62.09 Identifying Key Logistical Factors of a Mindfulness-Based Burnout Intervention in Residents

Posted on January 31, 2019

A. Desai1, E. Guvva1, C. Lebares1  1University Of California – San Francisco,Surgery,San Francisco, CA, USA

Introduction:  Burnout in physician trainees is a potent and increasingly prevalent issue which increases the risk of depression, errors and suicidal ideation. To date, interventions have been largely ineffective, which may reflect our incomplete understanding of this complex problem. Institution, systemic and individual factors impact the success of interventions through logistical elements that are poorly understood. Formal mindfulness training (MT) among surgery interns, and other high-performance populations, has been shown to be feasible and acceptable, as well as beneficial for burnout, mental health, executive function and performance. However, dissemination and successful implementation of MT in medical training has been limited. The aim of this study was to explore the logistical and structural factors critical for the successful implementation of MT interventions among physician trainees.

Methods:  Using mixed methods, the feasibility and acceptability of MT was explored in three different studies: a longitudinal pilot randomized controlled trial with surgery interns (n=40), a cohort study of mixed level urology residents (n=20), and a registered clinical trial of surgical and non-surgical interns (n=45). Group means were compared for attendance, attrition and daily home practice, with differences evaluated in the context of concepts and themes derived from grounded theory analysis of focus group feedback, field notes, satisfaction surveys and key informant interviews. Logistical and structural factors critical to MT feasibility and acceptability were identified across groups.

Results: Scheduling, protected time and a clear statement of value from leadership were found to be critical structural factors for MT success.  Specifically, successful scheduling required dedicated time within the work week, and minimal conflicts with other elements of resident training. Established educational days and natural lulls in the year (i.e. summer or winter holidays) were particularly useful. Protected time was found to be critical not only in terms of being excused to attend class, but also being free from pages. This allowed for consistent attendance and full participation in class without distraction. Attribution of value by leadership (i.e, department chairs and program directors) was found to determine the cultural attitude surrounding MT, both in terms of participant-perceived credibility and the willingness of colleagues to provide service coverage during MT class time, without hostility or retribution.

Conclusion: These results show that scheduling, protected time and attribution of value by leadership are crucial factors for the implementation of MT in a tertiary academic setting. The successful execution of these factors require rigorous planning, communication and flexibility with all program members. These three factors must be tailored in accordance with each program’s unique framework. 

 

62.08 Prospective Cohort Study of Burnout in General Surgery Residents

Posted on January 31, 2019

M. M. Symer1, A. Watkins1, H. Yeo1  1Weill Cornell Medical College,New York, NY, USA

Introduction: Burnout is a syndrome of depersonalization and emotional exhaustion that is associated with absenteeism and medical errors. Longitudinal studies in burnout are lacking, and the extent to which burnout fluctuates in individuals is unknown. The current gold-standard survey instrument of burnout, the Maslach Burnout Inventory (MBI), is not specific to surgeons and does not help identify sources of burnout.

Methods:  A prospective, longitudinal cohort study of categorical general surgery residents at a single institution was performed over 6 months. Residents were surveyed about their attitudes toward burnout, degree of depression, and current quality of life. Residents were also surveyed with the MBI and a novel, surgery-specific burnout questionnaire. The 34-item novel burnout questionnaire was developed by literature review, informal interviews, and pilot testing with faculty and residents. Included questions related to degree and common sources of burnout. Internal consistency and correlation with the MBI were assessed. Overall prevalence of burnout as well as change in depersonalization and emotional exhaustion at both time points were calculated and correlated with demographic features.

Results: 32 residents participated in the study. At the midpoint 100% of residents were classified as having high burnout in at least one MBI domain, 35% had high burnout in 2 domains, and 12% were classified as having high burnout in all three domains of the MBI. 32 (68%) of eligible residents participated in the study. Residents were mostly white (n=26, 78%), and 56% were men. Most (81%) felt that burnout was a problem which should be addressed. Burnout was highly prevalent at baseline, with 75.9% having high emotional exhaustion. At the start of the study the average emotional exhaustion MBI score was 29 (SD 5.4), and three months later the average score was 27 (SD 8.0; p=0.24). Residents reported a baseline average quality of life of 6.3 out of 10 (SD=2.3), and this also did not change during the study period (p=0.93). Internal consistency of the novel surgery-specific burnout survey was acceptable, with Cronbach’s alpha of 0.76. In survey responses (Figure 1: Major themes and categories of stress and support from qualitative survey responses), residents cited time pressures as the major driver of burnout, and n=31 (97%) agreed that lack of time prevented them from taking better care of themselves. 

Conclusion: Burnout is a highly prevalent but relatively stable phenomenon among general surgery residents, and time constraints contribute the most to burnout. The practice environment and institutional culture are also important contributors to burnout. These areas are key avenues for the improvement of burnout in residents.

 

62.07 "Cross-Sectional Analysis of Global Surgery Opportunities Among General Surgery Residency Programs"

Posted on January 31, 2019

P. J. Abraham1, M. N. Abraham1, B. Lindeman1, H. Chen1  1University Of Alabama at Birmingham,Birmingham, Alabama, USA

Introduction: Global surgery is a rising field within academic surgery. With the publication of recent landmark papers highlighting the need for increased global efforts to combat surgical disease, many general surgery residents seek opportunities to gain clinical, research, and educational experience related to global surgery during residency. This study aims to quantify the global surgery opportunities that are publicly available to residents training in ACGME-accredited general surgery programs.

Methods: The websites of all ACGME-accredited general surgery residency programs were surveyed for mention of global surgery training opportunities. Each opportunity was recorded in a database and categorized based on type. Recorded categories include international clinical rotations, international surgical research opportunities, and formal tracks or training pathways for global surgery.

Results: Of the 299 ACGME-accredited general surgery training programs, 38 (12.7%) mention some form of international surgical opportunity on their website. Among these programs, 7 (18.4%) note both clinical and research opportunities, 19 (50.0%) mention only clinical opportunities, and 12 (31.6%) list only research opportunities. Ten programs (26.3%) described a global surgery track or pathway within their program. The large majority of global surgery opportunities were based in training programs at academic medical centers (n=35, 92%), with the remaining 3 based in programs at community teaching hospitals.

Conclusion: Very few general surgery residency programs mention international training opportunities on their program websites. For those programs that do offer global surgery opportunities, these are typically international rotations offered as electives for upper-level residents. Increased global surgery opportunities are needed at residency programs nationwide to meet the desire of residents wishing to pursue a career in academic global surgery.

 

62.06 Surgical Coaching for Advancement of Global Surgical Skills and Capacity: a Systematic Review

Posted on January 31, 2019

D. El-Gabri1, A. D. McDow1, S. R. Pavuluri Quamme2, C. C. Greenberg3, K. L. Long1  1University Of Wisconsin,Division Of Endocrine Surgery/ Division Of General Surgery/ Department Of Surgery/ University Of Wisconsin School Of Medicine And Public Health,Madison, WI, USA 2University Of Wisconsin,Department Of Surgery/ University Of Wisconsin School Of Medicine And Public Health,Madison, WI, USA 3University Of Wisconsin,Division Of Surgical Oncology/ Division Of General Surgery/ Department Of Surgery/ University Of Wisconsin School Of Medicine And Public Health,Madison, WI, USA

Introduction:
Surgical coaching is an emerging concept of education and collaboration demonstrated to improve surgical performance, perceptions and attitudes of practicing surgeons. Continued surgical education in low-resource settings remains a challenge due to confounding barriers of access, resources, and sustainability. Despite early successes of surgical coaching in academic institutions, to our knowledge, no formal assessments of coaching as a means to improve surgical quality in low-middle income countries (LMICs) exist. The purpose of this review is to explore if surgical coaching is an effective method of fostering continued medical education and promoting advancement of surgical skills for established surgeons in low resource settings.

Methods:
We conducted a systematic literature search through PubMed, Scopus, Web of Science, and CINAHL in July 2018. Included studies were in English, peer-reviewed, and met pre-established study criteria. Studies must have assessed surgical coaching- specifically defined as a means to establish continuous professional growth of trainees and practicing surgeons. Additionally, we conducted a reference and citation analysis as well as a data quality assessment on included studies.

Results:
Our search produced 1377 results and 151 were selected for full text analysis, of which 23 met inclusion criteria for summary analysis. While the majority of the articles (13/23) evaluated coaching of trainees, 10 articles assessed or evaluated coaching surgeons in established careers. Of the articles that discussed skill acquirement (18/23), 3 assessed non-technical skills alone, and 14 assessed technical skills or both technical and non-technical skills. In studies that assessed skill performance after a coaching intervention (9/23), all of them (9/9) demonstrated skill improvement compared to a control. The idea of remote or cross-institutional coaching was explored in 8 of the 23 studies. None of the studies reviewed discussed or evaluated coaching in LMICs.

Conclusion:
Coaching is a widely applicable method of teaching surgeons at multiple stages of a career with clear educational benefits. The explored advantages of surgical coaching in academic institutions may be applied to continuous performance improvement and collaboration with surgeons in LMICs. Furthermore, coaching may aid in assessment of the well-established Lancet Global Surgery Indicators thereby improving surgical capacity in LMICs.
 

62.05 Evaluating an Evidenced-Based Guideline to Reduce Excessive Prescription of Post-Operative Opioid

Posted on January 31, 2019

M. R. Freedman-Weiss1, A. S. Chiu1, D. R. Heller1, V. Kurbatov1, P. S. Yoo1  1Yale University School Of Medicine,Surgery,New Haven, CT, USA

Introduction:
Prescription opioids are a main contributor to the current opioid epidemic as leftovers often get diverted for non-medical use.  Surgeons are known to dispense far more opioid pills than are needed to treat pain.  In academic institutions, junior residents (PGY-1, 2) write most postoperative prescriptions.  Few residents receive education on opioids, but trainees who did, cited opioid dosage recommendations as the most useful educational point.  Utilizing publsihed data on actual postoperative opioid use, we developed a card of recommendations for surgical residents to use when prescribing postoperative analgesia.  We studied the impact of this initiative and the value of the card, paying particular interest in junior resident use.

Methods:
A pocket-sized postoperative analgesia guideline card was developed, comprising specific recommended opioid doses for common general-surgical procedures, general guidelines for postoperative analgesia, instructions for Narcan use, an equianalgesic opioid chart, and smartphrases in the electronic medical record for use as patient instructions on opioid use, safety, and disposal.  The specific recommended doses were based on published data on actual postoperative opioid use and were approved by experienced surgeons from each included specialty.  The tool was distributed to all general surgery housestaff at a university-affiliated hospital.  Following the distribution of the card, an anonymous electronic survey (Qualtrics Survey Software) regarding its use and impact was distributed.  Descriptive statistics were used for all analyses.

Results:
Of 85 trainees, 62 (72.9%) responded to the survey in full.  Fifty respondents (80.6%) received the opioid guideline card, including 16 PGY-1’s and 10 PGY-2’s.  Of responding PGY-1 and PGY-2 trainees who received the card, 75% and 60% respectively use it, with 46% of responding junior residents accessing the tool on a daily-to-weekly basis.  Overall, 81.6% of included residents reported changing their opioid prescribing practices because of this intitative and 89.8% believe the card should continue to be distributed and used. The most valuable aspects of the card were the specific dosage recommendations (53.1%), the guidelines for analgesia after inpatient stays (40.8%), and the smartphrases for patient discharge instructions (28.6%).

Conclusion:
An evidenced-based guideline for postoperative analgesia, including specific recommendations for opioid doses after common surgical procedures, is useful for surgical residents, specifically junior residents.  Nearly all residents who received this card report that is has influenced their prescribing practices and advise its continued distribution and use.  A comprehensive guideline for postoperative analgesia should be considered for wide-use, specifically among junior residents at training hospitals.  Its impact on offsetting the over-prescription of postoperative opioids should be studied further.
 

62.04 Provider Education Decreases Opioid Prescribing After Pediatric Umbilical Hernia Repair

Posted on January 31, 2019

K. Piper1, K. J. Baxter1, M. Wetzel3, C. McCracken3, C. Travers3, B. Slater4, S. B. Cairo5, D. H. Rothstein5,9, R. Cina6, M. Dassinger7, P. Bonasso7, A. M. Lipskar8, N. Denning8, K. F. Heiss1, M. V. Raval2  1Emory University School Of Medicine,Division Of Pediatric Surgery, Department Of Surgery, Children’s Healthcare Of Atlanta,Atlanta, GA, USA 2Feinberg School Of Medicine – Northwestern University,Department Of Surgery, Division Of Pediatric Surgery, Ann & Robert H. Lurie Childen’s Hospital Of Chicago,Chicago, IL, USA 3Emory University School Of Medicine,Department Of Pediatrics, Children’s Healthcare Of Atlanta,Atlanta, GA, USA 4The University of Chicago Medical Center,Department Of Pediatric Surgery,Chicago, IL, USA 5John R. Oishei Children’s Hospital of Buffalo,Department Of Pediatric Surgery,Buffalo, NY, USA 6Medical University Of South Carolina,Division Of Pediatric Surgery,Charleston, SC, USA 7University of Arkansas for Medical Sciences,Department Of Pediatric Surgery,Little Rock, AR, USA 8Zucker School of Medicine at Hofstra/Northwell,Division Of Pediatric Surgery, Department Of Surgery, Cohen Children’s Medical Center,New Hyde Park, NY, USA 9University at Buffalo Jacobs School of Medicine,Department Of Surgery,Buffalo, NY, USA

Introduction:  Surgical procedures early in life may serve as an initial contact with opioids and contribute to the current opioid epidemic in the United States.  Educating adult surgical providers about their opioid prescribing practices has been shown to reduce overprescribing following a variety of procedures.  Our objective was to improve opioid stewardship for umbilical hernia repair in children. 

Methods:  An educational presentation intervention was conducted at 6 centers with 52 surgeons.  The presentation highlighted the importance of opioid stewardship, demonstrated practice variation, provided prescribing guidelines, encouraged non-opioid analgesics and limiting doses/strength if opioids were prescribed. Three months of pre- and post-intervention prescribing practices for umbilical hernia repair were compared. 

Results: A total of 224 patients were identified in the pre-intervention cohort (median age = 5 years) and 218 in the post-intervention cohort (median age = 5 years).  Baseline opioid use varied from 22% of patients to 100% across the 6 centers.  Overall, the percent of patients receiving narcotics at discharge decreased after the intervention from 73.2% to 45.4% (p < 0.001).  After adjusting for age, sex, umbilicoplasty, and hospital site, the odds ratio for opioid prescribing in the post-intervention period versus the pre-period was 0.28 (p < 0.001; 95% confidence interval (CI) = 0.18-0.45). There was no evidence for the intervention having hospital-specific effects (p = 0.77). All hospitals demonstrated improved opioid stewardship with the magnitude of the decrease in percent of patients prescribed opioids ranging from 24% to 100% (Figure).  Among patients receiving narcotics, the number of doses prescribed decreased slightly after the intervention (median doses 12.4 to 10, p = 0.002), and the morphine equivalents per kg per dose decreased (median 0.14 to 0.10, p < 0.001).  Among the entire cohort of patients, the total number of doses prescribed decreased by 50% when compared with the number that would have been prescribed before the educational intervention.  No patients required a refill (pre- or post-intervention) and there were no differences in returns to clinic or emergency departments or hospital readmissions.

Conclusion: Opioid stewardship can be improved after pediatric umbilical hernia repair using a low-fidelity educational intervention.  Pediatric surgeons appear receptive to these efforts supporting expansion to more procedures and populations.

 

62.03 Gender Differences within Surgical Fellowship Program Directors

Posted on January 31, 2019

C. Shaw1, C. Le1, T. Loftus1, A. Filiberto1, G. A. Sarosi1, A. Iqbal1, S. Tan1  1University Of Florida,Department Of Surgery,Gainesville, FL, USA

Introduction: The role of gender-specific mentorship in career choice for women has been well documented. Although women are increasingly represented in American surgery, national data on fellowship program leadership are unknown.  The academic rank and gender of surgical fellowship Program Directors (PDs) were analyzed with the null hypothesis that women and men would be equally represented and hold similar academic ranks among various fellowship programs.

Methods: Demographics and academic ranks for fellowship PDs, Associate Program Directors (APDs), and department faculty were collected for 811 surgical fellowship programs across 14 specialties in the United States.  The academic rank and gender of PDs were compared by Fisher’s Exact test. Proportions of women PDs and fellows were then compared to median compensation for the specialty.

Results: Women represented 23% of all departmental faculty, 18% of all fellowship PDs, and 14% of all APDs.  Fifteen percent of all PDs were Assistant Professors (20% women vs. 13% men, p=0.052), 29% were Associate Professors (32% women vs. 29% men, p=0.367), 37% were Professors (30% women vs. 39% men, p=0.038), and academic rank was unknown for 19%.  The percentage of women PDs was highest in Breast Surgery (65%), Endocrine Surgery (35%), Burn Surgery (25%), and Acute Care Surgery (25%), and lowest in Thoracic Surgery (6%), Minimally Invasive Surgery (6%), Vascular Surgery (11%), and Plastic Surgery (13%). This largely paralleled the percentage of women fellows within these programs with women being overrepresented in subspecialties with lower compensation.

Conclusion: Women surgeons are underrepresented among surgical fellowship PDs, especially in high-income specialties.  It remains unclear whether women surgeons achieve PD appointments at lower academic ranks, or if promotion of fellowship PDs is influenced by gender. Lack of same-sex mentorship could be a component of the difficulty in attracting women to high-paying subspecialties, further widening the gender pay gap among surgeons and perpetuating the lack of women in the pipeline to leadership within these fields.

62.02 Gender Gap amid Moderators, Speakers, Oral and Poster Presenters at National Surgical Conferences

Posted on January 31, 2019

A. L. Hoffman1, R. Ghoubrial1, P. Matemavi1, A. Langnas1, W. Grant1  1University Of Nebraska College Of Medicine,Surgery,Omaha, NE, USA

Introduction:

Discussions about gender representation in high profile positions at surgical conferences have been informal.  The objective of our study is to examine trends at four large United States surgical conferences which represent a variety of surgical specialties.

Methods:
We retrospectively collected data from publicly accessible programs on moderators, invited speakers, abstract and poster presenters at the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Society of Surgical Oncology (SSO), American Pediatric Surgical Association (APSA), and American Society of Transplant Surgeons (ASTS) between 2012-2017. Gender representation of society membership is not public record and was not available at our request.

Results:

In all four conferences over the 5-year period:

·  223 (21.9%) of 1,016 moderators were female.

·  1,294 (25.2%) of 5,119 invited speakers were female.

·  1,828 (27.1%) of 6,738 oral and abstract presenters were female.

The largest gender gap was observed at SAGES and ASTS for all categories whereas the APSA and SSO oral and poster presenters neared gender parity at the end of the review period.

During the review period, the percentage of female:

·  moderators increased from 19.5% to 26.7%.

·  invited speakers increased from 23.25% to 32.7%. 

·  abstract presenters increased from 17.8% to 27.3% and

· poster presenters increased 24.5% to 36.9%.

 

Conclusion:

Over the last five years, there has been an increased proportion of women in medical school and general surgery residency. Currently women make up 48.4% of medical students and 38.4% of surgery residents. The percentage of female representation at surgical meetings does not yet parallel trends in training. Though, shifts towards gender parity are seen in some areas, women are still under-represented in many aspects of surgical meetings.

62.01 Trends in Gender Representation at the Academic Surgical Congress

Posted on January 31, 2019

A. R. Wilcox1,2, S. L. Wong1,2  1Dartmouth-Hitchcock Medical Center,Department Of Surgery,Lebanon, NH, USA 2Dartmouth Medical School,Lebanon, NH, USA

Introduction: A growing body of data demonstrates persistent disparities in gender representation at scientific and medical meetings. It is also well established that women are underrepresented in positions of highest academic achievement in surgery. As visibility and active participation at national meetings contribute to career advancement, it is important to understand the gender parity of national surgical meetings. Our objective was to evaluate trends in the proportion of women panelists and moderators at the Academic Surgical Congress (ASC) meetings.

Methods: This was a retrospective analysis for which we manually extracted data from the ASC meeting programs for 2014-2018, which are publicly available on the meeting website. We performed an internet search of surgeons listed in the program to determine gender. We then performed counts and calculated proportions of surgeons by gender who were listed as panelists and moderators (including moderators for all oral, plenary, poster, and panel sessions). We also compiled data on the Association for Academic Surgery (AAS) and Society of University Surgeons (SUS), focusing on the composition of the ASC Program Committee, which is comprised of members of the AAS Program Committee and SUS Publications Committee.

Results: 20% of panels (12/59) at the ASC over the past 5 years did not include a woman panelist. 2016 was the most unequal year, as 55% of panels (6/11) did not include a woman panelist at all and only 23% of panelists overall (9/39) were women. In contrast, all panels in 2017 included at least 1 woman panelist. In 2018, although there were 2 panels without a woman, the proportion of woman panelists overall was 43% (24/56). (FIGURE)

Over the 5 years studied, 30% of moderators were women (280/945). 2016 had the lowest representation of women moderators at 25% (43/172). In turn, the Program Committee had the lowest representation of women in 2015 & 2016 (13/58 & 13/59, respectively, or just 22%). Interestingly, in 2016 both of the Program Committee chairs were men, whereas there was 1 man and 1 woman in each of the remaining four years analyzed. Women comprised 30% of the Program Committee in 2017 (17/57) and 29% in 2018 (19/65).

Conclusion: In the past 5 years, and most notably in 2016, women were underrepresented compared to men as panelists and moderators at ASC meetings. The lowest proportion of women on the Program Committee (including chairs) was seen in 2016, which is consistent with trends in the literature showing that representation of women on program committees correlates to the proportion of women speakers at meetings. However, there has been evidence of growing equity in the past 2 years, possibly reflective of increasing awareness of these disparities.
 

42.10 Using a Location-Based Time-Keeping App to Help Track Resident Duty-Hours: A Pilot Study

Posted on January 31, 2019

B. Zhao1, J. Lam1, A. Lee1, G. R. Jacobsen1  1University Of California – San Diego,Surgery,San Diego, CA, USA

Introduction:
Duty-hour limits continue to be an important topic in graduate medical education. Currently, the majority of programs rely in voluntary reporting of duty-hours by trainees. The accuracy of reported hours can be poor because tracking work-hours can be an arduous task for trainees. This can lead to trainees not regularly reporting hours, which can further decrease the accuracy of reported work-hours. In this study, we propose an innovative method to track trainee work-hours using a smartphone app.

Methods:
We performed a pilot study testing the feasibility of an automated, location-based time-keeping smartphone app on 10 general surgery residents at our institution. The app sets “geofences” around specific locations and automatically records work-hours once the user is within the “geofenced” area. Study personnel installed the app on each participants’ smartphones and instructed participants on how to check their work-hours using the app. A hypothetical work-hour record is shown in the Figure. We conducted a pre-installation survey and a post-installation survey 12 weeks later.

Results:
Prior to using the app, 80% of residents stated that it was too time-consuming to report hours and 40% of residents stated that it was difficult to accurately track duty-hours. 60% of residents thought they were under-reporting their duty-hours prior to using the app. However, after using the app, only 1 resident stated that he or she worked more than they previously thought. The frequency of hours-reporting did not change after using the app, with half of the residents stating that they reported hours less frequently than once per month in both surveys. In terms of usability, 80% of residents stated that the app was moderately easy to use and 60% stated that it was moderately accurate. 80% of residents actively used the app to check their duty-hours. Two residents complained that the app was slow to clock-out at times, leading to over-counting of work-hours, and two residents complained that the app was detrimental to their phone’s battery life. After using the app, 60% of residents stated that they were at least moderately likely to allow a location-based app to automatically report their work-hours in the future. 

Conclusion:
Using a location-based time-keeping smartphone app has potential to help residents track duty-hours. The app works in the background and allows residents easy access to their duty-hours. Further work needs to be done to improve the accuracy of the app and further integrate the app with the reporting of duty-hours. This will decrease the burden, and increase the accuracy, of duty-hour reporting for trainees.
 

42.09 Financial Costs of Urology Residency Interviews: Are Underrepresented Minorities at a Disadvantage?

Posted on January 31, 2019

J. Whitley2, B. D. Joyner1,2, K. Kieran1,2  1University Of Washington,Seattle, WA, USA 2Seattle Children’s Hospital,Seattle, WA, USA

Introduction:  Increasing diversity remains a goal of many urology training programs.  Failure to recruit and retain underrepresented minority (URM) applicants has been attributed to a “pipeline” issue, although it is unclear where in the “pipeline” this discrepancy is most pronounced.  Since the cost of residency interviews has been previosuly identified as a potential barrier to some applicants, we wondered whether differential cost might be a factor for URM students applying to urology.  We undertook this study to determine whether the structure of residency interviews at selected top residency programs is associated with differential cost to students at medical schools with high and low URM populations.

Methods:  We identified 22 theoretical applicants: 11 "students" at medical schools with the student body >20% URM ("high-URM"), and 11 "students" at randomly selected medical schools with the student body <15% URM ("low-URM").  We contacted each of 17 "top" urology residency programs to identify interview dates for the 2017-2018 match, created a theoretical interview  schedule for each "student," and calculated the cost of travel (by car for <3 hours drive, otherwise by air) and lodging from each of the 22 medical schools to the 17 residency programs on one of the planned interview dates.  The aggregate costs to "students" at high-URM and low-URM medical schools were compared.

Results:  The median aggregate costs of travel and lodging for "students" attending all 17 interviews was $9189 (range: $7202-13,703) for applicants from high-URM schools and $9035 (range: $6698-$11967) for applicants from low-URM institutions (p=0.81). 

Conclusion:  In the 2017-2018 urology interview season, costs to applicants from high-URM and low-URM institutions are statistically similar.  Absolute cost considerations are unlikely to account for differences in URM representation in top-tier residency programs. Program directors and undergraduate medical education leadership must continue to investigate real and postulated barriers to URM engagement and retention along the pipeline to urology graduate medical education.
 

42.08 The Anatomy of Gun Violence: Curriculum to train surgical residents in the management of gun violence

Posted on January 31, 2019

E. J. Onufer1, D. R. Cullinan1, E. G. Andrade1, P. E. Wise1, M. E. Klingensmith1, L. J. Punch1  1Washington University,Surgery,St. Louis, MO, USA

Introduction: Gun Violence (GV) is a complex public health issue which poses unique challenges to the practice of surgery. The management of GV as a disease engages the surgeon in a wide range of both technical and non-technical skills. The Anatomy of Gun Violence (AGV) curriculum was developed to teach surgical trainees these seemingly disparate skills, training residents to manage gunshot wounds in a contextualized setting. Moving beyond the technical aspects of treating penetrating injuries, this curriculum examines the risks for and experience of GV as well as the need for strong leadership, communication, and empathy in the management of GV.

Methods: The AGV curriculum was delivered over six weeks in the 2017-18 academic year and utilized multiple educational methods including didactic lectures, senior resident lead mock oral examination of junior residents, Stop the Bleed training session, a GV survivor’s personal story, and the Surgery for Abdominal-thoracic ViolencE (SAVE) simulation lab. The lab emphasized team-training in operative management of GV in an animate model, featuring stories of real patients treated by resident teams over the prior year. Content reviewed included epidemiology of GV, patterns of injury, management of critically ill patients, effect of GV on mental health, coordinated systems of care, and the importance of team work in managing of GV. Residents were evaluated via survey to assess skills obtained, team leadership, communication styles, overall experience of the curriculum.

Results: 63 surgical residents experienced the AGV curriculum and 42 completed a survey regarding their experiences (67% response rate). Prior to residency, 10 of 42 (24%) residents reported any type of training related to GV. 71% of residents had never heard someone speak about their experience as a GV survivor, and 89% believed this session positively contributed to their understanding of GV. The SAVE lab was the most highly favored with no significant difference between other portions of the curriculum. Overall AGV was rated highly at 4.9/5.0 with individual components rating 4.5-4.8/5.0 (Figure).

Conclusion: Through simulation, didactic, and immersive sessions, AGV created a simultaneous experience of the technical and non-technical skills necessary to manage the complex GV epidemic. The curriculum was well received in both these areas of competency. This comprehensive approach to GV may represent a unique opportunity to engage surgical trainees in both the treatment and prevention of GV.

42.07 Safety in allowing residents to independently perform appendectomy, a retrospective review

Posted on January 31, 2019

J. R. Barrett1, M. K. Drezdzon1, A. Monawer1, A. P. O’Rourke1, J. Scarborough1  1University of Wisconsin,Acute Care Surgery,Madison, WISCONSIN, USA

Introduction:

The "teaching resident" role provides senior surgical trainees with an excellent opportunity to demonstrate their independence with the intraoperative conduct of certain procedures.  It is not known, however, whether the practice of "two-resident" procedures impacts patient outcomes. 

Methods:

A single-center retrospective review of 500 consecutive patients from May 2016 to December 2017 who underwent appendectomy with the University of Wisconsin Hospital system. The outcomes of "two resident" procedures was compared with those of procedures which included only one resident, after adjustment for patient- and procedure-related factors.

Results:

A total of 303 cases were performed with a single resident, 190 with two residents, and 7 cases were excluded that were performed with no resident present. There were no differences in the incidence of postoperative SSI (7.9% for two resident vs. 7.3% for one resident procedures, P = 0.80), prolonged operation (28.4% for two resident vs. 26.4% for one resident, P = 0.62), or conversion from laparoscopic to open (3.7% for two resident vs. 2.3% for one resident, P = 0.37) between groups, either before or after adjustment for other variables.

Conclusion:

Allowing senior residents to take junior residents through laparoscopic appendectomy procedures does not impact patient outcomes.  Incorporation of this practice into the current entrustable professional activity (EPA) framework of surgical resident education is appropriate.

42.06 The Future of General Surgery Training: A Canadian Resident Nationwide Delphi Consensus

Posted on January 31, 2019

C. Huynh1, N. Wong-Chong2, P. Vourtzoumis3, W. Marini3, S. Lim4, G. Johal1, M. Strickland3, A. Madani5  1University Of British Columbia,Surgery,Vancouver, British Columbia, Canada 2McGill University,Surgery,Montreal, QC, Canada 3University of Toronto,Surgery,Toronto, Ontario, Canada 4University of Manitoba,Surgery,Winnipeg,Manitoba, Canada 5Columbia University College Of Physicians And Surgeons,Surgery,New York, NY, USA

Introduction:
Various pedagogical models have been introduced in an attempt to improve and restructure surgical training. Yet, there remain significant obstacles related to their method of implementation, timing and acceptance. Prior to implementing national guidelines, it is critical to explore residents’ opinions to ensure a successful transition that meets their needs and addresses the practical challenges of reformatting surgical residency. This study aimed to establish a nationwide Delphi consensus statement on the opinions and perceptions of Canadian residents regarding the future of general surgery training.

Methods:
Residents from each Canadian general surgery program participated in a moderated semi-structured focus group using a Nominal Group Technique to discuss issues related to surgical training across three domains: early sub-specialization (streaming), competency-based medical education (CBME), and a dedicated transition-to-practice (TTP) period. Qualitative verbal data was transcribed verbatim, coded, grouped into themes, and synthesized into a list of recommendation statements. Using an online, iterative Delphi survey, these statements were then ranked by a panel of residents on a 5-point Likert scale in terms of agreement. The survey was terminated once consensus was achieved, predefined as ≥2 survey rounds and internal consistency (Cronbach’s α) ≥0.80. Each statement was marked as “positive agreement” (67% majority ranked 4 or 5), “negative agreement” (67% majority ranked 1 or 2), or “no agreement” (neither positive or negative agreement).

Results:
Sixty-six statements were synthesized by 16 members of the Canadian Association of General Surgeons Resident Committee. Forty-nine residents participated in the Delphi consensus (2 voting rounds; Cronbach’s α=0.93). Participants agreed streaming should only be offered in the last clinical years as a bridge to one’s intended career path, and after “core” general surgery milestones and competencies have been achieved. Respondents also agreed there should be an explicit period at the end of residency that allows residents to transition to independent practice, by including rotations tailored to their career path, greater autonomy and patient ownership, opportunities to develop skillsets related to managing and running a practice, and “Resident Clinics”. Panelists agreed that residency should be remodeled to focus on the achievement of standardized competencies and milestones throughout various levels of training, based on residents’ ability to meet specific and measurable metrics. Ten barriers to CBME implementation were identified.

Conclusion:
A nationwide consensus regarding the future of surgical training was established. These findings can be used to implement guidelines and national curricula that meet the needs of residents and address the various challenges that face their training.

42.05 Controlled Substance Prescribing and Education in Orthopedic Residencies: A Program Director Survey

Posted on January 31, 2019

M. Dugan2, M. Crandall1, A. J. Bell3, B. K. Yorkgitis1  1University of Florida- Jacksonville,Acute Care Surgery,JACKSONVILLE, FLORIDA, USA 2Georgetown University School of Medicine,Washington, DC, USA 3University of Florida-Jacksonville,Orthopaedic Surgery,Jacksonville, FL, USA

Introduction:  Opioid misuse is currently plaguing the US.  Efforts to reduce this phenomenon include opioid prescribing education (OPE). Orthopedic residents often prescribe opioids but their education on this task is unknown.  A survey sent to program directors (PDs) assessed the current state of controlled substance (CS) prescribing and education among orthopedic residents.

Methods:  An IRB approved survey was sent via email to orthopedic residency PDs. The survey included program characteristics, knowledge of local PDMP, DEA registration and licensure requirements, perceived value of OPE, polices on prescribing outpatient CS, OPE presence and characteristics.

Results: 163 PDs were successfully offered participation in the survey with 60 (36.8%) completed.  On a 5-point Likert scale (0 not valuable, 5 very valuable), the mean PDs rated the value of OPE to clinical care was 4.3 (SD 0.88) and value to resident training was 4.5 (SD 0.79). Residents were permitted to prescribe outpatient opioids in 54 (90.0%) programs. In which, 41 (75.9%) do not limit which DEA schedule opioid types and 41 (75.9%) allow benzodiazepines. Nine (16.7%) programs require residents to obtain individual DEA registration, 39 (72.2.%) allow use of the hospital’s DEA registration and 6 (11.1%) PDs were unsure about DEA utilization. When queried about their state’s required use of PDMPs, 52 (86.7%) were correctly aware of their state laws, and 6 (10.0%) were not sure about this requirement. Presence of state required opioid education for fully licensed physicians was correctly answered by 43 (71.6%) PDs and 14 (23.3%) were unsure.

Only 28 (46.7%) programs had mandatory OPE.  Six (10.0%) PDs were unsure if OPE was a mandatory. Of programs that do not have a confirmed OPE, 16 (50.0%) were considering adding one.  Programs with an OPE, didactic lecture (21, 75.0%) followed by computer-based programs developed at their hospital (13, 46.4%) were the most common modalities. 17 (60.7%) programs used more than one educational modality.  Time for OPE ranged from <1 hour to > 3 hours with the mode being 1-3 hours (12, 42.8%). When PDs were queried which method would be best for OPE, the most common response was case-based scenarios (17, 28.3%) followed by didactic lectures (15, 25.0%).

Conclusion: The majority of programs permit residents to prescribe outpatient opioids; less than half provide mandatory OPE.  This survey demonstrated that half of the programs that do not have a mandatory OPE are considering adding it.  Several PDs were unaware if there is a mandatory OPE component in their residency or were unsure about institutional regulations regarding DEA registration utilization as well as local regulations on opioid education and PDMP use.  This study demonstrates a gap in OPE among orthopedic residencies and PDs’ knowledge of regulations regarding CS prescribing. A significant opportunity remains to provide OPE during residency and PD education on policies regarding CS prescribing.

42.04 Evaluating Factors Affecting Surgical Grand Rounds Attendance:

Posted on January 31, 2019

D. M. Carmona Matos1,2, B. Herring1, M. Mandabach1, Z. Aburjania1, A. Chang1, A. Janssen1, H. Chen1, B. L. Corey1  1University Of Alabama at Birmingham,Department Of Surgery,Birmingham, Alabama, USA 2San Juan Bautista School of Medicine,Caguas, Puerto Rico, Puerto Rico

Introduction:  As Surgical Grand Rounds (SGR) have paralleled the evolution of medicine over time, so have the needs of an increasingly diverse group of physicians and trainees. The purpose of this study was to evaluate factors (topic, rank, gender) that may alter attendance to SGR to facilitate the development of SGR that can better meet the needs of the physician workforce.

Methods:  Descriptive data of SGR attendees, speakers, and topics were obtained over the course of 10 months. Each presentation was categorized into the following topics: Education, Healthcare Management and Administration (HM&A), Professionalism, Research, and Treatment Strategies. The total mean attendance and attendance of each academic rank to SGR on topic categories was determined. Academic ranks included Professors, Associate Professors, Assistant Professors, Fellows, Residents, and Students. Further, the respective attendance of males and females to SGR by topic category was determined, then evaluated via chi-square test. Lastly, the average attendance of males and females to SGR given by males/females was calculated and evaluated via chi-square test. 

Results: The mean attendance was highest (116) for SGR on HM&A, while lowest (81) for SGR on Education. The highest/lowest mean attendance to SGR topics by academic rank are as follows: Professors- [Professionalism]/[Education], Associate Professors- [HM&A, Professionalism]/[Education, Research], Assistant Professors- [HM&A]/[Treatment Strategies], Fellows- [HM&A]/[Professionalism, Treatment Strategies], Residents- [Research]/[Treatment Strategies], Students- [Professionalism]/[Education]. While there was no significant difference in attendance within SGR topic categories by gender (p=0.8), the mean attendance of females to SGR given by M/F speakers was 31/30, while the mean attendance of males was 68/56 (p=.04), respectively.   

Conclusion: Marked differences exist in both total attendance to SGR on topic categories and attendance to SGR on topic categories within academic ranks. Further, although the difference in attendance within SGR topic categories by genders was not significant, the difference in male attendance to SGR presented by M/F was. These findings identify trends that can be used to tailor SGR in the future to better serve physicians and students throughout their careers

 

42.03 Perspectives and Priorities of Surgery Residency Applicants in Choosing a Training Program

Posted on January 31, 2019

P. Marcinkowski1, P. Strassle1, T. Sadiq1, M. Meyers1  1University Of North Carolina At Chapel Hill,General Surgery,Chapel Hill, NC, USA

Introduction:
Applicants pursuing surgery residency have a number of variables to prioritize in selecting a training program. We sought to evaluate the importance of various criteria to applicants applying to surgery residency.

Methods:
An anonymous electronic survey was distributed to applicants who interviewed at a single surgery program over a six-year period (Match years 2013-2018). Respondents were asked to categorize the importance of various criteria in considering a training program on a 5-point scale (very important/above average/average/below average/unimportant). Fisher’s exact tests were used to assess whether the percentage of respondents considering each variable ‘more important’ varied across application year (categorized as 2013-2014, 2015-2016, and 2017-2018), sex, medical school region, or medical school type (public vs. private).  A p-value <0.05 was considered statistically significant. All analyses were performed using SAS 9.4 (SAS Inc., Cary, NC).

Results:
176 responses were received (35% response rate). 47% female. 47% were from the Southeast region followed by 20% Midwest, 19% Northeast, 7% Southwest, 6% West. 40% attended private medical schools. 100% of applicants applying 2015-2018 ranked operative experience as very important/above average importance versus applicants applying from 2013-2014 who ranked it very important/above average importance 94% of the time (p=0.04). Applicants applying 2017-2018 ranked non-operative clinical experience very important/above average importance 90.7% of the time compared to 2013-2014 and 2015-2016 who ranked it similarly 77.6% and 73.9% of the time respectively (p=0.04). Applicants from the northeast region ranked research opportunities as very important/above average importance 96.9% of the time compared to the other regions (West: 63.6%, Midwest: 73.5%, Southeast: 75.3%, Southwest: 83.3%) (p=0.02). Otherwise, there was no statistically significant variation in applicant demographics and criteria they believed important to them in choosing a residency program.  Overall, applicants rated resident attitude/relationship (91% very important), faculty attitude (80% very important), resident/faculty relationship (75% very important) and operative experience (89% very important) as the most important characteristics.

Conclusion:
Surgery residency applicants appear to place greatest importance on interpersonal interactions and operative experience over other training program/hospital characteristics. There was some variability depending on the year applied and the region that the applicant applied from, but in general applicants had similar preferences. This information may be helpful to applicants and programs alike as they navigate the application and match process.
 

42.02 The Effect of Gender on Operative Autonomy in General Surgery Residents

Posted on January 31, 2019

S. L. Meyerson1, D. D. Odell1, J. B. Zwischenberger2, M. Schuller1, J. D. Bohnen4, G. L. Dunnington3, L. Torbeck3, J. T. Mullen4, S. P. Mandell5, M. A. Choti6, E. Foley7, C. Are8, E. Auyang9, J. Chipman10, J. Choi3, A. Meier11, D. S. Smink12, K. P. Terhune13, P. E. Wise14, N. Soper1, K. Lillemoe4, J. P. Fryer1, B. C. George15  1Feinberg School Of Medicine – Northwestern University,Department Of Surgery,Chicago, IL, USA 2University Of Kentucky,Department Of Surgery,Lexington, KY, USA 3Indiana University School Of Medicine,Department Of Surgery,Indianapolis, IN, USA 4Massachusetts General Hospital,Department Of Surgery,Boston, MA, USA 5University Of Washington,Department Of Surgery,Seattle, WA, USA 6Banner MD Anderson Cancer Center,Department Of Surgery,Gilbert, AZ, USA 7University Of Wisconsin,Department Of Surgery,Madison, WI, USA 8University Of Nebraska College Of Medicine,Department Of Surgery,Omaha, NE, USA 9University Of New Mexico HSC,Department Of Surgery,Albuquerque, NM, USA 10University Of Minnesota,Department Of Surgery,Minneapolis, MN, USA 11State University Of New York Upstate Medical University,Department Of Surgery,Syracuse, NY, USA 12Brigham And Women’s Hospital,Department Of Surgery,Boston, MA, USA 13Vanderbilt University Medical Center,Department Of Surgery,Nashville, TN, USA 14Washington University,Department Of Surgery,St. Louis, MO, USA 15University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA

Introduction: Despite an increasing number of women in surgery, bias regarding cognitive or technical ability may continue to impact the experience of female trainees differently than their male counterparts. The goal of this study is to examine differences between the degree of operative autonomy given to female and male surgical trainees.

Methods: A smartphone app was used to collect evaluations of operative autonomy measured using the 4-point Zwisch scale, which describes defined steps in the progression from novice (“Show and Tell”)  through increasing degrees of autonomy (“Active Help” to “Passive Help”) to competent to enter practice (“Supervision Only”). Autonomy was evaluated from both the faculty and resident perspectives. Differences in autonomy between male and female residents were compared using hierarchical logistic regression analysis.

Results: 412 residents and 524 faculty from 14 general surgery training programs evaluated 8900 cases over a 9 month period. Female residents received meaningful autonomy from faculty (“passive help” or “supervision only”) in 46.7% of cases (1053/2253) while male residents received meaningful autonomy in 52.7% of cases (1906/3614, p<0.001). Resident level of training and case complexity were the strongest predictors of autonomy. Even after controlling for potential confounding factors including level of training, intrinsic procedural difficulty, patient-related case complexity, faculty gender, and training program environment, female residents still received less operative autonomy than their male counterparts. The gap between autonomy granted to male and female residents was present from both the faculty and resident perspectives. The largest discrepancy was in the fourth year of training and both male and female faculty surgeons granted less autonomy to female residents.

Conclusion: There is a gender-based difference in the autonomy granted to general surgery trainees. This gender gap may affect female residents’ experience in training and possibly their preparation for practice. Strategies need to be developed to help faculty and residents work together to overcome this gender gap.

 

42.01 Surgical Trainees’ Sense of Responsibility for Patient Outcomes: A Multi-Institutional Appraisal

Posted on January 31, 2019

R. W. Randle1, S. L. Ahle2, D. M. Elfenbein5, A. N. Hildreth4, J. A. Greenberg3, P. J. Schenarts7, J. W. Kempenich6  1University Of Kentucky,Department Of Surgery,Lexington, KY, USA 2Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA 3University Of Wisconsin,Department Of Surgery,Madison, WI, USA 4Wake Forest University School Of Medicine,Department Of Surgery,Winston-Salem, NC, USA 5University Of California – Irvine,Department Of Surgery,Orange, CA, USA 6University Of Texas Health Science Center At San Antonio,Department Of Surgery,San Antonio, TX, USA 7University Of Nebraska College Of Medicine,Department Of Surgery,Omaha, NE, USA

Introduction:
Surgeon educators express concern about their current ability to impart a strong sense of patient ownership to trainees. We hypothesized that surgical residents’ sense of patient ownership would be associated with their perceived autonomy and other modifiable factors in the modern training environment. We aimed to compare resident and faculty perceptions on residents’ sense of personal responsibility for patient outcomes and to correlate patient ownership with resident and residency characteristics.

Methods:
An anonymous electronic questionnaire surveyed 373 residents and 390 faculty at 7 academic surgery residencies across the U.S. We used a modified version of a validated psychologic ownership scale to measure patient ownership among surgical trainees.

Results:
Respondents included 123 residents and 136 faculty (response rate 33% and 35%, respectively). Overall, 91.1% of resident respondents agreed that faculty modeled strong patient ownership, and 78.0% of faculty agreed that residents took personal responsibility for patient outcomes. 75.6% of residents perceived they felt a similar or higher degree of patient ownership than their faculty, but only 26.4% of faculty agreed. Faculty underestimated the proportion of residents that routinely checked on their patients when “off-duty” or “off-service” (36.8% vs 92.6% per resident report (p<0.001). Faculty and residents perceived that greater operative autonomy provided residents with a higher level of ownership (Figure). Almost all faculty (97.8%) reported providing more autonomy to residents who display strong patient ownership, but only 53.7% provide more autonomy in order to increase ownership.
Higher means on the patient ownership scale correlated with female sex (5.9 vs. 5.5 for males, p=0.009) and advanced PGY level (5.3, 5.5, 5.7, 5.8, 6.1, for PGY1-5, respectively, p=0.02). Additionally, residents who reported that patient outcomes affected their mood when off-duty achieved higher ownership means than those who claimed outcomes did not affect their mood (5.8 vs 4.8, p<0.001). Trainees who perceived better resident camaraderie (p=0.004), faculty mentorship (p<0.001), and that their program provided an appropriate degree of autonomy (p=0.03) felt greater responsibility for patient outcomes.

Conclusion:
Most faculty agree that residents assume personal responsibility for patient outcomes, but many still underestimate residents’ sense of patient ownership. Certain modifiable aspects of residency culture including camaraderie, mentorship, and autonomy are associated with patient ownership among trainees.
 

19.20 Measuring Uncertainty Intolerance in Surgical Residents Using Standardized Assessments

Posted on January 31, 2019

L. Ying1, R. Assi1, A. Harrington1, C. Thiessen1, M. Hubbard1, G. Nadzam1  1Yale University School Of Medicine,New Haven, CT, USA

Introduction: Due to ambiguities inherent to medical and surgical practice, a physicians’ intolerance for uncertainty (uncertainty intolerance, UI) can significantly impact the quality of their practice and their own mental well-being. Many residency programs, including our own, have introduced new education initiatives aimed at improving UI in our residents. However, currently there is no standard protocol to measure the effectiveness of such interventions, and there are no established methods for identifying the residents who would most benefit from the training. In this study, our goal is two-fold: 1. To validate the use of the Physician Reaction to Uncertainty (PRU) and Physician Risk Attitude (PRA) scales assessments for uncertainty intolerance, and 2. To determine if Myers-Briggs Type Indicator (MBTI) personality factors are associated with PRU and PRA scores and can be used to identify residents who are more likely to have higher UI.

Methods: The PRU and PRA scales, and the MBTI assessment were administered to a total pool of 71 general surgery residents. In addition to the survey questions, residents were asked to provide information regarding their gender (Male or Female), and stage of training (Junior or Senior).

Results: In total, 45 male residents and 25 female residents responded to the survey and completed the PRA and PRU scales (98.6%). There were no statistically significant differences found when comparisons were made between Junior versus Senior residents or Male versus Female residents. 37 male residents and 18 female residents also completed the MBTI assessment (80.4% and 72%, respectively). PRU and PRA scores were analyzed with respect to personality factors to determine if certain dichotomies are associated with increased uncertainty intolerance. Individuals identifying as Perceiving had significantly higher scores in the PRU category of “Concern about Bad Outcomes” (J: 8.76±3.39, P: 10.47±3.08; p<0.05), and on the PRA scale (J: 22.55±3.58, P: 20.71±2.34; p<0.05). Additionally, individuals identifying as Sensing had significantly higher scores on the PRU category of “Reluctance to Disclose Mistakes to Physicians” (S: 4.68±1.36, N: 3.74±2.40; p<0.05).

Conclusion: In this study, we have validated a new assessment for measuring the success of our education initiatives aimed at improving uncertainty tolerance. We found that the PRU and PRA assessments were simple to administer, and had a high completion rate due to buy-in from the residents. We have also demonstrated for the first time that specific personality factors are linked to higher uncertainty intolerance in surgical residents. These results will allow us to better identify residents who would benefit most from uncertainty intolerance training and to monitor their progress. 

 

« Previous Page
Next Page »