77.04 Learning Styles Preferences of Surgical Residency Applicants

Posted on December 22, 2014

R. H. Kim1, T. Gilbert2  1Louisiana State University Health Sciences Center – Shreveport,Surgery,Shreveport, LA, USA 2Louisiana State University Health Sciences Center – Shreveport,Academic Affairs,Shreveport, LA, USA

Introduction:

The learning style preferences of general surgery residents have been previously reported; there is evidence that residents who prefer read/write learning styles perform better on the ABSITE. However, little is known regarding the learning style preferences of applicants to general surgery residency and their impact on educational outcomes. In this study, the preferred learning styles of surgical residency applicants were determined. We hypothesized that applicant rank data is associated with specific learning style preferences.

Methods:

The Fleming VARK learning styles inventory was offered to all general surgery residency applicants that were interviewed at a university hospital-based program. The VARK model categorizes learners as: visual (V), aural (A), read/write (R), kinesthetic (K), or multimodal (MM). Responses on the inventory were scored to determine the preferred learning style for each applicant. Applicant data, including USMLE scores, class rank, interview score, and overall final applicant ranking were examined for association with preferred learning styles.

Results:

Sixty-seven applicants were interviewed. Five applicants were excluded due to not completing the VARK inventory or having incomplete applicant data. The remaining 62 applicants (92%) were included for analysis. Most applicants (57%) had a multimodal preference. 69% of all applicants had some degree of preference for kinesthetic learning. There were statistically significant differences between applicants of different learning styles in terms of USMLE Step 1 scores (p=0.001) and USMLE Step 2 CK scores (p=0.01), but not for class ranks (p=0.27), interview scores (p=0.20), or final ranks (p=0.15). Multiple comparison analysis demonstrated that applicants with aural preferences had higher USMLE 1 scores (233.2) than those with kinesthetic (211.8, p=0.005) or multimodal (214.5, p=0.008) preferences, while applicants with visual preferences had higher USMLE 1 scores (230.0) than those with kinesthetic preferences (p=0.047). Applicants with aural preferences also had higher USMLE 2 scores (249.6) than those with kinesthetic (227.6, p=0.006) or multimodal (230.1, p=0.008) preferences.

Conclusion:

Most applicants to general surgery residency have a multimodal learning style preference. Learning style preferences are associated with higher USMLE Step 1 and Step 2 scores, in particular for applicants with aural preferences. Students who performed well in lecture-dominated medical school environments due to their aural preferences could be at a disadvantage in the more independent, reading-focused learning environments of surgical residency.

77.05 At Home on the Road: The Impact of Visiting Student Electives on Match Results

Posted on December 22, 2014

S. C. Daly1, R. A. Jacobson1, J. L. Schmidt1, B. P. Fleming1, A. Krupin1, M. B. Luu1, J. A. Myers1, M. C. Anderson1  1Rush University Medical Center,Chicago, IL, USA

Introduction:  Residency applicants commonly complete visiting student electives (VSEs) away from their home institution. VSEs may benefit applicants through exposure to desired programs, and benefit programs by serving as an extended interview. To date, no study has quantified the impact of VSE completion on the residency application process, stratified by specialty. Consequently, medical students apply to VSEs on incomplete, often anecdotal information. As VSEs involve monetary and opportunity costs to students and administrators, data on their utility is vital for student wellbeing and ultimately, success in the Match. As such, the hypothesis of this study is that completion of VSEs correlates with increased odds of matching at a former host site.

Methods:  This is a retrospective review of VSE completion and Match data from one institution’s graduating classes from 2008-2014. De-identified records were analyzed for medical school GPA, USMLE exam scores, specialty choice, and site of VSEs. Data collected were analyzed using subgroup analysis, stratified by PGY2 specialty. Data was summarized with standard descriptive statistics. 

Results: Students who completed VSEs had higher GPAs and USMLE exam scores than those who did not. Specialty choice had a profound impact on rates of VSE completion. In total, 501 (55.2%) of the 907 records queried showed completion of a VSE, with 0.80 VSEs per applicant. Of these, students who completed one or more VSE matched into a program that had hosted them in 19.6% of cases. General Surgery applicants had a VSE completion rate of 58.8%, with 0.86 VSEs per applicant. 100% of Orthopedic Surgery applicants completed VSEs, with 2.19 per applicant. While General Surgery applicants matched into a host program 16.7% of the time, Orthopedic Surgery applicants matched into a host program at a rate of 44.4%. 

Conclusion: General Surgery applicants applied to a mean of over 25 programs from 2008-2014, thus the odds of matching into any program were 1 in 25. However, VSE completion increased the odds of matching into any of 1-3 host programs to roughly 1 in 6. Accordingly, our data suggest that applicants who completed a VSE were more likely to match into an individual host program than to a non-host. This concept can be extrapolated using Orthopedic Surgery match data: applicants who completed more VSEs were more likely to match into a host program than those who completed fewer. Limitations of this comparison include a different applicant pool. Also, data on applicants’ rank lists, which impact match results, is not available. Ultimately, applicants who complete VSEs may possess improved control over the residency match process by increasing their odds of matching into desired programs. Presently, General Surgery applicants complete VSEs at a rate near the all-specialty average. Encouraging future applicants to complete additional VSEs could improve the application experience and increase match rates at desired programs. 

77.06 Longitudinal Study Defining Students’ Preferences and Factors for Choosing a Surgical Career

Posted on December 22, 2014

J. Giacalone1, A. Berger1, J. Keith1  1University Of Iowa,Carver College Of Medicine,Iowa City, IA, USA

Introduction:  Many factors contribute to an undergraduate medical student’s career choice; these factors are variable and often change throughout one’s education. Importantly for surgical programs and medical education, analysis of longitudinal information will help clarify the considerations that influence career choices at each phase of training.

Methods:  This is the first survey of a longitudinal prospective study of students at the University of Iowa Carver College of Medicine. A self-administered questionnaire was distributed at the start of the first year. The questionnaire will be administered each subsequent year to the same cohort. The questions cover factors such as education related debt, mentorship experiences, healthcare work exposure, participation in research, and career preferences. Residencies classified as surgical include general surgery, neurosurgery, obstetrics-gynecology, ophthalmology, orthopedic surgery, otolaryngology, plastic/reconstructive surgery, and urology.

Results: 143 students responded to the survey. Thirty-six percent of students had a practicing physician in their family.  Of those students with a physician in their family, 31 percent were interested in a surgical career, compared to 22 percent among students without a physician in their family (p=0.32708). While not significant, there does appear to be a trend of increased interest in surgery for students with surgeons in the family (orthopedics, ophthalmology, obstetrics-gynecology, general surgery) compared to medical students with a nonsurgical physician in their family (p=0.126). Some of the most important career-related factors for students interested in surgery include intellectual stimulation, quality of life, patient contact, potential salary, technical skill, and work hours. 85 percent of students had debt. Of those with debt, 39 percent felt it influenced their choice of specialty, although these choices were widely dispersed. Interestingly, only 5 percent of those without debt felt it influenced their specialty choice, reflecting a statistically significant difference between groups (p=0.00104). That said, students who plan to choose a specialty based on debt were significantly less likely to specify a specialty choice at the beginning of medical school, compared to those who did not feel influenced by debt (38.8 percent versus 22.3 percent did not specify a specialty preference, respectively (p=0.037)).

Conclusion: The current information portrays student’s early career preferences. Of the factors assessed, student debt and physicians in the family plays a large role in specialty role. While other factors are not significant at this time, this longitudinal study will uncover influential factors such as family influences, research and mentorship experiences, and specialty-specific expectations.

 

77.07 Medical Students in Laparoscopic Cases: Increased Operative Time and Same Post-Operative Outcomes

Posted on December 22, 2014

M. Mori1, A. Liao1, T. Hagopian2, S. Perez1, J. F. Sweeney1, B. Pettitt1  1Emory University School Of Medicine,Surgery,Atlanta, GA, USA 2University Of Southern California,Plastic And Reconstructive Surgery,Los Angeles, CA, USA

Introduction:
Medical students are increasingly assuming active roles in the operating room (OR) as part of their clerkships. Laparoscopic surgeries offer increasing opportunities for MS participation, including camera driving, teaching through well-visualized operative field, and suturing. The effect of the presence of medical students on the procedure time and post-operative outcomes are unknown. We aimed to characterize the effects of medical student participation in laparoscopic cases.

Methods:
Data from the American College of Surgeons National Surgical Quality Improvement Program was linked to the institutional operative records for non-emergent, inpatient, laparoscopic general surgery cases at our institution from 01/2009 to 01/2013. Cases were grouped into eight distinct procedure categories. Hospital records provided information on the presence of medical students. Demographics, comorbidities, operative time, and postoperative complications were analyzed, using linear regression.

Results:
Of 700 laparoscopic cases reviewed, medical student was present in 38% of the cases. Controlling for wound class, procedure group, and surgeon, multivariate linear regression demonstrated that the presence of medical students in the OR was associated with an additional 30 minutes of total operative time on average (p<0.0001, 95% CI [17-43 mins]). No association between medical students and the number of postoperative complications was observed (0.21 vs. 0.19, p=0.79).

Conclusion:
This is the first study to examine the effect of medical student’s presence during laparoscopic procedures. While it is reassuring that no increase in the complications was observed, the association with increased operative time in laparoscopic cases needs to be examined further, especially given the financial burden incurred by the increased OR time.

77.08 Perceived vs Desired Competence at Procedural Skills in 3rd Year Students Across Two Institutions

Posted on December 22, 2014

J. Carr1, M. Meyers1, A. Deal1, F. Johnson2, T. Schwartz2  1University Of North Carolina At Chapel Hill,Chapel Hill, NC, USA 2St. Louis University,St. Louis, MO, USA

Introduction:  Ensuring that medical students acquire basic procedural skills is increasingly challenging. We previously reported experience and expectations of students over several years at our institution. In this study, we compare students’ experience and expectations at two institutions over two years.

Methods:  With IRB approval, an online survey was conducted at the end of 3rd year in 2013 and 2014 at the University of North Carolina at Chapel Hill (UNC) (n = 76, 91 respectively) and St Louis University (SLU) (n = 54, 55). Opinions were sought as to experience, level of competence and desired level of competence for nine procedural skills (Foley, NG placement, venipuncture, IV placement, arterial puncture, basic suturing, LP, thoracentesis, intubation) using a 4-point Likert scale (1=unable to perform; 2=require major assistance; 3=require minor assistance; 4=independent). Responses were compared by Student’s t-test. 

Results: Gender (UNC 51% male, SLU 46%) and plans to enter a procedural-based specialty (49% vs. 51%) were comparable. No differences were seen in perceived or desired competence for any skill in 2013 or 2014 at either institution. Differences were seen for the mean number of procedures performed between the two schools for Foley (4.2±1.06 at UNC vs 2.98±1.34 at SLU; p<0.0001), IV placement (2.24±1.35 vs 1.55±1.06; p<0.0001), arterial puncture (1.47±.88 vs 2.03±1.13; p<0.0001), LP (1.49±.77 vs 1.30±.63; p=0.037) and basic suturing (4.74±.78 vs 4.42±.90; p=0.002). UNC students reported their self-perceived competence was greater than at SLU for Foley (3.63±0.63 vs 3.15±0.82; p<0.0001), NG tube (2.45±0.88 vs 1.75±0.89; p<0.0001), IV placement (3.08±0.75 vs 2.71±0.84; p=0.0002), arterial puncture (1.67±0.62 vs 1.50±.70; p=0.01) and LP (2.18±0.74 vs 1.69±0.75; p<0.0001). A difference between desired competence between the two schools was observed for Foley (UNC 3.78±0.43 vs SLU 3.65±0.50; p=0.02), NGT (3.38±0.68 vs 3.06±0.75; p=0.0002) and LP (2.84±0.71 vs 2.66±0.75; p=0.045). For all skills at both schools, there was a significant difference in actual vs. desired competence (p<0.0001 for all). 

Conclusions: A significant gap between medical students’ self-assessed competence and their desired competence at performing basic procedural skills persists over years and across institutions. Several differences exist between institutions in self-perceived competence, a finding that may be partially explained by disparities in experience level. Differences in desired competence between institutions is more difficult to explain, and is not influenced by desire to pursue a procedural specialty. These data suggest that despite decreasing student procedural experience, the desire still exists for greater proficiency during medical school.

77.09 Focused Medical Student Intersession Improves Knowledge, Technique, and Interpersonal Interactions

Posted on December 22, 2014

C. M. Freeman1, J. M. Sutton1, D. B. Pettigrew3, P. L. Jernigan1, E. F. Midura1, J. W. Kuethe1, B. R. Davis1,2, K. P. Athota1,2,3  1University Of Cincinnati,Department Of Surgery,Cincinnati, OH, USA 2University Of Cincinnati,Department Of Surgical Education,Cincinnati, OH, USA 3University Of Cincinnati,Department Of Medical Education,Cincinnati, OH, USA

Introduction:  For the previous century, resulting from the Flexner Report, medical school curricula has consisted of two years of didactics followed by two years of clinical rotations. More recently, the Liaison Committee on Medical Education has mandated a more integrative approach to medical student education. While the value of incorporating clinical activities into the basic science educational years has been previously investigated, the efficacy of integrating basic science modules within the clinical rotations has not been well-studied. 

Methods:  We developed an intensive review course of anatomy via a laparoscopic perspective to reaffirm anatomical and spatial relationships initially taught during gross anatomy. Utilizing fresh, prosected cadavers, medical students entering the third year clerkships underwent a systematic review of anatomic landmarks of intra- and retro-peritoneal organs. Stations were designed to provide overview of the use of the laparoscope and to review abdominal, pelvic and retroperitoneal anatomy. Further discussion regarding differential diagnoses of various clinical scenarios was held to reinforce anatomic relationships of the organs within the abdomen. Medical student perceived interest, knowledge gain, comfort level with surgical instruments, pertinent anatomy and interaction with surgery attending and resident preceptors were assessed via voluntary survey at the conclusion of the session. Statistical analyses were performed using Fischer’s exact test.

Results: Thirty nine medical students participated in the surgical intersession prior to beginning core clerkships with the majority (90.6%) finding the gross anatomy sessions valuable.  Twenty one students returned a detailed voluntary survey regarding their experience with the intersession. A significant improvement in the students’ understanding of anatomy relevant to gallbladder pathophysiology and laparoscopic anatomy was noted (66.7% felt uncomfortable with the topic before vs. 4.8% after the intersession, p <0.0001).   Students also demonstrated a significant improvement in comfort with use of the laparoscope (4.8% before vs. 90.5% after, p <0.0001).  Additionally, students demonstrated decreased sense of anxiety regarding their interaction with surgical attendings and residents after intersession (71.4% before vs. 28.6% after, p <0.01).

Conclusion: A focused intersession integrating pre-clinical knowledge of anatomy and pathophysiology prior to the medical student surgery clerkship can be used to reinforce clinically-relevant anatomic knowledge gained within the initial two years of medical school.  The improved knowledge base and comfort with laparoscopic anatomy, use of the laparoscope, and improved interactions with surgery faculty and residents may translate to an enriched educational experience for medical students throughout their surgical clerkship.

 

 

 

77.10 Impact of the Senior Year of Medical School on Procedural Skill Acquisition

Posted on December 22, 2014

S. S. Kim1, M. O. Meyers1  1University Of North Carolina At Chapel Hill,Department Of Surgery,Chapel Hill, NC, USA

Introduction:   Acquisition of procedural skills during medical school continues to evolve.  In this study, we examine the impact of the 4th year on actual and desired procedural competence. 

 

Methods:   Under IRB approval, we conducted a survey of 3rd and 4th year students over a three-year period.  Experience, actual and desired levels of competence were measured for nine procedural skills using a 4-point Likert scale (1=unable to perform; 2= major assistance; 3= minor assistance; 4=independent). Responses were compared by Fisher’s exact test.

 

Results: 4th year students in 2012 reported a greater number of procedures performed for every skill assessed as compared to 2011 3rd year students (p<0.001 for all); 2013 4th years reported greater numbers only for NG(p=0.01), intubation(p,0.001), IV(p<0.001), Art(p<0.001),  LP(p<0.001) and Thor(p=0.04).  Actual skill level for selected procedures is reported in the table.  2011 3rd year students desired greater competence than their graduating counterparts for Foley(p=0.01), NG(p=0.003), venipuncture(p=0.006), IV(p=0.002), Art p=0.0005) and LP(p=0.003). In 2012 this was true only for IV(p=0.03).  For no skill was there a greater level of actual or desired competence by 4th year students. A greater level of desired competence than actual competence was seen in both 3rd and 4th year for all skills (p<0.001). 

 

Conclusion:  No difference in competence was seen between 3rd and 4th year students, despite having greater experience at the end of 4th year.  Interestingly, 3rd year students were more likely to desire a higher level of independence with procedures than their 4th year counterparts.  Both groups desire a greater level of competence than they accomplish. 

 

77.11 Development of a Novel Tool to Aid Medical Student Decisions During the Resident Application Process

Posted on December 22, 2014

S. C. Daly1, R. A. Jacobson1, J. L. Schmidt1, B. P. Fleming1, A. Krupin1, M. B. Luu1, M. C. Anderson1, J. A. Myers1  1Rush University Medical Center,Chicago, IL, USA

Introduction:
The interview process for medical students places significant financial stress on a group already facing mounting debt. Undergraduate students applying to medical school have ample access to resources that guide application decisions. For example, many medical schools publish matriculating students’ median MCAT scores and GPA, which is used as an informal guide to gauge students’ individual competitiveness for admission. No such resource currently exists for medical students interviewing for residency positions. Our aim was to develop a specialty and site-specific tool that medical students could reference when applying for residency positions. We hypothesize that this tool could help prospective residents make informed decisions on where to seek interviews based on their individual competitiveness. If our hypothesis is proven correct, this information could lead to both time and cost savings for future residency applicants.

Methods:
This is a retrospective review of all matriculating medical students (n=1,125) from a single, large medical school between 2008-2014. Data analyzed included age, sex, number of interviews granted, number of interviews completed, match site, clerkship grades, USMLE Step 1 scores, USMLE Step 2 scores, GPA and completion of away rotations. Data were first grouped by specialty and then by specific program site. Median values and ranges were calculated for data points contributing to an individual’s competitiveness at a specific program within a specific specialty.

Results:
For individual programs within each specialty we determined the median and the range USMLE step 1 scores, USMLE step 2 scores and medical school GPA for matriculating students. In addition, we enhanced our competitive student profile by quantifying the number of students accepted who received honors, high pass, or pass in the corresponding clinical clerkship. The numbers of interviews granted and completed were included, as well as the number of students completing away rotations. This profile was established for over 250 sites in over 20 specialties. The results of this effort have been made available to our current medical students.

Conclusion:
Current and future students going through the application process can use this novel tool as a guide to assess their competitiveness for being granted an interview and eventual matriculation into target programs. Used effectively, our data may produce cost savings and improve interview efficiency for medical students. Ongoing analysis includes identification of data points that are most predictive of interview invitation and/or matriculation, and students’ perceptions of the tool. Further development plans include Match outcome analysis over the years to come, when students at our institution are given access to our compiled data prior to residency application. Future implementation of this tool on a social media platform could improve outcomes for applicants on a national scale.
 

77.12 Epidemiology of Paediatric Surgery Disorders: Implications for Developing Undergraduate Curriculum

Posted on December 22, 2014

A. O. Ademuyiwa1, C. O. Bode1, B. C. Nwomeh2  1University Of Lagos,Paediatric Surgery/Surgery/College Of Medicine,Lagos, LAGOS, Nigeria 2Ohio State University,Paediatric Surgery/Surgery,Columbus, OH, USA

Introduction:  Curriculum review is a dynamic process. Products of a medical curriculum must be prepared to meet the health challenges in their own communities. The aim of this study was to assess the epidemiology of paediatric surgical diseases in a low and middle income country and classify competences that medical students must acquire during their clerkship, with emphasis on conditions most prevalent in the community. 

Methods:  We analysed the diagnoses of 1000 consecutive patients managed in the paediatric surgery unit of a university teaching hospital in southwestern Nigeria. Conditions that represented more than 5% of the diagnoses were classified as ‘compulsory – must know’ (CMK); 2.0 – 4.9% classified as ‘required – should know’ (RSK) and <2% classified as ‘selective – may know’ (SMK).

Results: 

Competency levels were assigned based on the frequency of each diagnosis and the data is presented as a table.

Conclusion: More than half of the patients seen in paediatric surgery practice are represented by 6 diagnoses classified as CMK. Under this framework, these conditions will receive the greatest emphasis during the clerkship and students will be expected to develop competences in their embryology, pathophysiology, clinical presentation, diagnostic testing, and therapeutic decision-making.

 

77.13 Trauma Education in a State of Emergency: A Curriculum-based Analysis

Posted on December 22, 2014

S. D. Waterford1, M. Williams4, P. M. Fisichella3, A. Lebenthal2,3  1Massachusetts General Hospital,Department Of General Surgery,Boston, MA, USA 2Brigham And Women’s Hospital,Division Of Thoracic Surgery,Boston, MA, USA 3Boston VA Healthcare System,Department Of Surgery,Boston, MA, USA 4Oakwood Southshore Medical Center,Department Of General Surgery,Trenton, MI, USA

Introduction:  Trauma is the leading cause of death among persons aged 1-44 in the United States and is the 5th leading cause of death overall. It accounts for more lost years of life than atherosclerosis and cancer combined. Trauma education in American medical schools has received little attention. In this pilot project, we sought to quantify the number of curricular hours devoted to each of the 5 leading causes of death in the United States.

Methods:  We performed a review of the pre-clinical curriculum at a northeastern Medical School with full LCME accreditation and hospital affiliations with three adult and one pediatric American College of Surgeons verified Level I trauma centers. We tabulated the total number of hours devoted to education of the 5 leading cause of death in the United States and we included class lectures as well as small group case-based meetings with a faculty preceptor. We then compared the total number of curricular hours devoted to trauma to other major causes of death in the United States. For the statistical analysis we used standard ANOVA with a p < 0.05 significance threshold.

Results: Of the leading 5 causes of death, heart disease was the most covered topic with 128 hours of dedicated curriculum time (Table I).  Chronic respiratory disease was the second most discussed topic with 80 hours of dedicated curriculum time.  The number of hours of curriculum time devoted to heart disease, chronic lower respiratory diseases, malignant diseases, and cerebrovascular diseases far exceeded that devoted to trauma. This was statistically significant for all 5 leading causes of death except cerebrovascular disease.  In the first two pre-clinical years of curriculum 6.5 hours were dedicated to trauma. Six hours of tutorial time was devoted to a single trauma case, involving an accidental blunt trauma. A half hour lecture on orthopedic fractures concluded the total time allocation. No lectures were given on the basic management of trauma patients.

Conclusion: A pilot study comparing curricular hours of the 5 leading causes of death demonstrated a statistically significant discrepancy in the allocated time devoted to trauma education compared to other causes. Based on these preliminary data, we advocate a broader multi-institutional study to further ascertain the amount and quality of trauma education in American medical schools.

77.14 Improvement of an Acute Care Surgery Medical Student Rotation:Use of Feedback & Loop Closure

Posted on December 22, 2014

J. R. Cherry-Bukowiec1, D. A. Machado-Aranda1, K. To1, K. Raghavendran1, M. J. Englesbe1, L. M. Napolitano1  1University Of Michigan,Surgery,Ann Arbor, MI, USA

Introduction:

The unpredictable and sometimes chaotic environment present in an Acute Care Surgery Services (Trauma, Burn, Surgical Critical Care, Non-Trauma Emergency Surgery) can cause high levels of anxiety and stress that could impact a medical students’ experience during their M3 surgical clerkship. This negative perception perhaps is a determinant influence in diverting talented students into other medical subspecialties. We sought out to objectively identify potential areas of improvement through direct feedback and implement programmatic changes to address these areas. We hypothesized that as the changes were made students perception of the rotation would improve.

Methods:

Review of end of clerkship M3 Trauma Burn Surgery Rotation evaluations and comments was performed for the 2010-2011 academic year. Trends in negative feedback were identified and categorized into 5 areas for improvement: Logistics, Student Expectations, Communication, Team Integration, and Feedback. (Table 1.) A plan was designed and implemented for each category. Feedback on improvements to the rotation was monitored via surveys and during monthly end of rotation face-to-face student feedback sessions with the rotation faculty facilitator and surgery clerkship director. Data was compiled and reviewed

Results:

Perceptions of the rotation markedly improved within the first month of the changes, and continued to improve over the study time frame (2011-2013) in all five categories. We also observed an increase in the number of students who rotated through the ACS service selecting a surgical residency in the NRMP Match from a low of 8% in 2009-2010 prior to any interventions, to 25% after full implementation of improvement measures in 2011-2012.

Conclusion:
A systematic approach using direct feedback from students to address service specific issues improves perceptions of students on the educational value of a busy Trauma –Burn Acute Care Surgery Service and may have a positive influence on students considering surgical careers to pursue a surgical specialty.

77.15 Medical Student Perceptions of the Operating Room in Acute Care Surgery

Posted on December 22, 2014

D. A. Machado-Aranda1, J. Cherry-Bukowiec1, K. To1, M. Englesbe2, L. M. Napolitano1, K. Raghavendran1  1University Of Michigan,Division Of Acute Care Surgery/Department Of Surgery,Ann Arbor, MI, USA 2University Of Michigan,Division Of Transplant Surgery/Department Of Surgery,Ann Arbor, MI, USA

Introduction: Declining medical student interest in surgical careers has been a worrisome trend in the last few years. A repetitive criticism in modern surgical education is the decreased value of educational experiences in the operative room. The unpredictable and intimidating atmosphere in the operating theater of Acute Care Surgery (ACS), including Trauma, Burns, Surgical Critical Care and Emergency Surgery Services, can lead to an poor perception among medical students, creating a negative experience that could divert talented students from choosing a career in ACS. However tools to evaluate teaching in the operating room remain poorly developed. We set out to interrogate this ACS operative perception in order to maximize its educational value and convert it into a positive experience.  

Methods: Third-year medical students (M3) rotating through a four-week long course in ACS from the 2013-2014 academic years were the subject of this study.  A tool (OR-card) was created to deconstruct the phases within the operative process (preoperative, intra-operative and postoperative debriefs) and capture potential areas of improvement.

Results: A total of 12 students were included in the initial sample.  Close to 30 OR-cards were collected.  All students (100%) correctly identified and named the operative procedure and its indication.  However, only 66.6% could enumerate pertinent preoperative workup.  Conversely, 83.3% could review principles of anatomy and physiology important for the operation, and 83.3% had a clear postoperative plan. Importantly, despite the unpredictable nature of ACS, only 16.6% of operations changed from the proposed surgery.  Using an analogue scale where a “10” was exact to discussion and “1” was completely different from discussion, students' appreciation score was an 8.3 ±  2.4.  Best memorable learning experiences were Anatomical Review (66.6%), Participation (50%), Individual Skill (50%) and Operative Surgical Principles (50%).  Finally, the highest sources of information for students were residents (83.3%) followed by surgical attending (33.3%), whereas no traditional references were used (textbooks, peer-reviewed publications or atlases). 

Conclusions: Despite the unscheduled nature of ACS operations, medical students were able to greatly follow through the different phases of the majority of emergency surgical interventions.  Potential areas of improvement include understanding of pertinent preoperative workup, strengthening anatomical review, and inviting more participation within the intervention.  Finally, attending surgeons should assume their critical role as teachers within the OR, as students are greatly depending on sources that are still in-training (residents).

77.16 The Characteristics of Lurkers for a Twitter-based International General Surgery Journal Club

Posted on December 22, 2014

S. B. Bryczkowski1, C. Jones4, N. J. Gusani3, L. Kao5, B. C. Nwomeh4, K. Reid Lombardo7, M. E. Zenilman6, A. Cochran2  1New Jersey Medical School,Surgery,Newark, NJ, USA 2University Of Utah,Surgery,Salt Lake City, UT, USA 3Penn State University College Of Medicine,Surgery,Hershey, PA, USA 4Ohio State University,Surgery,Columbus, OH, USA 5University Of Texas Health Science Center At Houston,Surgery,Houston, TX, USA 6Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA 7Mayo Clinic,Surgery,Rochester, MN, USA

Introduction:  The International General Surgery Journal Club (IGSJC) is a Twitter-based journal club that was initiated in March, 2014.  This monthly asynchronous moderated event extends over 2 days using a pre-identified freely available high-impact general surgery article for discussion.  An author of the selected article and a moderator help stimulate discussion during the designated time period for the journal club.  The purpose of this study was to identify characteristics of “lurkers”, those who followed the discussion but did not post tweets using the #IGSJC hashtag, in an effort to increase active participation from this group.

Methods:  Symplur.com transcripts were reviewed to identify lurker data and the number of tweets posted using the #IGSJC hashtag during monthly discussions. Lurkers were defined as followers of the @IGSJC Twitter account who did not tweet during monthly discussions. Followers were classified by their level-of-training and geographic location according to information provided in their Twitter profile augmented by Internet search. Percent of lurkers was calculated by dividing the number of lurkers by the number of followers.

Results: During the four IGSJC discussions from March to June 2014 there were 159 unique Twitter users from more than 14 countries who posted 2,848 tweets using the #IGSJC hashtag; 452 unique followers of the @IGSJC account were identified.   Of those followers whose roles could be identified (n=409, 90%), trainees (medical students, residents, and fellows) were the group most likely to lurk (99/108, 92%), (Table 1).  Other followers who lurked included associations, nurses, patient advocates, and marketers (83%). Attending physicians were the most likely to contribute and the least likely to lurk (77%).

Conclusion: Of those whose characteristics could be identified, trainees including medical students, residents and fellows, were the most likely Twitter users to lurk without actively tweeting during the moderated monthly IGSJC discussions.  The basis for non-contribution by trainees may be perceived lack of expertise in a topic area, fear of questioning established surgeons and researchers, or simply a product of many Twitter users’ lack of active tweeting.  Using simple metrics as we have, it is not possible to evaluate the impact of the IGSJC on lurkers.  Future directions for increasing IGSJC participation include surveying followers of the IGSJC Twitter account and directly encouraging trainees to tweet during the monthly IGSJC discussions.

76.11 Teaching the Core Competency of Practice-Based Learning and Improvement Through Surgical Debates

Posted on December 22, 2014

P. P. Patel1, E. Y. Chan1  1Rush University Medical Center,General Surgery,Chicago, IL, USA

Introduction:

Practice-based Learning and Improvement (PBL) is one of the six core competencies set by the Accreditation Council for Graduate Medical Education.  It is defined as the ability to investigate and evaluate care of patients, appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning.  Although this competency has been established for more than 10 years, many general surgery training programs have struggled with the best method to incorporate this skill into their curriculum.  The purpose of our study is to demonstrate that the preparation and presentation of surgical debates by residents is an effective method of applying PBL.

Methods:
Senior residents were assigned controversial debate topics that focused on common general surgery scenarios based on self-identified strengths, deficiencies and limits in their knowledge base.  They were provided a month to set learning goals and complete the appropriate learning activities. These learning activities focused on locating and critically appraising evidence from scientific studies relating to their clinical scenario and assimilating this information into a grand rounds presentation in the form of a debate. The debates were conducted by two senior residents who using evidence based data centered on current literature defended their surgical approach to approximately 50 surgical attendings and residents.  Four debates were held throughout the year. To evaluate the efficacy of this teaching method, presenters were asked if participation in this debate increased proficiency at acquiring and critically reviewing medical literature.  Additionally, they were asked if the skills acquired during the debate would be applied to practice evidence based surgery and improve patient care in the future.  As a secondary measure, the audience was asked if this debate influenced their approach.

Results:

In preparing for their presentation, each resident reviewed on average 20 articles and cited 14 journal articles.  Half of the residents stated they felt more comfortable searching for and reading scientific literature after completing their presentation.  At the conclusion of the year, 75% of residents expressed that they were now more likely to practice evidence-based surgery and refer to literature to justify their patient care plan.  As a secondary measure, more than 50% of the audience stated that the debate influenced their decision on approach to the clinical scenario presented.

Conclusion:

Overall, the debate format to acquire the core competency of PBL was successful in more than 50% of participants. Surgical debates provide an innovative and effective way to incorporate PBL into the general surgery residency curriculum.

76.12 Effect Of 80-Hour Work Week On Resident Publication Frequency

Posted on December 22, 2014

J. D. Forrester1, M. L. Melcher1  1Stanford University,Surgery,Palo Alto, CA, USA

Introduction:

Expressing ideas, decisions, and research findings clearly in writing is an essential skill for surgeons in leadership and academic positions. An intriguing consequence of the 80-hour work week is the possibility for increased academic productivity among surgical residents.  We hypothesized that graduating chief residents would have a greater publication frequency after work-hour restriction implementation.

Methods:  

Names of graduating chief residents from 1983 to 2013 from a single academic institution were cross-referenced with SCOPUS identification numbers to determine first-author publication frequency. Publication frequency of residents graduating before 2003 were compared to those graduating after 2003 accounting for gender distribution and graduating resident volume. Statistical evaluation was performed using Epi Info™  Version 7.1.1.14 (Centers for Disease Control and Prevention, Atlanta, GA) and comparisons were performed using the Mann-Whitney U-test or Fisher’s Exact where appropriate.

Results:

From 1983 to 2013, 116 graduating chief residents produced 153 first-author publications. There were a median 0.5 publications per resident (range [0-12], n=90) graduating before 2003, and there were a median 2 publications per resident (range [0-16], n=63) graduating in 2003 or later. This difference was statistically significant (p=0.014).

Conclusions:

A statistically significant difference in the publication frequency of resident graduating before 2003 and those graduating after 2003 was observed at a single academic institution. Surgical residents graduate with a wide range of publications suggesting that there are opportunities for intervention to help residents with fewer publications.  Educational programs directed at improving resident writing could promote additional academic productivity.

76.13 Impact of Resident Involvement on Surgical Outcomes after Hepatic and Pancreatic Resections

Posted on December 22, 2014

A. Ejaz1, G. Spolverato1, Y. Kim1, C. Wolfgang1, K. Hirose1, M. Weiss1, T. M. Pawlik1  1Johns Hopkins University School Of Medicine,Baltimore, MD, USA

Introduction:  Resident participation and level of involvement during major hepatic and pancreatic resections varies.  The impact of resident participation on surgical outcomes in major hepatic and pancreatic resections is poorly defined.  

Methods:  We identified 25,511 patients undergoing a hepatic or pancreatic resection between 2006-2012 using the American College of Surgeons National Surgical Quality Improvement Program database.  Operations were categorized based on resident participation.  Outcomes were analyzed in a propensity score-matched cohort adjusting for nonrandom assignment of resident participation.

Results: Resident participation was found in the majority of cases (n=21,857, 85.7%). Median patient age was 62 years (IQR: 53, 62) and comorbidities were common (ASA Class 3&4: n=17,093, 67.1%).  Pancreatic resections (n=16,045, 62.9%) were more common than liver resections.   Resident participation was more common in younger patients (OR 1.10, 95%CI 1.02-1.18), females (OR 1.09, 95%CI 1.01-1.16) (both P<0.05).  Resident participation resulted in longer mean operative times for both hepatic (9 minutes) and pancreatic (22 minutes) resections (both P<0.01).  Need for perioperative transfusion, total hospital length of stay, and reoperation rates were unaffected by resident participation (all P>0.05).  After adjusted analysis in the propensity score-matched cohort, resident participation resulted in higher risk of perioperative morbidity (OR 1.35, 95%CI 1.21-1.51; P<0.001) but equivalent 30-day mortality (OR 1.27, 95%CI 0.97-1.67; P=0.08).  

Conclusion: Resident participation during hepatic and pancreatic resections results in longer operative times, higher rates of morbidity, but equivalent rates of mortality.  As such, resident participation and involvement should be encouraged during these complex cases.  

 

76.14 How clinical training influences trainees’ perceptions of the clinical scope of a pediatric surgeon

Posted on December 22, 2014

D. Schindel1,3, L. Burkhalter3, L. Chen2, D. Schindel1,3  1University Of Texas Southwestern Medical Center,Pediatric Surgery,Dallas, TX, USA 2Baylor University Medical Center,Department Of Surgery,Dallas, TX, USA 3Children’s Medical Center,Pediatric Surgery,Dallas, Tx, USA

Introduction: We sought to evaluate the perceptions of third year medical students and second year pediatric residents of the clinical scope of a pediatric surgeon and determine the impact of a pediatric surgical clerkship on these views.

Methods: Over a two year period, 73 trainees (50 third year medical students and 23 second year pediatric residents) were given a multiple choice questionnaire surveying their views on the training and clinical scope of a pediatric surgeon.  The questionnaire was provided both before and after the 4-week clinical rotation. The trainees were queried as to what surgeon type would be expected to provide “surgical management” to several commonly seen surgical diagnoses at tertiary referral urban children’s hospital.  In addition, the questionnaire queried the participant’s expectations of the role of a pediatric surgeon in areas of postoperative management.  Descriptive and non-parametric analyses were used in the analyses of the data.

Results:Twenty-one,  (91%) pediatric residents reported having not rotated on a pediatric surgery service during their medical school training.  Forty-six (63%) trainees, prior to the rotation, correctly defined a pediatric surgeon’s training being a “2 year fellowship after completing a general surgery residency.”  Prior to the rotation, trainees opined  a pediatric surgeon would not be expected to manage many of the surgical conditions common to the field as noted in Figure 1.  The majority of trainees also answered that a nonsurgical physician or care-provider would be expected to manage a patient’s postoperative need for pain medication, antibiotics, or parenteral nutrition.  Following the rotation, as noted in Figure 1, trainees correctly identified a “pediatric surgeon” to manage those surgical diagnoses only managed by a pediatric surgeon (p<0.001) and answered that a “pediatric surgeon” would be expected to manage patients’ postoperative needs. (p<.0001).

Conclusion:Most trainees would not expect a pediatric surgeon to manage many of the surgical conditions common to the field.  Exposure to the clinical scope of a pediatric surgeon during a clinical rotation appears to modify the trainee’s views significantly and may prove vital to the success of pediatric surgery as a subspecialty.  Awareness of trainees’ perceptions will assist  pediatric surgical educators with designing experiences that promote a broad knowledge, appreciation and interest in the field.

76.15 Working at home: A qualitative study of general surgery residents

Posted on December 22, 2014

F. G. Javier1, L. S. Lehmann4, M. J. Erlendson1, K. A. Davis2, M. R. Mercurio3, C. Thiessen2  1Yale University School Of Medicine,New Haven, CT, USA 2Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA 3Yale University School Of Medicine,Department Of Pediatrics,New Haven, CT, USA 4Brigham And Women’s Hospital,Department Of Medicine,Boston, MA, USA

Introduction: Electronic medical records (EMRs) have emerged as residents face increasing duty hour restrictions. EMRs allow residents to perform patient care work at home. Our study investigated this work-shifting phenomenon.

Methods: We conducted semi-structured interviews of general surgery residents. We randomly selected one intern and one chief resident at each of 13 participating US programs and invited them to complete a 20-30 minute telephone interview. We asked about EMR access; frequency and magnitude of, type of, and reasons for work at home; and whether residents included work at home in their recorded duty hours. Interviews were recorded, transcribed, and coded using an iterative major and minor coding process in Dedoose.

Results: Fourteen surgery residents from 11 US programs completed interviews (8 interns, 6 chiefs, 6 women, 8 men). All participants had remote access to their institution’s EMR and all reported working at home at least occasionally. The majority (12/14) reported working at home for approximately 5 hours per week (range 15 minutes-20 hours). They checked patient’s labs and results (14/14), prepared for cases (11/14), and reviewed charts before new rotations (11/14). Most residents (11/14) expressed the “need to get out of the hospital…take a break and just finish things later on in the evening.” Half preferred the comfort of home: “It’s just more relaxed. If it’s at the end of the day and there’s some paperwork, I’d rather not do it at the hospital, I’d rather do it in my pajamas in my bed.” Working at home “because they can’t get the full job done at the hospital” or to finish work that “gets pushed off things like dictations…patient notes” was a common theme (7/14). Review of labs and results was often prompted by a sense of responsibility for patient care or “out of a personal curiosity that that patient had not done well during the day and I was wondering how they were going to do at night.” Many residents invoked work at home as training for becoming an attending. Working at home was “just part of being a physician”: “as an attending, you’re always on pager call…you need to be aware of what’s going on and checking in on your patients.” This perception was reinforced by “hav[ing] seen our attendings do it” and the fact that they “ended up getting quite a few home calls” because “attendings don’t always know when we’re in the hospital or not.” No participant recorded work at home in their duty hours. Most felt that “it’s not in-hospital work.” Many stated that their work at home was too little or too much to count.

Conclusion: Our results indicate that general surgery residents often work at home to follow-up on patients or complete required documentation, without counting this time as duty hours. Working at home is primarily driven by professionalism and preference. The extent of working at home is not yet fully recognized; institutional and ACGME policies responsive to work-shifting should be developed.

76.16 Resident Perceptions after the Acquisition of a Community Surgery Residency by a University Program

Posted on December 22, 2014

J. J. Tackett1, W. E. Longo1, A. H. Lebastchi1, G. S. Nadzam1, R. Udelsman1, P. S. Yoo1  1Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA

Introduction:
Attitudes, career goals, and educational experiences of general surgery residents are profiled during the acquisition of a community residency program by an academic residency program.

Methods:
The study population includes all general surgery residents PG2-5 in a tertiary academic medical center divided into community program matriculates (CPM) or academic program matriculates (APM). A survey compared perceptions before and after residency amalgamation in seven training categories: relationships among residents, relationships with faculty, systems interactions, clinical training, surgical training, scholarship, and career plans. Responses were recorded on a Likert scale. Fisher’s exact test and one-sided t-test were applied.

Results:
Thirty-five trainees (83%) participated. There were 23 APM (66%) and 12 CPM (34%).  Neither cohort reported significant perceptions of negative effects regarding surgical training, career planning, or scholarship (p>0.05).  There was a greater likelihood of significant negative perceptions regarding inter-resident relationships among CPM (p<0.05). CPM perceived significantly improved opportunities for scholarship (p<0.01) and nationwide networking through faculty (p<0.05) after acquisition. There was a nearly-significant trend toward CPM perceiving greater access to competitive specialties after acquisition. Overall, CPM perceptions were affected more often after acquisition; however, when affected, the APM were less likely to be positively affected (Odds Ratio 2.9).

Conclusion:
Acquisition of a community surgery residency by an academic program does not seem to negatively affect trainees’ perceptions regarding training. The effect of such acquisition on Community Program Matriculates decision to pursue competitive fellowships remains ill-defined, but Community Program Matriculates perceived improved research opportunities, faculty networking, and programmatic support to pursue a career in academic surgery.
 

76.17 The Role of International Electives in a Surgical Residency Program

Posted on December 22, 2014

M. A. Boeck1,3,4, Y. Woo1, A. L. Kushner1,3,4, T. D. Arnell1, M. A. Hardy1,4  1Columbia University Medical Center,Department Of Surgery,New York, NY, USA 3Johns Hopkins Bloomberg School Of Public Health,Baltimore, MD, USA 4Surgeons OverSeas (SOS),New York, NY, USA

Introduction:  General surgical care is critical for adequate healthcare delivery around the world. With training in North America increasingly focused on surgical specialization, international electives during residency enable future surgical leaders to return to the foundations of general surgery. The validation of international rotations by the American Board of Surgery (ABS) and ACGME Residency Review Committee (RRC) in 2011 formalized this effort. Despite this, and ample evidence of resident and program director interest, the number of such electives remains relatively limited. Here we present the evolving international surgical elective experience at New York Presbyterian Hospital-Columbia.

Methods:  From 2008 – 2013 categorical senior general surgery residents participated in non-ACGME RRC accredited international surgical electives, selected jointly by the program director and participant. Prompt post-rotation analyses, combined with a recent anonymous survey, were reviewed to effectively evaluate and improve the program.

Results: A total of 13 international electives at 8 sites (Brazil, Ethiopia, France, India, Israel, Kenya, S. Korea and Thailand) were completed since 2008, with 0-4/7 (mean=2) residents participating per year, each for a period of 6-8 weeks. The Graduate Medical Education office and the Department covered salaries and other expenses, respectively. Perceived strengths included adaptation to the use of limited resources, open surgeries, significant supervised operative autonomy, advanced disease presentations, honing physical exam skills, and teaching prospects at all levels. Criticisms focused on large variations in case volume, limited operating room involvement, language barriers hindering patient and staff interactions, inadequate guidance on living logistics, and a lack of adequate medical and leisure supplies. 100% (7/7) survey respondents would repeat the experience if given the opportunity, with the same number expressing a continued interest in global surgical work due to the elective.

Conclusion: Some residency programs affiliate with one international location, minimizing the importance of resident preference for site selection. Columbia’s approach, despite challenges in creating multiple, concurrent surgical international electives, is favored by the residents. Site inspections by a faculty member, including evaluation of projected case volume, level of supervision, degree of clinical involvement, language proficiencies, potential for research, and bidirectional exchange, are essential. Further reflection is needed to ensure educational, mutually beneficial, sustainable, standardized rotations. The potential returns and effects on career trajectories are undeniable, providing incentive for program directors to strongly consider making international rotations available to trainees.

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