertake research during their general surgery program. The aim of this study was to identify research opportunities, structure of research programs, and academic outputs during general surgical residency in United States of America (USA).

Methods:
A web-based review of all accredited general surgery residency programs in the USA was undertaken. Individual websites were reviewed for information regarding mandate, duration, and type/structure of research pursued by residents during their training. The research outputs (advanced degree, publications, presentations, grants), current projects in surgical departments and availability of faculty supervisors were also identified. 

Results:
Data was available for 236 general surgery residency programs of which 135 (57.2%) offer dedicated research years, ranging from one to four years, and 29 (12,3%) programs mandate such time as required. 139 (58.9%) programs offered opportunities in clinical research, 124 (52.5%) in basic sciences research, 28 (11.9%) in health services and outcomes-based research, and 15 (6.4%) in education research. Advanced degree were mentioned for 37 (15.7%) programs: 16 (6.8 %) offer MBA, 21 (8.9%) Master of Public Health, 16 (6.8%) PhD, 12 (5.1%) Master of Sciences, 7 (3.0%) Master of Clinical Investigation and 5 (2.1%) Master in Education. 16 (11,9%) programs explained research structure and how resident research progress is followed. 52 (22.0%) programs provided examples of past resident research, 195 (82.6%) programs offered a list of faculty supervisors, and 128 (54.2%) listed examples of current department research projects.

Conclusion:
Opportunities for dedicated time for research during general surgical residency are present in about half of programs with over 10% mandating such time, though the structure and academic outputs of these programs are inconsistent and poorly portrayed. The majority of programs offer basic or clinical research with a paucity of programs offering education and health services research opportunities. About a quarter of the programs offer residents to pursue advanced degrees; the majority being MBA, MPH or PhD. Whilst research opportunities are ample during surgical US residency training, there is opportunity to provide better structure and guidelines to potentially enhance the research outputs.
 

56.07 Do Women Perceive Surgical Residency Training Differently? A FIRST Trial Analysis

Posted on January 26, 2017

K. A. Ban1,2,3, J. W. Chung1, R. S. Matulewicz1, R. R. Kelz4, A. R. Dahlke1, C. Quinn1, A. D. Yang1, K. Y. Bilimoria1,3  1Northwestern University,Surgical Outcomes And Quality Improvement Center (SOQIC), Department Of Surgery, Feinberg School Of Medicine,Chicago, IL, USA 2Loyola University Medical Center,Department Of Surgery,Maywood, IL, USA 3American College Of Surgeons,Chicago, IL, USA 4University Of Pennsylvania,Department Of Surgery, Perelman School Of Medicine,Philadelphia, PA, USA

Introduction: No studies have systematically investigated if gender differences exist in perceptions of residency training with respect to patient safety, resident education, wellbeing, and job satisfaction and if duty hour policies affect such gender differences. The Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial collected novel survey data from all surgical residents on perceptions within these areas. Our objectives were to (1) compare male and female surgical resident perceptions of patient safety, resident education, wellbeing, and job satisfaction and (2) determine if duty hour policies affect gender differences in perception.

Methods: Using FIRST Trial resident survey data, we compared the proportion of male and female residents in categorical intern, junior (PGY 2-3), and senior (PGY 4-5) resident cohorts who expressed dissatisfaction (vs. neutrality or satisfaction) with dimensions of patient safety, resident education, and wellbeing or a perceived negative effect (vs. neutral or positive effect) of duty hours on patient safety, wellbeing, and job satisfaction. The association between dissatisfaction (or a perceived negative effect of duty hours), gender, duty hour policy, and the interaction between duty hour policy and gender was modeled using logistic regression with robust standard errors accounting for clustering of residents within programs.

Results:Comparing perception differences between males and females in each training level cohort, there were no significant differences among interns. Female junior residents were more likely to be dissatisfied with patient safety (OR 2.50, p=0.007) and overall wellbeing (OR 2.10, p<0.001) than males. Female senior residents were more likely to be dissatisfied with resident education (OR 1.56, p=0.035) than males. Comparing differences in gender perception differences between the standard and flexible duty hour arms in each training level cohort (i.e., significance of a gender by study arm interaction), female interns under standard duty hours were more likely to perceive a negative effect of duty hours on their satisfaction with the decision to become a surgeon than males, whereas female interns under flexible duty hours were less likely than males to perceive a negative effect (p=0.028). Among junior residents, females in both duty hour arms were more likely to perceive a negative effect of duty hours on patient safety and job satisfaction than males, and this gender difference was augmented under flexible duty hours (p<0.001 and p=0.007, respectively). For senior residents, there were no statistically significant differences in gender perception differences between the standard and flexible duty hour study arms.

Conclusion:Important gender differences may exist in perceptions of surgical residency regarding patient safety, resident education, wellbeing, and job satisfaction. These differences vary across cohorts and may be influenced by duty hour policies.

 

56.06 The Components of a Surgery Residency Program That Contribute to Scholarly Success.

Posted on January 26, 2017

M. Eby1, J. Buicko1, S. Scurci1, L. Tamariz2  1University Of Miami,General Surgery,Miami, FL, USA 2University Of Miami,Population Health And Computational Medicine,Miami, FL, USA

Introduction:
Scholarly work during a surgical residency is an accreditation requirement. A motivation to do scholarly work is fellowship application. Many residency programs have published the success and failures of their research programs. However, the specific components of a successful program are unknown. Our aim was to conduct a systematic review of the published surgery research methods programs and evaluate what components increase scholarly activity.  

Methods:
We performed a search of the MEDLINE database (1966 to February 2016) supplemented by manual searches of bibliographies of key relevant articles. We included studies that reported a description of the research methods program. The components that were evaluated came from literature review and the themes evaluated included a research director, mentorship, a curriculum, biostatistical support, progress meetings, funding, research day, online educational modules and protected time. We defined scholarly activity as conducting original research and presenting in a national meeting or publishing in peer-review journals. 

Results:
The search strategy yielded 1161 studies, of which 9 met our eligibility criteria. The studies included 497 surgery residents and median program duration was 2 years; IQR (1.5-4). The most commonly reported theme was having a curriculum and having research progress meetings. The least commonly reported theme was having funding and having online research resources. The table shows the tertiles of the components of the research program. The components more commonly associated with higher scholarly activity were having a curriculum, research director, having an active mentorship program and having protected time. The factors related with lower scholarly activity were not having a research director and not having biostatistics support.

Conclusion:
Surgical training programs should have a research director, protected time, mentorship plans and an educational curriculum to assure research scholarly success.

 

56.05 Professionalism and Communication Competencies in Surgical Residency: A Pilot Humanities Curriculum

Posted on January 26, 2017

J. Colvin1, J. French1, A. Siperstein2, T. Capizzani1, V. Krishnamurthy2  1Cleveland Clinic,General Surgery,Cleveland, OH, USA 2Cleveland Clinic,Endocrine Surgery,Cleveland, OH, USA

Introduction:
The six core competencies of Accreditation Council for Graduate Medical Education include professionalism and interpersonal skills and communication; however, formalized educational didactics are poorly defined and widely vary between programs. We aimed to conduct professionalism and social competencies (PSC) training by integrating humanities into structured workshops, and to assess reception of this curriculum by first-year surgical residents.

Methods:
An IRB-approved, pilot curriculum consisting of four interactive workshops for interns was developed at a surgical residency with 10 categorical graduates annually. The workshops were scheduled quarterly, often in small group format, and supplemental readings were assigned. Humanities media utilized to illustrate PSC included survival scenarios, reflective writing, television portrayals, and social media. Emphasis was placed on recognizing personal values and experiences that influence judgment and decision-making, using social media responsibly, identifying and overcoming communication barriers related to generational changes in training (especially technology and work-life balance), and tackling stereotypes of surgeons. Anonymous and voluntary pre and post-curriculum surveys were administered. Univariate analysis of responses was performed with JMP Pro v12 using Fisher’s exact,  χ2, and students’ t-tests for categorical and continuous variables.

Results:
Sixteen surgical interns participated in the curriculum: 69% were domestic medical school graduates (DG) and 31% were international medical school graduates (IMG). Overall, the majority (81%) of residents had received PSC courses during medical school: 100% of DG compared to 40% of IMG (p=0.02). Prior to beginning the curriculum, 86% responded that additional PSC training would be useful during residency, which increased to 94% upon completion (p=0.58). Mean number of responses supporting the usefulness of PSC training increased from 1.5 ± 0.2  prior to the curriculum to 1.75  ± 0.2 upon completion (p=0.4). When describing public and medical student perceptions of surgeons, 60% and 83% of adjectives used were negative, respectively. When describing perceptions of female surgeons, 88% of adjectives used were negative. More negative adjectives were used to describe media representations of female surgeons compared to males (51% vs. 40%, p=0.3).

Conclusion:
Most interns received prior PSC coursework; however, the majority still desired additional training during residency. After completion, a greater percentage of interns responded that PSC training was important and choose more reasons in favor of the curriculum. Formalized didactics should be strongly considered, especially in programs with IMG. Future areas of investigation include expanding the cohort to additional years of residency, potentially identifying unique PSC needs for each postgraduate year.

56.01 Resident Education on Handoffs Can Reduce Patient Harm

Posted on January 26, 2017

J. Sugrue1, A. Ejaz1, S. Eftaiha1, H. Shah1, J. Nordenstam1, A. Mellgren1, G. Havelka1  1University Of Illinois At Chicago,Surgery,Chicago, IL, USA

Introduction:

Increasing patient handoffs among surgical residents due to duty hour restrictions have been linked to discontinuity in patient care and potentially worse patient outcomes.   Educational interventions designed to evaluate and improve handoffs, however, are lacking. The aim of the current study was to assess resident attitudes towards patient handoffs and to evaluate the impact of resident education on patient handoffs.

Methods:  

All 39 general surgery residents at a single academic institution were administered a voluntary survey regarding their attitudes about patient handoffs. Two months after the initial survey, a supplemental voluntary educational course was administered. The course reviewed published literature regarding patient handoffs and provided suggestions to improve the handoff process. One month after the course, the survey was re-administered. In the survey, patient harm was considered minor when there were limited clinical consequences and major when there were significant clinical consequences.

Results:

31 residents (response rate: 79%) completed the initial survey.  The majority of residents spent an average of one minute or less on handoffs per patient (n=17, 55%).  90% of residents stated they received an inadequate handoff resulting in minor (n=28, 90%) or major (n=15, 48%) patient harm within the past 12 months.  The most common reasons for inadequate handoffs were lack of information in the verbal handoff (57%), lack of information in the written handoff (43%), interruption during the handoff process (26%), and time constraint affecting the incoming resident (26%).  Overall, 20 residents (48%) responded that they had been educated on patient handoffs within the past 12 months, including 11 residents (response rate: 28%) who completed the follow-up survey after attendance of the educational course.  Resident education reduced the incidence of inadequate handoffs that resulted in minor harm to a patient (p=0.05), and major harm (p=0.13) (Figure 1).

Conclusions:

Nearly all residents received a patient handoff resulting in minor or major patient harm. Resident education reduced the incidence of inadequate handoffs that resulted in patient harm. Further studies are needed to better characterize the optimal manner with which to educate residents on handoffs and to validate instruments to assess the quality of patient handoffs.

55.20 An Analysis of Discussions Following National Presentation of a Surgical Case Series

Posted on January 26, 2017

A. Siy1, E. Winslow1  1University Of Wisconsin,Department Of Surgery,Madison, WI, USA

Introduction: One unique method of clinical research in surgical disciplines is the surgical case series.  A case series typically details the outcomes of consecutive patients operated on at a single center. Although these series lend understanding, they also have limitations. Because no reporting guidelines specific to case series exist, the elements described in their presentation are quite varied. We aimed to determine the primary areas of academic inquiry after presentation of a case series at national surgical meetings.

Methods: Abstracts of manuscripts published in Journal of the American College of Surgeons and Annals of Surgery from 2010 to 2015 were reviewed. A case series was defined as the study of a consecutive series of patients at a single institution for the purpose of describing their clinical outcomes. Those case series with accompanying discussions were analyzed. All interrogative sentences in the discussion were selected for thematic analysis and were classified by a redundant iterative process into descriptive categories.

Results: 186 case series were identified, 55 of which included the transcript for the post-presentation discussion. A total of 476 unique interrogatives were identified and classified into 4 categories and 13 subcategories. The most frequent single inquiry (20.8%) pertained to the applicability of the findings to patient care (e.g. how the data changed the author’s practice). A full 18% sought clarification of study variables (e.g. personnel involved, technical details, definitions of study terms). Nearly 7% highlighted selection bias (i.e. how patients not selected for the procedure fared in comparison). Interestingly, areas that received minimal to no attention included: cost, long-term outcomes, statistical methods, details of data collection or patient satisfaction.

Conclusion: This analysis of inquiries after presentation of surgical case series to national academic audiences highlights some areas of common concern. Of most importance is the direct applicability of the data presented to the care of patients. Specifically stating how the findings of the presented study have affected the authors’ clinical care for patients would improve face validity. In addition, defining all study variables including personnel and technical approaches is of primary interest to the audience. Finally, a description of the potential effects of selection bias on the outcomes appears to also be of major import. Addressing these areas of interest at the time of presentation of a case series is likely to improve its quality and to maximize the utility of this form of clinical research.

 

55.19 A Comparison of Post-Operative MI Rates Based on the Universal 2012 and NSQIP Definitions

Posted on January 26, 2017

K. S. Shrestha1, A. A. Gullick2, T. S. Wahl2, R. H. Hollis2, J. Richman2, J. K. Kirklin2, M. S. Morris2  1University Of Alabama at Birmingham,School Of Medicine,Birmingham, Alabama, USA 2University Of Alabama at Birmingham,Department Of Surgery,Birmingham, Alabama, USA

Introduction:  The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) provides benchmarking quality standards designed to improve quality of care and surgical outcomes. We explore NSQIP’s current definition (2007 Universal Definition) of myocardial infarctions (MI) and compare to an updated definition, the 2012 Universal Definition of MI.

Methods:  All NSQIP assessed post-operative cardiac events in 2013-2015 from a single institution were examined as part of a quality improvement project. The current NSQIP definition (2007 Universal definition) classifies an MI by one of the following: a troponin elevation 3-times the upper limit of normal (ULN), ischemic EKG changes, or any charted physician diagnosis. The 2012 Universal definition is defined by a troponin elevation of 5-times the ULN and at least one of the following: ischemic symptoms, ischemic EKG changes, wall motion abnormalities on imaging studies, or an intraluminal thrombus detected on an angiogram. The study group included all patients who met the NSQIP definition for postoperative MI. The 2012 Universal definition was then applied to the group with patient- and procedure-specific characteristics compared by MI definition (NSQIP vs. 2012) using Chi-Square tests. 

Results: Eighty-one patients were identified. Only 27 (33.3%) of patients meeting the NSQIP definition also met the 2012 Universal definition of MI. Overall, the average patient was a 68.1 (SD 12.2) year old white (69.1%) male (54.3%) with a BMI of 28.2 (SD 7.8). There were no significant differences between definition groups (NSQIP vs. 2012) regarding patient demographics or perioperative complications. Only 22.2% of the NSQIP defined group had a troponin level 5-times the ULN meeting the 2012 Universal defined group (p<0.0001). Patients classified using the 2012 Universal definition had significantly more ischemic EKG changes compared to the NSQIP definition (ST-elevation: 25.9% vs 3.7%, respectively, p=0.01; Q wave: 22.2% vs. 0%, respectively, p= 0.001). NSQIP defined MI occurrences were more likely to be NSTEMI type II events compared to the 2012 Universal group (85.2% vs. 51.9%, p = 0.003). Patients with MI meeting 2012 definition were more likely to have Ischemic symptoms (70.4% vs 37%, p=0.005) and abnormal imaging changes (33.3% vs 13%, p=0.03) compared to the current NSQIP definition.

Conclusion: Only one-third of patients with a MI defined by the current NSQIP definition met the 2012 universal MI definition. Compared to the current NSQIP MI definition, the 2012 Universal definition captures patients with more ischemic symptoms, ischemic EKG changes, abnormal changes on imaging studies, and higher troponin levels during an MI with fewer NSTEMI Type II events. The current NSQIP definition may over-estimate true coronary events. Further consideration to update and reclassify NSQIP’s MI definition may be warranted.

The project described was supported by Awards Numbered T32DK062710 and P30DK079626 from the National Institute of Diabetes and Digestive and Kidney Diseases. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Diabetes and Digestive and Kidney Diseases or the National Institutes of Health.

55.18 Preoperative Invasive Care Setting and Postoperative Infection in Pancreaticoduodenectomy

Posted on January 26, 2017

A. T. Nguyen2, Z. M. Dong2, J. W. Marsh1, A. Tsung1  1University Of Pittsburgh,Department Of Surgery,Pittsburgh, PA, USA 2University Of Pittsburgh,School Of Medicine,Pittsburgh, PA, USA

Introduction:  Pancreaticobiliary and duodenal tumors often present with obstructive pathology and require invasive procedures for therapeutic and diagnostic purposes such as ERCP or endoscopic biopsy. Currently, there is no evidence favoring inpatient versus outpatient intervention. Though admission for these procedures may be more convenient for providers, it may also predispose patients to microbial colonization and consequent infection. The purpose of this study is to evaluate the relationship between inpatient and outpatient preoperative management and postoperative infection. 

Methods:  This retrospective cohort study includes 301 patients who underwent pancreaticoduodenectomy from 2012 to 2015. Demographic, preoperative care and tumor characteristic data were collected. All patients underwent either endoscopic biopsy, ERCP, or PTC prior to surgery. Patients were categorized as inpatients or outpatients based on the setting of preoperative intervention 180 days prior to surgery. Chi-square, Mann-Whitney U, univariable and multivariable logistic regression were carried out with Stata 14. Adjustment variables had p-values less than 0.2.

Results: Of the 301 patients 34.9% were outpatients and 65.1% were inpatients. The groups did not differ in prevalence of diabetes, hypertension, coronary artery disease, age, sex or type of cancer. The primary outcome was postoperative infection subdivided into specific infection type. The rate of all postoperative infections was 45.8% and not significantly different between groups (p = 0.45). Of the infection subtypes, SSI significantly differed and occurred in 20.9% of outpatients versus 32.7% of inpatients (p = 0.032). In univariable logistic regression for SSI, inpatient status had an OR of 1.83 (95% CI 1.05 – 3.19, p = .034). The multivariable model adjusted for tumor size, stage and type of preoperative intervention. In multivariable logistic regression for SSI, inpatient status had an adjusted OR of 1.74 (95% CI 0.95 – 3.18, p = .071). No adjustment variables were significantly related to SSI. 

Conclusion: Inpatient invasive care prior to pancreaticoduodenectomy was associated with a significant increase in postoperative surgical site infection. This suggests that patients with pancreaticobiliary and duodenal cancers should receive outpatient workup whenever possible to reduce postoperative morbidity. 

 

55.17 Correlation of Hebal-Malas Index with Haller Index in Pediatric Patients with Pectus Excavatum

Posted on January 26, 2017

F. Hebal1, J. Green2, B. Malas1, M. Reynolds1,2  1Ann & Robert H Lurie Children’s Hospital Of Chicago,Pediatric Surgery,Chicago, IL, USA 2Northwestern University,Feinberg School Of Medicine,Chicago, IL, USA

Introduction: Computed tomography (CT) derived Haller Index (HI) is the gold-standard metric of Pectus Excavatum (PE) deformity severity. White Light Scanning (WLS), a novel 3D imaging modality, offers a potential alternative that is quick, inexpensive, and safe. Using no ionization radiation, WLS may be safely used for repeated scanning in longitudinal monitoring of progression of PE deformity. Previous pilot investigation demonstrated feasibility of using a handheld White Light Scanning (WLS) device to measure PE deformity and showed promising early correlation results of a new WLS-derived PE severity index, the Hebal-Malas Index (HMI), with CT-derived HI. Further investigation is necessary to establish WLS-derived HMI as a potential preoperative study modality in PE. This study assesses correlation of HMI with HI measured in preoperative CT scans of pediatric patients with PE.

Methods: We conducted a retrospective review of preoperative CT scans in pediatric patients with PE from 2006-2015. Reported HI was collected from the CT impression documented in the electronic medical record (EMR), and two raters independently measured HI and HMI using this same CT scan. Pearson correlation assessed rater measured HMI with EMR reported HI and rater measured HI. Intraclass Correlation (ICC) assessed interrater reliability of HMI. Measurement and calculation of HMI and HI is shown in Figure 1.

Results:Of 140 identified charts, 35 with incomplete data collected were excluded (18 HI undocumented in record, 8 HMI unmeasurable in scan, 4 no CT image found, 5 incomplete HMI data) leaving 105 for review. For Rater 1 measured HMI, Pearson analysis showed strong correlation with EMR reported HI (r=0.74;p-value<.0001;n=105), Rater 1 measured HI (r=0.77;p-value<.0001;n=105), and Rater 2 measured HI (r=0.71;p-value<.0001;n=41). For Rater 2 measured HMI, Pearson analysis showed moderate correlation with Reported HI (r=0.41;p-value=0.012;n=37), Rater 1 measured HI (r=0.43;p-value=0.008;n=36), and Rater 2 measured HI(r=0.42;p-value=0.009;n=37). To date, complete HMI data for both raters was collected for 36 scans. For these 36 scans, ICC showed strong interrater reliability of HMI between two raters (ICC=0.71;CI:0.501-0.841;P-value<0.0001). 

Conclusion:Correlation of HMI with HI and reliability between raters demonstrates strong potential for the use of HMI as a proxy for Haller Index. Currently enrolling prospective investigation of WLS-derived HMI with CT-derived HI continues with the goal of establishing WLS as a preoperative study and progress monitoring modality for patients with PE

 

55.16 Continuous Monitoring of Vital Signs on the General Ward

Posted on January 26, 2017

M. Weenk1, S. Bredie2, L. Engelen3, T. Van De Belt3, H. Van Goor1  1Radboudumc,Surgery,Nijmegen, GELDERLAND, Netherlands 2Radboudumc,Internal Medicine,Nijmegen, GELDERLAND, Netherlands 3Radboudumc,Radboud REshape Innovation Center,Nijmegen, GELDERLAND, Netherlands

Introduction: Measurement of vital signs in hospitalized patients is necessary to assess the clinical situation of the patient. Early warning scores (EWS), such as the Modified Early Warning Score (MEWS) are generally measured three to four times a day and may not capture early deterioration. A delay in diagnosing  deterioration is associated with increased mortality and costs. Clinical deterioration might be detected earlier by wearable devices continuously monitoring vital signs, which allows clinicians to take corrective interventions. Further these devices potentially reduce patient discomfort and work load of nurses. In this pilot study, reliability of continuous monitoring using the ViSi Mobile (VM; Sotera; HR, RR, saturation, BP, skin temperature) and HealthPatch (HP; Vital Connect; HR, RR, skin temperature) was tested and experiences of patients and nurses were collected.

Methods: Twenty patients, 10 at the surgical and 10 at the internal medicine ward, were monitored with both devices simultaneously for 2-3 days and data were compared with MEWS measurements taken as reference method. Artifacts in continuous data were registered and analyzed. Patient and nurse experiences were obtained by semi-structured interviews.

Results: Eighty-six MEWS measurements were compared with VM and HP measurements. Almost all VM vital signs (mean difference HR -0.09 bpm; RR 1.00 breaths/min; saturation 0.19%; temperature 0.00 ?C; BP systolic 1.33 mmHg) and all HP vital signs (HR -2.10 bpm; RR -0.58 breaths/min; temperature 0.00 ?C) were in range of accepted discrepancies, although wide limits of agreement were found. The largest discrepancy in mean difference was found for VM diastolic blood pressure (-8.33 mmHg) probably due to inaccuracy of measurement by nurses. Predominant VM artifact (70%) was a connection failure. Over 50% of all HP artifacts had unknown cause, were self limiting and took less than one hour. The majority of patients, family members, and nurses were positive about VM and HP, e.g. increased feelings of safety, better sleep and more comfort for patient and nurses. Devices did not restrict patients’ daily activities. Disadvantage were the cables (showering) and the short battery life of the VM device.

Conclusion: Both VM and HP have potential for continuously measuring vital signs in hospitalized patients. The devices were well received and comfortable for most patients. A further study focuses on the different effects of VM or HP compared to routine MEWS on patient comfort and safety and nurse workload, and on early detection of deterioration.

 

55.15 The Ottawa Criteria for Appropriate Transfusions in Hepatectomy (OCATH)

Posted on January 26, 2017

S. Bennett1,10, A. Tinmouth2,10, D. I. McIsaac3,10, S. English2,10, P. C. Hébert4, P. J. Karanicolas5, L. McIntyre2,10, A. F. Turgeon7, J. Barkun8, T. M. Pawlik9, D. Fergusson10, G. Martel1,10  1University Of Ottawa,Department Of Surgery,Ottawa, Ontario, Canada 2University Of Ottawa,Department Of Medicine,Ottawa, Ontario, Canada 3University Of Ottawa,Department Of Anesthesiology,Ottawa, Ontario, Canada 4Centre Hospitalier De L’Université De Montréal,Department Of Medicine,Montréal, QUEBEC, Canada 5University of Toronto,Department Of Surgery,Toronto, Ontario, Canada 6Université Laval,Department Of Anesthesiology,Quebec City, QUEBEC, Canada 7Université Laval,Department Of Anesthesiology,Quebec City, QUEBEC, Canada 8McGill University,Department Of Surgery,Montreal, QUEBEC, Canada 9Ohio State University,Department Of Surgery,Columbus, OH, USA 10Ottawa Hospital Research Institute,Ottawa, ONTARIO, Canada

Introduction:  Hepatectomy is associated with a high prevalence of blood transfusions. A transfusion can be a life-saving intervention in the appropriate patient, but is associated with important adverse effects. Given the prevalence of transfusions, their potential for great benefit and harm, and the difficulty in conducting clinical trials, this topic is well-suited for a study of appropriateness. Using the RAND/UCLA Appropriateness Method, the objective of this study was to determine the indications for which the expected health benefits of a transfusion exceed expected negative consequences in patients undergoing hepatectomy.

 

Methods: An international, multidisciplinary panel of eight experts in hepatobiliary surgery, surgical oncology, anesthesiology, transfusion medicine, and critical care were identified. The panelists were sent a recently conducted systematic review and asked to rate a series of 468 intraoperative and postoperative scenarios for the appropriateness of a blood transfusion using a validated, 1-9 ordinal scale. The scenarios were rated in two stages: individually, followed by an in-person moderated panel session. Median scores and level of agreement were calculated to classify each scenario as appropriate, inappropriate, or uncertain.

 

Results: 48% of scenarios were rated appropriate, 28% inappropriate, and 24% uncertain. Level of agreement increased significantly after the in-person session. Based on the scenario ratings, there were five key recommendations.

Intraoperative:

1) It is never inappropriate to transfuse for significant bleeding or ST segment changes.

2) It is never inappropriate to transfuse for a hemoglobin value of 75 g/L or less.

3) Without major indications (excessive bleeding or ST changes), it is inappropriate to transfuse at a hemoglobin of 95 g/L, and transfusion at 85 g/L requires strong justification.

Postoperative:

1) In a stable, asymptomatic patient an appropriate transfusion trigger is 70g/L (without coronary artery disease) or 80 g/L (with coronary artery disease).

2) It is appropriate to transfuse for a hemoglobin of 75 g/L or less in the recovery unit immediately post-operative, or later with a significant hemoglobin drop (>15 g/L).

Factors that increased the likelihood of a transfusion being inappropriate included no history of coronary artery disease, normal hemodynamics, and good postoperative functional status. Patient age did not affect the rating significantly.

Conclusion: Based on the best available evidence and expert opinion, criteria for the appropriate use of perioperative blood transfusions in hepatectomy were developed.These criteria provide clinical guidance for those involved in perioperative blood management. In addition, the areas of uncertainty and disagreement can inform the direction of future clinical trials.

« Previous Page
Next Page »