82.10 A Fetal 3D Surgical Simulator of Minimally Invasive In Utero Gastroschisis Repair

Posted on January 31, 2019

E. H. Steen1, J. Fisher1,3, O. Olutoye1,3, J. Zaneveld4, N. Salas1, T. Lee1,3, S. Keswani1,3  1Baylor College Of Medicine,Department Of Surgery,Houston, TX, USA 3Texas Children’s Hospital,Division Of Pediatric Surgery,Houston, TX, USA 4Lazarus 3D,Houston, TX, USA

Introduction: We have reported the clinical benefits of fetal minimally invasive surgery (MIS) in attenuating preterm labor, uterine morbidity, and subsequent C-sections – complications associated with open fetal surgery. Other non-lethal diseases may also benefit from fetal MIS, such as gastroschisis. 3D printing allows the creation of lifelike human models. The aim of this study is developing and validating a 3D fetal MIS model to test an in utero procedure for gastroschisis repair.

Methods: A 3D reconstruction of a uterus and fetus with gastroschisis (based on a mid-gestation fetal MRI) was optimized (3D Slicer) and rapidly prototyped using a next-gen Lazarus 3D printer. A four-step MIS procedure (evaluation of fetus, evaluation of bowel, reduction of bowel, coverage of defect) was designed and time-tested in three cohorts repeated in triplicate (fetal/neonatal surgeons, residents, and students, n=6/group). A ten question post-trial validation survey was administered to the participants. Data is presented as mean +/-SD, analysis by ANOVA, post-hoc Tukey HSD, p<0.05.

Results: All procedures were completed successfully (n=54). Operative time was significantly related to surgical training level (fetal/neonatal surgeons 125s+/-29s, residents 141s+/-30s, students 376s+/-107s; p<0.05) with sequential attempts yielding significant rates of improvement in all cohorts. All surgeons reported that the model 1) is an accurate tactile and visually representative model, 2) adequately assessed technical skills required for the procedure, and 3) would be a valuable training tool. The cost for this model was $68.69/trial and can be refurbished/reused for $200.

Conclusion:Our data supports construct, content, and face validity of a novel 3D fetal surgical simulator. This model is more cost effective than animal models in developing fetal techniques and seems to be more representative of the human disease. With the attenuation of maternal-fetal risk observed in fetal MIS, in utero therapies for gastroschisis may be considered.

 

82.09 Traditional versus Realistic Bleeding Control Training Models

Posted on January 31, 2019

M. Araujo1, F. Cai1, R. Lei1, E. E. Fox1, C. E. Wade1, S. D. Adams1  1McGovern Medical School at UTHealth,McGovern Medical School,Houston, TX, USA

Introduction: Uncontrolled bleeding is the main cause of preventable traumatic death and the arrival of first responders may be delayed due to safety concerns. The educational “Stop the Bleed” program was created to train non-medical bystanders with skills to control hemorrhagic wounds until first responders arrive, potentially saving lives. Prior studies found that 1-hour hands-on instruction an effective method to teach these techniques. We hypothesized that a realistic bleeding simulator would improve the quality and impact of this training.

Methods: Third year medical students (MS3) and non-medical summer students (NMS) underwent “Stop the Bleed” training. Each student was given an anonymous identifier to track results and was randomized into standard “DRY” model or realistic “WET“ bleeding simulator groups. After a didactic lecture by a certified instructor they each had hands-on training to pack wounds and place tourniquets.  Students completed pre and post surveys to evaluate baseline knowledge, teaching effectiveness, and willingness and preparedness to intervene to help a bleeding stranger.  They were observed placing a tourniquet and packing a wound, timed and evaluated on technique.  Statistical significance, set at p? 0.05, was analyzed using T-test and the Likert scale by Wilcoxon-signed ranked test.

Results: Students (n=360) were trained in bleeding control techniques (241 MS3, 119 NMS) and stratified between WET (n=171) and DRY models (n=189).  Results were excluded if unpaired or incomplete. While both groups demonstrated improved average correct of 5 knowledge questions after training (MS3 3.9 to 4.8, NMS 3.3 to 4.2) there was a significant difference in the NMS compared to the MS both before and after. Both groups had a similar and significant increase in willingness and preparedness to help a bleeding stranger after training, irrespective of the method. Compared to the DRY teaching model, students on the WET model needed more correction on technique and significantly more time for tourniquet placement (DRY: 50 sec, WET: 62 sec). For wound packing, however, students on the WET model were faster (DRY: 72 sec, WET: 62 sec), but this could be attributed to different packing spaces between the models.

Conclusions: Students receiving training in bleeding control techniques are confident and empowered to aid a bleeding victim irrespective of method. Students on the WET tourniquet model voiced anxiety due to the active “bleeding”, and were visibly fumbling, which may account for the longer time to placement.  This may be a better representation of the real world experience, and may help them overcome those anxieties to intervene while still in a training situation.

 

82.08 Deceased Organ Donors a Valuable Source of Surgical Experience for Residents and Medical Students

Posted on January 31, 2019

T. J. Hathaway1, R. S. Mangus1  1Indiana University School Of Medicine,Surgery / Transplant,Indianapolis, IN, USA

Introduction:
An increasing number of rules and regulations govern interactions between learners and patients in the clinical setting. This strict oversight limits the amount of hands-on training available to medical students and residents alike. This paradigm has resulted in increased use of procedural labs with “virtual” experience. A potential source of human subjects available for clinical practice are the thousands of organ donors each year who consent to use of their body for  education and research purposes. This study evaluates the potential surgical learning available from deceased organ donors with an intact cardiopulmonary system.

Methods:
The records of all deceased organ donors processed locally by the Indiana Donor Network over the last 18 months (Feb 2017-Aug 2018) were reviewed. Patient consent for research and education was documented. A list of proposed procedures was developed to predict the potential benefit of organ donors as a learning platform for medical students and residents. Limitations to this approach were identified.

Results:
During the study period, 242 of 255 (95%) donors consented for their bodies to be used for education purposes. A list of 27 potential procedures was developed. Simple procedures include endotracheal intubation, central venous catheter insertion, tube thoracostomy, and insertion other peripheral venous and arterial catheters. Complex procedures include more invasive and time consuming procedures such as splenectomy, prostatectomy, hysterectomy, bowel resection and anastomosis. Primary barriers to general adoption of this model for surgical education included extending time in the operating room, risks of contamination to transplant organs, additional cost of extra equipment, potential risks of travel to the donor hospital, and disfigurement of the donor body. After analysis of these factors, it was determined that a single learner could easily participate in 3-5 procedures per donor with implementation of a robust system and support from the attending surgeon. In the last 18 months at this center, 242 donors consented for use of their body for education purposes, suggesting 40-70 missed procedural opportunities per month. Approximately 90% of the available donations occurred in hospitals within a 30-minute drive of a medical education site in our state.

Conclusion:
Routine use of organ donors in the procedural education of medical students and residents could serve as a valuable resource throughout the world. The use of these opportunities will likely become more important as further limitations are placed on the clinical learning environment. In instituting this model, care must be taken to protect the donor and to be responsive to concerns from the donor’s family.
 

82.07 An Analysis of Verbal Response Modes, Team Role, and Teamwork in Simulated Trauma Resuscitations

Posted on January 31, 2019

B. Statz2, I. H. Osman2, A. A. Rosser2, S. Sullivan2, R. Thompson1, H. Jung2  1University Of Wisconsin,Department Of Emergency Medicine,Madison, WI, USA 2University Of Wisconsin,Department Of Surgery,Madison, WI, USA

Introduction: We sought to understand if role or gender affected the way team members spoke during trauma resuscitations and if those differences impacted trauma team performance.

Methods: Communication in 27 interdisciplinary trauma simulations was transcribed. Three physicians (trauma chief resident, trauma junior resident, emergency medicine resident) and two nurses (emergency medicine) participated in each simulation. Team performance was assessed using the Team Emergency Assessment Measure (TEAM) scale.
Speech was coded with Verbal Response Modes (VRM). VRM is a taxonomy that describes the relationship dynamics present in conversation by how the speech acts relate to the speaker or the person whom the speech targets. VRM codes can be classified into three dimensions: Attentive vs. Informative, Presumptuous vs. Unassuming, and Directive vs. Acquiescent. All utterances concerning another’s experience are considered Attentive, whereas utterances concerning the speaker’s experience are considered Informative. When an utterance presumes knowledge about the other person, it is considered Presumptuous. If no such presumption is made, the utterance is Unassuming. Finally, Directive utterances use the speaker’s frame of reference in order to guide conversation, while Acquiescent utterances allow the other’s viewpoint to determine the course of the conversation.
Ratios of speech acts in the three VRM dimensions for each team member were examined. We aggregated these proportions to compute mean VRM dimension ratios for each role and gender within the trauma team. Multiple regression and cluster analysis were performed to investigate relationships between VRM, team role (all physicians, trauma chief, nurses), gender, and TEAM score.

Results: T-tests of VRM dimension ratios demonstrated significant differences between physicians and nurses in how they spoke within simulated trauma resuscitations. Nurse speech was more attentive and unassuming than that of physicians. However, both physicians and nurses used equally directive speech. Trauma teams whose leaders used unassuming speech acts more than presumptuous speech acts had higher TEAM scores (p=0.039). Team member gender did not correlate with differences in speech acts or team performance.

Conclusion: Physicians and nurses speak differently within trauma resuscitations. Teams with leaders who communicate in an unassuming manner perform better. Based on VRM, the relationships between team members and the ways they spoke to one another did not correlate with gender.

 

82.06 Impact of Trauma Responders Unify to Empower (TRUE) Communities Course in Chicago High Schools

Posted on January 31, 2019

L. C. Tatebe1, D. Ferrer1, D. Kang2, M. Saeed3, M. Swaroop1  2Rush University Medical Center,Chicago, IL, USA 3State University of New York Health Science Center at Brooklyn,Brooklyn, NY, USA 1Feinberg School Of Medicine – Northwestern University,Chicago, IL, USA

Introduction:  Chicago’s ballooning violence disproportionately affects socioeconomically disadvantaged neighborhoods exposing young people to trauma. Bystanders are present at 60-97% of traumas and more likely to assist if given prior training. The Trauma Responders Unify to Empower (TRUE) Communities Course was designed and implemented across the city to create Immediate Responders to traumatic events. We evaluated the impact of bringing these skills to high schools in at-risk neighborhoods, in an attempt to improve self-efficacy and ultimately outcomes for victims of trauma.

Methods:  A three-hour trauma immediate responder course was designed using community based focus groups and qualitative analysis of the bystander effect. The course addressed basic first aid, trauma wound care, principles of bystander care, and the psychological impact of trauma. The course was taught in community centers, churches, and schools, to both minor and adult participants. Pre- and post-course questionnaires were offered. Seven evidence-based empowerment questions were assessed on a scale of 1 to 10. Ten knowledge-based questions were presented as single best of four multiple choice answers. The change in empowerment measures and knowledge scores were analyzed using chi-squared and t-test methods with p<0.05 considered significant. Subset analysis was performed comparing results from current high school students were compared to the rest of participants.

Results: Of the182 high school students and 286 individuals post-high school who participated, approximately half of each cohorts had seen someone shot with a gun (45.3% vs 55.6%, respectively, p=0.04). However, far fewer high school students received prior first-aid training (33.9% vs 60.4%, p<0.001). For the high school students, the mean increase in empowerment was 2.9 out of 10 (p<0.001) while the remaining cohort increased scores by 2.7 (p<0.001). The increase was not different between the groups (p=0.45). The students were outperformed by the remaining cohort in both the pre- and post-course knowledge evaluation (5.2 vs 6.7 and 6.8 vs 7.5, both p<0.001); although, the high school students showed a significantly larger increase in their scores (1.5 vs 0.7, p<0.001). 

Conclusion: Violence remains a pervasive public health issue in Chicago. Within at-risk communities, high schoolers are not spared exposure to this violence but have not yet received Immediate Responder training on how to approach a victim of trauma. Our evidence-based community course successfully improved self-efficacy and knowledge of trauma first-aid among Chicago’s high school students. Such training should be considered for high school students nationwide. 

 

82.04 Resident Endoscopy Experience Correlates Poorly with Colonoscopy Performance on a VR Simulator

Posted on January 31, 2019

K. S. Oberoi1, M. T. Scott2, J. Schwartzman1, N. Maloney Patel2, M. M. Alvarez-Downing1, A. M. Merchant1, A. Kunac1  1Rutgers New Jersey Medical School,Department Of Surgery,Newark, NJ, USA 2Rutgers Robert Wood Johnson Medical School,Department Of Surgery,New Brunswick, NJ, USA

Introduction: Fundamentals of Endoscopic Surgery (FES) certification is now required for American Board of Surgery exam eligibility. Previous studies have shown that there is a correlation between clinical endoscopy experience and FES exam scores, which are based on a summation of one’s performance of 5 individual tasks on a virtual-reality simulator (VRS). These tasks are meant to test specific endoscopy skills in isolation of one another. When one performs a complete diagnostic colonoscopy, however, one must utilize all of these skills concurrently, rather than in isolation. As such, we aimed to evaluate the association between clinical endoscopy experience and performance of a complete diagnostic colonoscopy on a VRS at two large, academic surgical residency programs.

Methods: PGY2 through PGY5 residents in two large, academic general surgery programs completed an assessment on the Symbionix GI Bronch-Mentor™ VRS. This included 2 brief practice modules followed by “easy” and “difficult” diagnostic colonoscopies. The difficult colon was prone to loop formation. The simulator recorded several performance parameters. Endoscopy numbers for each resident were obtained from ACGME case logs. Correlations between endoscopy experience and performance parameters were assessed using Spearman’s correlation. Bivariate logistic regression was used to assess for an association between experience and both the ability to retroflex as well as complete the colonoscopy. A p-value of <0.05 was considered significant.

Results: The assessment was completed by 55 out of 66 total PGY2 through PGY5 residents across both institutions.

Easy colonoscopy: There was a positive correlation between upper endoscopy experience and percentage of mucosa examined (ρ=0.30; p=0.03). This correlation was not seen with lower or total endoscopy experience. There was no correlation between endoscopy experience and time to cecum, percentage of time the virtual patient was in pain, or ability to retroflex.

Difficult colonoscopy: There was a correlation between upper (ρ=0.37; p=0.02), lower (ρ=0.29; p=0.02), and total (ρ=0.38; p=0.004) endoscopy experience and time to cecum. There was no correlation between endoscopy experience and percentage of mucosa examined, withdrawal time greater than 6 minutes, ability to complete the colonoscopy, and percentage of time the virtual patient was in pain.

Conclusions: Clinical endoscopy experience may correlate with time to cecum in a colon prone to loop formation, suggesting that residents with more experience may be more facile at loop reduction. However, there is no correlation between clinical endoscopy experience and any of the other meaningful performance parameters recorded during a VRS colonoscopy and the VRS may not be a useful surrogate for testing endoscopic skills.

82.03 Surgical Boot Camp for Senior Medical Students: Impact on Objective Skills and Subjective Confidence

Posted on January 31, 2019

J. Simon1, L. A. Bevilacqua1, D. Rutigliano1, S. Docimo1, J. Sorrento1, R. Verma1, A. Wackett2, L. Chandran3, M. Talamini1  1Stony Brook University Medical Center,Surgery,Stony Brook, NY, USA 2Stony Brook University Medical Center,Emergency Medicine,Stony Brook, NY, USA 3Stony Brook University Medical Center,Office Of The Dean,Stony Brook, NY, USA

Introduction: In recent years, boot camp courses for senior medical students have risen in popularity with the goal of improving preparation for residency. While studies have demonstrated increased student confidence after such boot camps, data is lacking on the impact of these courses on objective clinical skills. The American College of Surgeons (ACS) has developed a curriculum for use in such courses. This study aims to test the impact of a Surgical Boot Camp course using the ACS-based curriculum and objective, observer-based rating tools, on both subjective confidence and objective skills of fourth-year medical students.            

Methods: Fourth-year medical students who had matched into surgical subspecialties were invited to participate in a two-week Surgical Boot Camp. Informed consent was obtained on the first day of the course. Prior to any teaching, students performed five tasks (patient handoff, suturing, knot tying, central line placement, and chest tube placement) which were scored using objective rating tools provided by the ACS. Students also completed two subjective confidence measures, the New General Self-Efficacy scale (NSGE) and a Task-Specific Confidence Scale (i.e., "How confident are you placing a central line"). Both measures used a 5-point likert scale. After two weeks of dedicated lectures, simulation, and cadaver-based anatomy review, students were scored on the same five tasks and repeated the confidence measures. To help avoid potential bias, each scorer graded a different skill at pre- and post-course testing, so that they were unaware of scores given by the previous assessor.

Results: Twelve students participated in the Boot Camp. Average age was 26.7 years; 25% of subjects were female. Subspecialties represented included general surgery (N=5) orthopedics (N=3), integrated plastics (N=2), urology (N=1), and neurosurgery (N=1). Scores on objective skills improved significantly in all five tasks at post-course testing (Table 1). Mean NSGE scores did not improve over the study period (4.49 vs. 4.46; p=0.866), however mean scores on task-specific confidence improved significantly (2.77 vs. 3.64; p<0.0010). 

Conclusion: Implementation of a two-week, multimodal Surgical Boot Camp improved student performance on objectively-rated surgical skills and increased student confidence. Research is still lacking on whether, and for how long, these improvements persist into surgical residency. Future studies utilizing larger samples of students with matched controls are needed to confirm these findings and support the use of such boot camps in undergraduate medical education nationwide.

82.02 Implicit Biases in the Operating Room: A Simulation Based Study

Posted on January 31, 2019

S. Jones1, P. P. Parikh1, T. N. Crawford4, P. Hershberger3, A. Cochran2, L. Peterson1, G. Falls1  1Wright State University,Department Of Surgery,Dayton, OH, USA 2Ohio State University,Department Of Surgery,Columbus, OH, USA 3Wright State University,Department Of Family Medicine,Dayton, OH, USA 4Wright State University,Division Of Epidemiology And Biostatistics, Department Of Population And Public Health Sciences,Dayton, OH, USA

Introduction: Implicit biases are increasingly recognized as a wide-spread phenomenon in medicine, including surgery.  In surgery, physicians and other providers of different specialties and expertise work together in an operating room (OR) that impacts lives. Any implicit biases in such dynamic environments could lead to poor satisfaction and performance of providers, which in turn may result in poor patient outcomes. The primary objective of this study was to assess perception of the lead surgeon in OR.

Methods:
The simulated scenarios used 8 different actors as lead surgeon with the combination of age (<40 vs. >55), race (white vs. black), and gender (male vs. female). An IRB approved anonymous video-based survey was distributed nationwide to surgeons, residents, OR nurses and ancillary OR staff. It included demographic questions, 3 short videos and questions regarding the perception of the situation and surgeon. The perception towards the lead surgeon was divided into favorable, unfavorable, and neutral categories. Favorable perception included the surgeon’s behavior that was thought to be commendable, acceptable, or the surgeon should have received an apology. The unfavorable perception included responses such as “inform managers of surgeon’s behavior,” “surgeon should apologize to the OR staff,” or the “surgeon should receive probation.” The participants also rated overall performance of the surgeon using a 5-star rating system.

Results:
There were 419 respondents, 53.7% were females. A higher proportion of the respondents (53.5%) were attending surgeons. Our results suggest that both gender and age are significantly associated with the perception of a lead surgeon. Older surgeons were perceived more favorably than their younger counterparts; 50.5% versus 35.6%, respectively. Similarly, male surgeons were perceived more favorably than female surgeons; 47.2 vs. 37.7 (Figure 1). The overall rating of a surgeon suggests that older surgeons were rated higher than younger (3.27 vs 3.05). While assessing the group of older surgeons in details for race, our data showed that older white males were ranked significantly higher (3.53/5) than all other group of surgeons. 

Conclusion:
Widespread perception of gender bias in surgery may not be the only bias that exists in the OR. Our data shows that older surgeons, especially older white males, are perceived more favorably than any other lead surgeon. These results shed light on some of the challenges faced by young surgeons, particularly females, taking on a leadership role in OR.  These results can provide insight in developing inter-professional education curriculum or training for residents, attendings and OR staff to address implicit biases and to foster cohesiveness of the surgical team in order to provide optimal patient care.
 

82.01 Can VR be used to track skills decay during the research years?

Posted on January 31, 2019

H. Mohamadipanah1, K. H. Perrone1, B. Wise1, C. Parthiban2, M. Zinn2, A. Witt1, C. Pugh1  1Stanford University,Palo Alto, CA, USA 2University Of Wisconsin,Madison, WI, USA

Introduction:
In surgery, time away from practice can lead to skills decay. Laboratory residents are thought to be prone to skills decay given their lack of experience and limited exposure to clinical activities. This study takes a cross-sectional approach to assessing differences in residents’ skills at the start and end of their laboratory years using Virtual Reality (VR). We hypothesize that laboratory residents will have measurable decay in psychomotor skills when evaluated using VR.

Methods:
Surgical residents (N=28) were divided into two groups based on where they were in their research time. The first group was just beginning their research time (N=19) and the second group (N=9) had just finished at least 2 years of research. All participants were asked to perform a target-tracking task using a haptic device in a VR environment (Figure 1). In this task participants used a stylus to follow a moving target on a screen. To challenge residents to demonstrate their psychomotor abilities, random distracting forces were applied to the stylus throughout the task with varying levels of force. Psychomotor skills demonstrated during this task include hand-eye coordination, motor-control, reaction time and error management. The metric investigated in this study was “Tracking Error”, defined as the average distance of the stylus to the center of the moving target. Analysis was conducted using a two-sample t-test.

Results:
The second group, who just finished their research time, showed a higher level of “Tracking Error”, when compared to the first group, who just started their research time, (mean 16.9±4.3mm vs 14.1±2.0mm; t(26)=2.39, p=0.0245).

Conclusion:
The increased “Tracking Error” among residents at the end of their research time suggests psychomotor skills decay in residents who spend time away from clinical duties in a laboratory. This decay demonstrates the need for research residents to regularly participate in clinical activities, simulation or assessment to minimize and monitor skills decay while away from clinical practice. Additional longitudinal studies may help to better map learning and decay curves for residents who spend time in the laboratory.
 

62.20 “Flipping the Surgical Classroom”: Using Modern Technology to Improve Surgical Education

Posted on January 31, 2019

T. J. Vreeland1, D. A. Vicente1, R. W. Day1, C. J. Allen1, T. E. Newhook1, E. Grubbs1, B. Bednarski1  1University Of Texas MD Anderson Cancer Center,Surgical Oncology,Houston, TX, USA

Introduction:
As training in Complex General Surgical Oncology (CGSO) continues to evolve as a board certified specialty, it is imperative to incorporate innovative approaches for time-effective education. Modern technological applications have changed the landscape of adult education with the utilization of on-line video and audio lectures, allowing adult learners to consume media at their convenience. These platforms can be used to prime learners prior to a planned lecture in a “flipping the classroom” model, which allow for a more meaningful interaction between students and teachers. This strategy is gaining popularity across all stages of education, but has yet to be applied to advanced surgical training. As part of our CGSO fellowship, we have a one-hour weekly educational conference, which typically consists of a peer-to-peer lecture given by a fellow, with oversight and a short discussion from a faculty surgeon. To enhance this educational experience, we conducted a pilot study implementing a “flipping the classroom” strategy for this weekly conference.

Methods:
A pre-conference, narrated video lecture was created and placed on YouTube one week prior to a planned one-hour conference focused on case discussions with a faculty surgeon. A link for the video was sent to the 18 fellows at our institution. We were able to track the number of times each video was viewed prior to, and after, the conference. Learning preferences and satisfaction with this educational model were assessed with a survey of conference attendees.

Results:
Twelve of 15 (80%) attendees responded to the survey. Prior to the institution of pre-lecture videos, 9/12 (75%) respondents did not typically prepare at all for weekly conferences. Eleven (92%) respondents watched the video prior to conference at least once, and 3 (25%) watched the video more than once to prepare for conference. Per YouTube analytics, the video was viewed a total of 15 times prior to the conference. Ten (83%) respondents found the video very/extremely helpful in preparation for conference, 2 (17%) somewhat helpful, and none responded that it was not helpful. Eleven (92%) respondents answered they likely would use videos to prep for conference every week and 10 (83%) said they would use archived videos to study for board review. In the following 3 weeks, the video was viewed 5 times. While 10 (83%) respondents preferred this format, only 6 (50%) said they would be willing to prepare a pre-lecture video assuming 2-3 hours of additional preparation time would be required. 

Conclusion:
“Flipping the classroom” strategies are applicable for advanced surgical education. Our preliminary data shows that this strategy increases preparation for education conference and that trainees actively engage in, and prefer, this type of education. Future studies examining this strategy will examine the impact of the flipped classroom strategy on knowledge transfer.
 

62.19 Fellowship or Family? A comparison of residency leave policies with the Family and Medical Leave Act

Posted on January 31, 2019

S. T. Lumpkin1, M. K. Klein1, S. Scarlet1, M. Williford1, K. Cools1, M. C. Duke1  1University Of North Carolina At Chapel Hill,Surgery,Chapel Hill, NC, USA

Introduction: In 1993, the Family and Medical Leave Act (FMLA) required 12 weeks of unpaid, job-protected leave. Residency training is inherently demanding and inflexible. While 40% of residents anticipate having a child during training, taking leave to care for personal and family needs may delay residency graduation, board certification, and fellowship initiation. Our hypothesis is that a 12-week (FMLA) leave would delay board certification and fellowship training with the current specialty board training requirement policies.

Methods: We categorized the primary specialties recognized by the Accreditation Council for Graduate Medical Education (n=24) into surgical (n=10) and non-surgical (n=14) specialties. We excluded secondary specialties and specialties with fewer than 100 active residents nationwide. From May 2018 to August 2018, we examined the specialty leave policies to determine the impact of leave on the duration of residency training, board eligibility, and fellowship training. We compared our findings to a similar study of policies published in 2006.

Results: Across all specialties, the mean maximum leave allowed per year was 4.9 weeks (range 4-8). Among surgical specialties, the mean maximum leave per year was 5.3 weeks (range 4-8), compared to 4.6 weeks (range 4-6) among non-surgical specialties (p=0.38). Only five (21%) specialties have specific policy language regarding parental leave, and four (16%) regarding medical leave. Since 2006, seven specialty boards have substantially changed leave policies. In 2006, a 6-week leave would cause a delay of one year in board eligibility in 6 specialties; whereas in 2018, a 6-week leave would not result in delayed board eligibility for any specialty. A minority of specialties offer strategies to mitigate the impact of a 6-week leave, including taking leave during elective or non-clinical rotations (n=2), averaging leave across multiple years (n=8), extension of chief year (n=2), merit-based advancement (n=3), and exclusive program director discretion (n=2). In 2018, a 12-week (FMLA) leave during residency would extend training by a mean of 4.1 weeks (range 0-8) and delay board eligibility by a mean of 2.25 months (range 0-12). A 12-week leave in 17 specialties (71%) would delay fellowship training by at least one year.

Conclusion: Residents training in surgical and non-surgical specialties have similar allowable time for leave, although this is less than half of the FMLA requirement. Overall, there has been minimal change in the maximum duration of leave since 2006, but the impact of such leave on board eligibility has been mitigated. Unfortunately, a 12-week, FMLA-eligible, leave would cause significant delays in training, board eligibility, and entry into fellowship. The long-term effect of extending the duration of training may affect the decision to pursue fellowship, decrease the protected time to study for boards, and ultimately increase physician burnout.

62.18 Shedding Light On the Sunshine Act Among Surgical Residents at a Large Academic Institution

Posted on January 31, 2019

R. D. Rampp1, J. R. Porterfield2, H. Chen2, A. Asban2, G. E. McFarland2  1University Of Tennessee Health Science Center,Chattanooga/Department Of Surgery/College Of Medicine,Chattanooga, TN, USA 2University Of Alabama at Birmingham,Department Of Surgery/School Of Medicine,Birmingham, Alabama, USA

Introduction: The Physician Payments Sunshine Act, effective as of 2013, requires manufacturers of pharmaceuticals, biologics, and devices to track and report certain payments and items of value given to U.S. physicians and U.S. teaching hospitals.  A “payment” may include cash, food, entertainment, gifts, travel, honoraria, funding, grants, stock, royalties, and licensing fees, among others. The act was written to include fellows but exclude residents. However, many residents are still reported to the Centers for Medicare and Medicaid Services (CMS). We hypothesized that a considerable portion of residents can be found on the publicly-accessible website. Furthermore, we suspect most residents are unaware of the act and have unknowingly accepted any form of payments.

Methods: All general surgery residents from a large tertiary medical center were searched on the CMS open payments database. Of the residents found on the site, the total cost of payments, total number of payments, and the nature of payments were documented. The residents were surveyed to determine if they were aware of the Sunshine Act and if they were reported in the database.

Results: Of the 45 categorical surgical residents, 9 (20%) were found in the CMS database. Of these 9, one (11%) was aware of the Sunshine Act and that their payments received were being tracked. The median amount received was $50.12 (range: $13-$782). The median total number of payments was 2 (range 1-8). The nature of all payments was in the form of food and beverage.

Conclusion: The Sunshine Act was created to increase the transparency of financial relationships between physicians, teaching hospitals, and pharmaceutical manufacturers and uncover potential conflicts of interest. However, we discovered the vast majority of residents were unfamiliar with the act, let alone individually-identified in the CMS database. Increased efforts should be made to raise awareness among residents and provide transparency to those susceptible to being reported.

 

62.17 Ranking United States Plastic Surgery Residency Programs Based on Academic Achievement

Posted on January 31, 2019

C. B. Davis1, S. Kurapati1, T. W. King1  1University of Alabama at Birmingham,Department Of Plastic Surgery,Birmingham, ALABAMA, USA

Introduction:  Choosing a residency program is the most important decision in a medical student’s career. Most specialties have significant resources to help inform student decision making. However, there is a significant deficit in reliable ranking lists of Plastic Surgery Programs. The available resources for plastic surgery residency programs primarily includes the Doximity Residency Navigator, which provides subjective and objective rankings of programs with a set algorithm for all specialties, and other crowdsourcing internet resources with questionable reliability. Previous studies have investigated the role of bibliometric measures of plastic surgery faculty in correlation to academic rank, gender disparities, and program size. In this study, we introduce a new standardized model of residency program ranking focused on bibliometric measures of academic achievement to give prospective students a reliable and readily updated list of plastic surgery residency programs’ academic rank.

Methods:  A comprehensive list of plastic surgery residency programs was compiled from FREIDA Online (Fellowship and Residency Electronic Interactive Database). The following data was obtained for each program: list of full time faculty, amount of 2017 National Institute of Health (NIH) and (Veterans Administration) VA funding, lifetime and 5 year h-index of each faculty member, and faculty position on editorial boards of 9 major plastic surgery journals. The h-index represents the productivity and impact of a faculty member as measured by number of publications and the citations of those publications. The overall ranking of the top twenty-five programs was determined by weighting each factor reflective of academic achievement equally. The five categories of measurement included lifetime and 5 year h-index, annual funding, faculty positions on journal editorial boards, and number of faculty members at each program.

Results: Summary results for each individual category were determined.  The top program for annual funding was the University of Southern California. The top programs based on lifetime h-index of faculty members were the University of Michigan (integrated) and Harvard University (independent). University of Pennsylvania programs were ranked first for 5 year h-index of faculty members. Harvard University programs were ranked first in the presence of faculty members on journal editorial boards.

Conclusion: While there are many criteria that can be used to evaluate a residency program, academic achievement is one of the important factors a prospective student might use in selecting a residency program. We present a rank model that incorporates the most impactful metrics in determining academic productivity in a standardized format that can be readily updated annually to provide a reliable and easily accessible resource for prospective students.

 

62.16 Addition of Trauma Center Volume from 12 Level 1 Trauma Centers to Guide Trauma Center Apportionment

Posted on January 31, 2019

Y. M. Wong2, S. K. Madiraju1, D. Livingston3, R. Albrecht4, D. Ciesla5, J. Davis6, R. Dicker7, A. Eastman8, R. Kozar9, M. Lorenzo10, F. Moore11, S. Savage12, T. Scalea9, M. Schreiber13, D. Shatz14, N. Namias1,2, E. Ginzburg1,2  1University of Miami,School Of Medicine,Miami, FL, USA 2Jackson Memorial Hospital,Trauma And Surgical Critical Care,Miami, FL, USA 3University Hospital,Trauma And Critical Care,Newark, NJ, USA 4University Of Oklahoma College Of Medicine,Trauma And Surgical Critical Care,Oklahoma City, OK, USA 5University Of South Florida College Of Medicine,Trauma And Surgical Critical Care,Tampa, FL, USA 6University of California – San Francisco, Fresno,Trauma And Surgical Critical Care,Fresno, CA, USA 7University Of California – Los Angeles,Trauma And Surgical Critical Care,Los Angeles, CA, USA 8University Of Texas Southwestern Medical Center,Trauma And Critical Care,Dallas, TX, USA 9University Of Maryland,School Of Medicine,Baltimore, MD, USA 10Methodist Dallas Medical Center,Trauma Surgery,Dallas, TX, USA 11University Of Florida,Department Of Surgery,Gainesville, FL, USA 12Indiana University School Of Medicine,School Of Medicine,Indianapolis, IN, USA 13Oregon Health And Science University,Trauma, Critical Care And Acute Care Surgery,Portland, OR, USA 14University Of California – Davis,Department Of Surgery,Sacramento, CA, USA

Introduction:   The American College of Surgeons Committee on Trauma (ACS COT) developed a Needs Based Assessment Tool (NBAT) to provide evidence based resource allocation. Recent study has shown an inverse relationship between increasing volume and mortality rates at Levels 1 and 2 trauma centers (TC). However, this study did not address the relationship of volume with measurement of trauma fellow experience at Level 1 academic trauma centers (L1ATC).  Any diminution of training may negatively impact future trauma surgeons’ preparedness. The goal of this work was to define the current experience of fellows at L1ATCs as potential thresholds for future refinements of NBATs.

Methods:   A survey requesting 2016 caseloads and fellow numbers was collected from 12 L1ATC trauma program managers and trauma directors.

Results:  Median and interquartile range (IQR) for total number of cases and cases/fellow ratio (CFR) are presented in Table 1. Median absolute cases with injury severity score (ISS) > 15 = 676 (IQR 454, 796). Median CFR with ISS > 15 = 226 (IQR 153, 312).

Conclusion:  We propose that maintaining ≥ 650 admissions/center and ≥ 225 admissions/fellow of patients with an ISS > 15 at existing L1ATC be considered before introducing new TC to a region. This survey provides an additional baseline for ACS COT to evaluate the impact on training volumes as part of the verification process and trauma system design.
 

62.15 Effect of Surgery Specific Opioid Prescribing Education in a Safety-Net Hospital

Posted on January 31, 2019

C. Paffett1, M. Crandall1, B. K. Yorkgitis1  1University of Florida College of Medicine-Jacksonville,Department Of Surgery,JACKSONVILLE, FL, USA

Introduction:  As the nation works to improve the opioid epidemic, safer opioid prescribing is needed.  Prescriber education is one method to assist with this aim. To gauge current surgical residents’ opioid prescribing practices at a safety-net hospital, a survey was completed prior to a general surgery specific opioid prescribing education (OPE) session. The effectiveness of this OPE was measured through a post-participation survey.

Methods:  A voluntary, anonymous survey prior to and after a one-hour OPE session was performed at an urban safety-net hospital.  Descriptive statistics and Student’s t-test comparisons of means were performed to analyze the results.

Results: 

Twenty-three residents completed the surveys. Eleven (47.8%) completed prior OPE with the most common modality being online (7, 63.6%). No participant performed an opioid risk assessment prior to prescribing opioids.  More than half of the residents (14, 60.9%) never used the Prescription Drug Monitoring Program. Less than 1/3 (30.4%) used pre-operative gabinoids (gabapentin or pregabalin) for elective surgeries.  Only two residents provided information on unused opioid disposal. 

After the OPE, the participants were more likely to prescribe pre-operative gabinoids: 5 sometimes, 9 most of the time and 7 all the time. The mean opioid pills prescribed for laparoscopic cholecystectomy, open inguinal hernia repair, laparoscopic ventral hernia repair and laparoscopic appendectomy were reduced by 2.6 (14.2%), 3.7( 18.9%), 2.6 (13.1%), and 1.1 (7.3%) pills respectively (Table 1).

Conclusion: A short OPE delivered to surgical residents at a safety-net hospital improved the use of preoperative gabinoids and reduced the mean number of opioid pills prescribed after common surgical procedures.  While none of these results were statistically significant, there was a consistent reduction in amount of opiates prescribed after OPE. However, clinical significance is important, as a reduction in any amount of opioid medication can help deter misuse and diversion. This suggests surgeons could participate in a specialty specific OPE to assist with opioid prescribing.

62.14 Smartphone Use as an Educational Tool for Trainees

Posted on January 31, 2019

J. Savoy1, D. Ballard2, C. Carroll1, A. Dubose1, G. Caldito1, N. Samra1  1Louisiana State University Health Sciences Center,Shreveport, LA, USA 2Washington University School of Medicine in St. Louis,Mallinckrodt Institute Of Radiology,St. Louis, MO, USA

Introduction: 100% of U.S. adults ages 18-29 own a cellphone with 94% of those being smartphones. The ubiquitous presence of smartphones makes them a convenient educational tool and communication platform for surgical residents and medical students. There is a growing area of research investigating smart phones and their use as educational tools. A text message based educational initiative was launched at our institution to reinforce key points of trainee’s observed cases or patient presentations (termed "academic epinephrine"). This study was designed to evaluate medical trainees’ opinions and experiences with text messaging for educational purposes.

Methods: This was an IRB approved, single site study. Included in the study were LSUHSC Shreveport School of Medicine 3rd and 4th year medical students on their surgery rotations, as well as surgery residents. Subjects were recruited via email. An anonymous, cross-sectional, web-based survey was emailed to medical trainees between March and June of 2017. Statements in the survey were scored on a 5-point Likert scale regarding experiences and opinions on the topic of smartphone use and text messaging for educational purposes. We also aimed to address concern about text messaging as a possible invasion of a trainee's privacy (as indicated in our literature review) by including this as one of the items in our survey.

Results:Among the 69 respondents who were texted educational materials, the agreement proportions for items favoring text messaging and the disagreement proportion on whether text messaging is an invasion of privacy were all significantly greater than 50%. All observed proportions were greater than 90%. Among the 35 respondents who were not texted educational materials, the agreement proportions for items favoring text messaging and the disagreement proportion on whether text messaging is an invasion of privacy were all significantly greater than 50%. All observed proportions were greater than 88%.

Conclusion:In this study, medical students and surgical residents viewed text messaging as a valuable tool and supplement for education. The majority of trainees who were not texted educational material were interested in participating in the future and saw text messaging for educational purposes as a good idea. An overwhelming majority of medical trainees within the study did not see text messaging for educational purposes as a violation of their privacy. However, the 3% minority indicates the importance of an opt in policy for future text message/smart phone based educational programs. Future initiatives to substantiate this finding should include objective testing of text messaging/smart phones for educational uses with or without randomization.
 

62.13 Surgery Resident Skill Retention After Focused Assessment With Sonography In Trauma (FAST) Training

Posted on January 31, 2019

K. A. Boyle1, T. W. Carver1, A. Brandolino1, P. N. Redlich2, M. J. Malinowski2, R. W. Treat3, P. J. Schenarts4  1Medical College Of Wisconsin,Division Of Trauma And Acute Care Surgery, Department Of Surgery,Milwaukee, WI, USA 2Medical College Of Wisconsin,Division Of Education, Department Of Surgery,Milwaukee, WI, USA 3Medical College Of Wisconsin,Department Of Academic Affairs,Milwaukee, WI, USA 4University Of Nebraska College Of Medicine,Department Of Surgery,Omaha, NE, USA

Introduction: Skill decay is relevant in general surgery given the procedural nature of this specialty. Since the introduction of the FAST exam, surgeon educators have debated how to teach novices this technique. FAST training is typically done as massed practice, which can introduce basic concepts, but considerable hands-on skill and knowledge must be maintained for the correct interpretation of a FAST. There is no literature regarding skill decay following initial FAST training and no clear recommendations for maintenance of competency.

Methods: This was a prospective observational study on skill degradation and knowledge loss following an introductory FAST training which consisted of an in-person didactic session followed by hands-on education with model patients. First and second-year surgery residents were assessed pre-training, post-training, at 1 month, 3 months, and 6 months. At each time point, subjects completed a survey of their experience and confidence performing a FAST, a written assessment, and a hands-on assessment. The Quality of Ultrasound Imaging and Competence (QUICk) score, comprised of a Global Rating Scale (GRS) and a Task Specific Checklist (TSC), was used to grade the learner’s performance. Two reviewers scored the performances retrospectively. Statistical analyses were performed using SPSS, and analytical modeling was generated with repeated measures analysis of variance (RM-ANOVA) to assess mean scores across the five points in time.

Results: Nineteen surgery residents (12 PGY-1, 7 PGY-2) were followed for 6 months with 100% retention until the 6-month test when two were lost to follow up. Seven residents (36.8%) had previous FAST training. There were no differences noted for year of training and no correlation of performance to either previous FAST experience or confidence. Resident performance of the FAST significantly deteriorated by 1 month, but this decay stabilized at 3 months and 6 months. Knowledge decay was not significant until the 3-month test.

Conclusion: Traditional ultrasound education has focused on achieving short-term competency, however, this study shows that massed training is associated with a significant decline in hands-on performance at 1 month and knowledge at 3 months. While further deterioration was not appreciated at 6 months, the nature of this study design limits that finding. Additional studies must be performed to determine the best strategy to combat skill and knowledge decay in FAST education.

62.12 Gender Representation in Pediatric Surgery Authorship

Posted on January 31, 2019

A. Marrone1, L. Berman2, D. Rothstein1  1State University Of New York At Buffalo,Department Of Surgery,Buffalo, NY, USA 2Nemours/Alfred I DuPont Hospital for Children,Department Of Surgery,Wilmington, DE, USA

Introduction:
Multiple studies have found gender disparities in representation of women physicians in scientific authorship. Although the proportion of women graduating from pediatric surgery training programs appears to be increasing, we hypothesized that gender disparities remain in female representation in first or senior authorship of publications in a leading pediatric surgery journal. 

Methods:  Tables of contents for the Journal of Pediatric Surgery (JPS) in the years 2007, 2012, and 2017 were examined. We quantified the prevalence of female first and last authorship of original research articles, case reports, reviews, and lectures that came from United States or Canadian institutions. Author gender was assigned by either typical name recognition or internet searches. The same methods were used for names of members of the American Pediatric Surgical Association (APSA) from the years 2012 and 2017 (2007 data not available). Lastly, we determined the proportion of female members among all surgeons granted pediatric surgery specialty certificates by the American Board of Surgery (ABS).

Results: Of the 1338 JPS articles reviewed, 24 (1.8%) were excluded due to inability to identify gender of either author. In the years 2007, 2012, and 2017 the percentages of female first authors were 32.3%, 34.1%, and 53.8% respectively. The percentage of female senior authors were 15.7%, 23.0%, and 26.0%, respectively. The percentage of female members of APSA in 2012 and 2017 were 20.5% and 23.8%, respectively. Among the 1153 surgeons with ABS pediatric surgery certificates, 276 (23.9%) are women.

Conclusion: Female representation in academic pediatric surgical authorship is increasing, particularly among first authors. Although a relatively small proportion of senior authors are women, this proportion is concordant with society membership gender distributions. 

 

62.11 Adapting the AAS Fundamentals of Surgical Research Course to West Africa: A 10-year evaluation

Posted on January 31, 2019

A. Ekeh1, J. Laryea2, B. Nwomeh4, A. Omigbodun5, J. Ladipo6, K. Yawe7, S. Krishnaswami8, F. Nwariaku3  1Wright State University,Surgery,Dayton, OH, USA 2University Of Arkansas for Medical Sciences,Surgery,Little Rock, AR, USA 3University Of Texas Southwestern Medical Center,Surgery,Dallas, TX, USA 4Ohio State University,Surgery,Columbus, OH, USA 5University of Ibadan,Obstetrics And Gynaecology,Ibadan, OYO STATE, Nigeria 6University of Ibadan,Surgery,Ibadan, OYO STATE, Nigeria 7University of Abuja,Surgery,Abuja, FCT, Nigeria 8Oregon Health And Science University,Surgery,Portland, OR, USA

Introduction:

The Association for Academic Surgery (AAS) has annually administered the Fundamentals of Surgical Research  (FSR) course for almost 30 years – designed primarily for residents and junior faculty in surgery and surgical specialties. In 2008, the course was launched internationally, starting in West Africa. Commencing as a collaboration between the AAS and the West African College of Surgeons (WACS), the course was held 6 times between 2008 and 2014 in different West African countries, and utilized chiefly US based faculty who traveled to the region to participate in conjunction with local faculty. In 2015, the course was reconfigured to utilize primarily local faculty based in the sub region, fewer US based personnel and further adapted to local needs We evaluated the course after 4 consecutive years of this new format, with respect to the attendance, the number of US based faculty utilized, costs from external sources (above and beyond participant registration fees) and participants evaluations.

Methods: Data collating the number of attendees, funding from external sources (sponsorships), the number of US based faculty and student evaluations were obtained for the first 6 iterations of the AAS FSR West African course (2008 -2014). The same data was obtained for the next 4 courses (2015 – 18) which had been renamed the WACS/AAS Research Methodology Course (RMC). The mean number of attendees, external support (above and beyond registration fees in US Dollars) and the number of US faculty were compared statistically using student t-tests.  

Results:
In the first 6 years of the AAS FSR course (2008 – 2014) the average number of attendees per course was 67 (range 20 to 120) while the mean number of attendees for the WACS/AAS RMC was 150 (range 141 – 160), p = 0.0032. The average costs from external sources for the AAS FSR was $29,183 (range $20000 to $50000) and for the WACS/AAS RMC $5000. p = 0.0106. On average, 9.7 US faculty were used for the AAS FSR and just 2.3 for the WACS/AAS RMC. (p < 0.0001)  Student evaluations were more difficult to directly compare as the highest tiers were rated " Good and Excellent " in the AAS FSR period and "Useful and Very Useful " in the WACS/AAS RMC period. Over 90% of the evaluations however were in these two highest tiers in every course in both periods.  

 

Conclusion:
The adaptation of the AAS Fundamentals of Research Course to the West African region has correlated with increased average attendance, reduced external support costs over and above participant fees, a reduced number of US faculty utilized and similar excellent evaluations from the course participants.  With appropriate mentorship, the regional adoption of courses like the AAS FSR course in different environments is feasible.  The with the utilization of local faculty, the reduced need for external funding and equivalent evaluations by participants makes this approach attractive for the implementation of such courses in resource-poor environments

 

62.10 In Hot Water: Graduating General Surgery Residents Perform Fewer Pediatric Surgery Cases Each Year

Posted on January 31, 2019

N. A. O’Neill1, R. G. Conway1, C. T. Laird1, K. M. Lumpkins1, S. M. Kavic1, E. D. Strauch1  1University Of Maryland,Surgery,Baltimore, MD, USA

Introduction:  General surgery training is experience based, and the transition from novice to expert occurs after optimizing surgical case volume. Here we explored the trends in graduating general surgery residents’ reported cases for pediatric surgery.

Methods:  Using the Accreditation Council of Graduate Medical Education’s (ACGME) published case log statistical reports for general surgery residents, the mean major pediatric surgery cases, pediatric major subcategory cases, and total major cases logged for each academic year’s graduating class were reviewed from 2000 – 2017.  Statistical analysis was performed using linear regression with SAS.

Results: The total number of general surgery residents in the United States has linearly increased from 989 residents in 2000 to 1211 residents in 2017 (R2: 0.89, p <0.001), as has the number of pediatric surgery fellows taking the qualifying board examination from 34 in 2000 to 56 in 2017 (R2: 0.70, p<0.001).  Junior residents logged 93.7% (SD 0.9%) of pediatric surgery cases. The average major pediatric surgery cases logged by graduating general surgery residents are steadily declining from a peak of 42 (4.5% of total major cases) in 2003 to 26 (2.6%) in 2017 (R2: 0.92, p <0.001; Figure 1). The most commonly logged pediatric case subcategory each year is “inguinal/umbilical herniorrhaphy.” Subcategory “repair omphalocele/ gastroschisis” (+21%, R2: 0.64) and “anti-reflux procedure – laparoscopic” (+579%, R2: 0.86) have increased over the study period, but both “branchial cleft/thyroglossal duct” (-37%, R2: 0.85) and “anti-reflux procedure – open” (-92%, R2: 0.94) have decreased. Since 2003, the reported major pediatric cases are decreasing with a rate of 1 case every academic year. If this rate continues, residents graduating in 2023 will be logging only 20 pediatric surgery cases, which is the minimum requirement by the ACGME.

Conclusion: In the past 17 years, there has been a slow, persistent decline in pediatric surgery cases performed by graduating general surgery residents. Just as in the fable of a frog in water that is slowly boiled, if this trend continues, we risk a critical erosion of pediatric experience for general surgery residents. While the exact cause is unknown, the experience gap may lead to a vicious cycle where attendings and fellows are performing more cases with the focus on protecting outcomes and institutional reputation, which in turn decreases the operating opportunities for their trainees.

Next Page »