19.19 A Pilot Study of a Resident-Led ABSITE Review Course

Posted on January 31, 2019

D. Cassidy1, S. McKinley1, A. Mansur1, J. Mullen1, E. Petrusa1, R. Phitayakorn1, D. Gee1  1Massachusetts General Hospital,General Surgery,Boston, MA, USA

Introduction:  Resident performance on the American Board of Surgery In-Training Examination (ABSITE) may correlate with passage rates on the American Board of Surgery Qualifying Examination. ABSITE scores are also an increasingly key component of fellowship applications. The best methodology for sustained study habits of residents and subsequent ABSITE performance is still unclear. Peer teaching increases motivation and knowledge acquisition and retention for both the learner and peer teacher.  This pilot program introduced and tested the feasibility of a targeted, structured ABSITE review curriculum utilizing peer teaching from senior surgical residents.

Methods:  An 8-week resident-led ABSITE review course was offered to surgical residents prior to the administration of the 2018 ABSITE exam. Topics were selected based on resident input and analysis of historic exam knowledge deficiencies within our institution. Each session was led by a volunteer senior surgical resident (PGY3 level or above). Participation was voluntary, and attendance was recorded at each session. 2018 ABSITE score reports were transcribed into a deidentified, digital database. ABSITE scores from residents who participated in 3 or more sessions were compared to all general surgery residents with no participation with subgroup analysis at each post-graduate level.

Results: Total preparation time for this course was 20 hours. Each session lasted 1 hour. There were 4 resident volunteer teachers. Out of 57 residents who took the ABSITE, 17 (30%) residents came to at least one session and 13 (23%) participated in 3+ sessions. Participants ranged from 50% of PGY1 residents (n=5) to 0% of PGY4 residents. Residents who participated in 3+ sessions did not have statistically significant higher ABSITE percentile scores (70.3 vs. 57.7; t=1.33, p=0.10) compared to residents who did not participate. The greatest difference in percentile scores was seen in PGY1 residents (85.6 vs. 67.8; U=8.5, p=0.23), although this was not statistically significant. A post-exam survey demonstrated high levels of resident satisfaction with the course and interest in continued participation.

Conclusion: A peer-taught ABSITE review course is both feasible and useful to participants with high rates of participant satisfaction. Residents who participated did not have statistically significant higher percentile scores than residents who did not participate. While the sample size prohibited findings of significance, future studies are underway to establish a more formalized program with analysis of a larger dataset for the 2018-2019 academic year.

 

19.18 Diversity in a General Surgery Residency in the South

Posted on January 31, 2019

M. K. Mandabach1, E. N. Williams1, H. Chen1, L. C. Tanner1  1University Of Alabama at Birmingham,Surgery,Birmingham, Alabama, USA

Introduction:  General surgery residencies have been historically dominated by Caucasian males, especially in the South. The purpose of this study is to examine how the demographics of surgical residents, including race, gender, and medical school region, have changed from 1980 to 2017.  We hypothesize that there has been an increase in diversity over time.

Methods:  Demographic information of the general surgery residents from 1980 to 2017 was collected. The race, gender, medical school, year of application, and categorical status were recorded. The resident’s medical school was classified into one of five regional groups: Southern, Central, Northeast, Western, and foreign. The Southern, Central, Northeast, and Western regions were defined by the Association of American Medical Colleges (AAMC), while the foreign group contained medical schools that fell outside of the United States and Canada and the classification of the AAMC. The residents were compared by five-year increments.  

Results: During this 37-year period, 639 residents were in general surgery training. The percentage of women in the resident population increased from 9% in 1980-1984 to 36% in the 2015-2017 group. The percentage of non-Caucasian students increased from 3% in the 1980-1984 group to 26% in 2015-2017 group.  While 90% of the residents were from the South in the 1980-1984 group, only 69% of residents were from the South between 2015-2017.   

Conclusion: This Southern general surgery residency program has increased in diversity over the course of nearly forty years.  More women and minorities are becoming surgeons, and our institution has stretched to recruit students from across the United States and worldwide. While much progress has been made to further surgeon diversity in all respects, continued efforts must be made to grow a surgeon population that mirrors the diversity in the population they intend to serve.

 

19.17 Developing a Screening Tool to Evaluate Burnout Risk in Surgery Residents

Posted on January 31, 2019

A. Jambhekar1, Z. Nasrawi2, R. Lee2, H. Ali2, J. Rucinski2  1Columbia University College Of Physicians And Surgeons,Breast Surgery Division,New York, NY, USA 2New York Presbyterian Brooklyn Methodist Hospital,Department Of Surgery,Brooklyn, NY, USA

Introduction:  Current literature identifies burnout as a significant problem in all residency programs with emphasis on the highest risk for burnout in surgical residents. Several screening tools have been developed and validated, but none have been developed specifically pertaining to the surgical culture. The objective of the current study was to develop a screening tool to evaluate burnout risk in surgical residents.

Methods:  The Surgery Burnout Survey was developed through the collaboration of two university affiliated community programs with components detailing emotional health, physical health, work-life balance, interpersonal relationships, compassion fatigue, and resilience. The survey was given to current surgical or surgical subspecialty residents in postgraduate years two through five (n = 7) as well as recent graduates (n= 7). Recent graduates were defined as surgical fellows and attendings who had graduated from residency in the past two years. The tests were scores out of a total of 200 points with higher scores indicating greater risk for burnout. Statistical analysis was conducted using Student’s t-test. Data is expressed as mean +/- standard deviation.

Results: The current surgical residents had a mean score of 138.1 +/- 18.0 compared to 109.7 +/- 12.4 for the recent graduates (p = 0.004). The residents scored higher in physical health, interpersonal relationships and resilience, and similar to recent graduates in emotional heath, work life balance, and fatigue. Qualitative interviews with all of the participants revealed they felt the survey captured the pressures of residency well and that many of these issues were not specifically addressed in other screening tools.  

Conclusion: The Surgery Burnout Survey identified current surgical residents at higher risk for burnout compared to recent graduates. The breakdown of the scores suggested that current residents are experiencing stress in the areas of physical health, resilience, and interpersonal relationships which may allow for targeted interventions. Further studies are ongoing to validate the screening tool in a larger group of current surgical residents.

 

19.16 Effective Resident Oral Case Presentation Skills During Surgical Consultations

Posted on January 31, 2019

J. W. Feimster1, S. W. Knight1, M. L. Boehler1, C. J. Schwind1, H. Han2, R. H. Kim1  1Southern Illinois University School Of Medicine,Department Of Surgery,Springfield, IL, USA 2Southern Illinois University School Of Medicine,Department Of Medical Education,Springfield, IL, USA

Introduction: Resident oral patient case presentations are important means for physician-physician communication and a key component of a resident’s progression from a junior resident to a senior resident role. Entrustment decisions by faculty attendings are based, in part, on resident communication through oral case presentations. Despite this importance, there are few guidelines that define an effective surgical oral case presentation. This preliminary study aims to discover assessment criteria that characterize effective and authentic surgical oral presentation skills that could be utilized to develop guidelines for the assessment of surgical oral case presentations.

Methods: Utilizing qualitative research methodology, audio recordings and transcriptions from actual surgical consults that were presented by a resident to an attending surgeon were evaluated by 3 evaluation panels of surgeons and senior residents. The evaluation panel discussions were moderated, recorded, coded, and analyzed by three experienced qualitative researchers. Themes were then identified from the data that characterized effective and non-effective presentation skills.

Results: Preliminary data analysis of the panel discussions indicated that authentic assessment criteria should embrace various contextual considerations including time of the day, level of training, mutual trust, and attending variability. Themes identified that characterized effective communication included an opening summary statement, concise and succinct presentation, mutual trust between the presenter and attending surgeon, and a deductive flow. These themes are interrelated and dynamically shape the nuance of assessment criteria of the skills. Themes that were associated with non-effective communication skills included vague introductions, inclusion of unrelated or irrelevant history, and following an inductive flow pattern. The length of a presentation was deemed to be equivocal, as more complex cases or junior level resident presentations may require more supporting evidence for their reasoning in presentations.

Conclusion: This preliminary study identified themes that characterize effective and non-effective communication skills that attending surgeons use to internally assess surgical residents during a surgical oral case presentation. These themes can be utilized to develop standardized guidelines for the assessment of surgical oral case presentations.

 

19.15 Case-Based Simulation Workshop to Teach Surgical Residents the Skills of Goals-of-Care Discussions

Posted on January 31, 2019

M. Fiorentino1, F. Hwang1, K. Oberoi1, S. Pentakota1, A. Kunac1, S. Lamba1, A. C. Mosenthal1  1New Jersey Medical School,Surgery,Newark, NJ, USA

Introduction:
Surgical residents report lack of confidence and training in discussing goals-of-care (GOC) with patients and families, especially in emergency surgery settings.  Effective July 2019 the ACGME will mandate training in GOC discussions. We evaluated the feasibility and efficacy of a simulation workshop to teach surgical residents the skills of effective communication in discussing GOC.

Methods:
Surgical residents (PGY 1 and 2) attended a two-hour simulation workshop during their weekly education time. The curriculum included: 1) an interactive didactic session on a step-by-step guide for GOC discussions, 2)  small group simulation/role play sessions with 2 case scenarios with a standardized patient (SP)/family portrayed by a senior resident, and 3) debriefing and feedback by senior residents, a surgical attending board-certified in hospice and palliative medicine, and members of palliative care team.  The case scenarios focused on eliciting treatment preferences from family of a patient with sepsis and a prolonged postoperative ICU stay and from a patient with a malignant bowel obstruction. A pre and post questionnaire (5-point Likert like) assessed residents’ attitudes and knowledge about GOC discussions. The responses were analyzed using a paired t-test.

Results:
20 junior surgical residents (PGY-1 and 2) participated in the workshop. Post intervention scores (“somewhat agree” or “strongly agree”) increased on knowledge (65% to 100%) and comfort in having GOC discussions (35% to 70%). Despite the increase in knowledge and comfort level, only 35% of residents felt comfortable teaching how to have GOC discussions. When comparing pre and post test workshop responses each resident, showed improvement in knowledge and comfort in discussing and teaching GOC(Table).

Conclusion:
A two-hour structured workshop increased residents’ knowledge and comfort in having GOC discussions. This session addresses a perceived gap by trainees.  Case-based simulation to teach GOC discussion is feasible and effective for surgical residency programs to reproduce within budget and time constraints.
 

19.14 Factors that Influence Publication Rates of Abstracts Presented at the Academic Surgical Congress

Posted on January 31, 2019

H. L. Minton2, S. Goyer1, K. Feng1, H. Chen1, B. L. Corey1,3  1University Of Alabama at Birmingham,Department Of Surgery,Birmingham, Alabama, USA 2University Of Alabama at Birmingham,School Of Medicine,Birmingham, Alabama, USA 3Birmingham Veteran’s Affairs Medical Center,Department Of Surgery,Birmingham, AL, USA

Introduction:

As medical school and residency programs encourage increased student and resident research, thousands of abstracts are submitted to conferences annually. The purpose of this study is to determine the rate of publication of the oral and plenary presentations from the 2017 Academic Surgical Congress (ASC) and assess factors that influence the likelihood of publication.

Methods:  

Abstracts selected for oral and plenary presentations at the 2017 ASC were evaluated for publication status via PubMed, Google Scholar, and NIH Reporter searches. Publication status, including date of publication and journal title, the academic rank of first and senior authors, and the type of study, such as basic science (BS), clinical outcomes (CO), and education (Edu) were collected. The impact factor of each journal was determined using the 2017 Journal Citations Report. Impact factors were categorized as low (0-3), moderate (3.1-7), or high impact (7.1-10+). In addition, senior author funding status, source, and amounts were cataloged. Statistical analysis was conducted using SAS.

Results: 

There were a total of 360 oral and plenary presentations. 41.4% (n=149) of oral and plenary presentations were published, including one by correspondence. BS, CO, and Edu presentations had publication rates of 31.7%, 51.1%, and 57.7%, respectively. Senior authors with an academic rank of Professor, Associate Professor, and Assistant Professor had publication rates of 41.8%, 49.4% and 43.3% respectively. First authors were primarily residents, students, or fellows and had publication rates of 40.4%, 59.5%, and 45.7%, respectively. None of these factors were statistically significant (p= 0.07, 0.697, and 0.183).

159 (44.2%) senior authors had a source of funding, of which 129 (35.8%) were from the National Institute of Health. 57.8% of abstracts with a source of funding were published. 36.6% of abstracts without funding were published. Funding sources had a positive association with publication (p <0.001). Manuscripts were published 1 to 16 months after ASC. Published abstracts were primarily printed in low or moderate impact journals, with 51.9% in low, 35.9% in moderate, and 12.2% in high impact journals. The majority of manuscripts were CO (62.8%) in nature, followed by BS (25.6%), then Edu (11.5%).

Conclusion:

After 16 months, 41.4% of the oral and plenary presentations had achieved publication, a rate similar to previous studies within other fields. Academic rank of first or senior authors had no influence on publication rate, while a funding source increased the likelihood of publication. Further investigation of factors that influence publication should be completed, as well as a follow-up study including additional ASC conferences.
 

19.13 Integration of Interactive Quiz Technology into Modern Surgical Education

Posted on January 31, 2019

D. Dolan1, J. Aalberg2, C. Divino1  1The Mount Sinai Hospital,General Surgery,New York, NEW YORK, USA 2Tufts University School of Medicine,School Of Medicine,Boston, MA, USA

Introduction:
The didactic lecture style used to teach residents hasn’t significantly changed since the beginning of the 20th century. Only in the last 20 years has problem-based learning begun to accompany lectures. Previously, questions were asked via PowerPoint© and Personal Digital Assistants (PDAs) during lectures. Now digital applications (apps) on smartphones have replaced PDAs. One example of an app is PollEverywhere© which allows audience response to questions, surveys, and images posted by the presenter. The presenter can then assess learners’ understanding and address problem areas. By using the app with the lectures given during surgical education, it was hypothesized that both subjective satisfaction with learning and objective scores on the American Board of Surgery In-Training Exam (ABSITE) would increase.

Methods:
The 31 categorical surgery residents at the Icahn School of Medicine of postgraduate year (PGY) 2 or higher in January 2017 were eligible to participate. PollEverywhere© was used to ask quiz questions in large group lectures from Fall 2016 to the 2017 ABSITE. After IRB approval and individual consent was obtained, the residents were surveyed before and after the 2017 ABSITE and data on previous test performance acquired including all ABSITE raw, calculated out of 800 total points, and percentile scores. Satisfaction score and raw score changes were then calculated.

Results:

19 of 31 residents (61%) completed the pre- and post-ABSITE surveys. 53% believed using the app contributed to their learning. 74% were satisfied with the current way the app was used. 84% were interested in continuing to use the app in the next academic year. ABSITE raw score change before PollEverywhere© in 2015-2016 was determined for each PGY level and then compared to the raw score change of the same PGY level from 2016-2017 to measure the app's effect. After PollEverywhere©, raw scores improved in the PGY 1-2 and 2-3 groups but this was not noted to be statistically significant (Table 1). Previous test performance, sleep prior to exam, and difficulty of rotation were not found to be modifying propensity factors.

Conclusion:

Most residents were satisfied with PollEverywhere© and believed it contributed to their learning. The ABSITE cannot test all concepts taught within the academic year and so sample error of the test itself will change the score changes seen. Despite this, scores generally improved with use of the app. This study lacked statistical power due to sample size. Further work is needed with a larger sample to determine statistical significance, refine how to better implement the technology to improve satisfaction and scores, and determine any propensity modifying factors.

19.12 Mentorship: Easier Than We Think

Posted on January 31, 2019

K. E. Bingmer1, C. M. Wojnarski1, J. T. Brady1, V. P. Ho2, E. Steinhagen1  1Case Western Reserve University School Of Medicine,General Surgery,Cleveland, OH, USA 2MetroHealth Medical Center,General Surgery,Cleveland, OH, USA

Introduction:
Mentorship is often identified as a key component in surgical education, and is associated with decreased rates of burnout and attrition. Residents are more likely to identify and meet with a mentor if their institution has a formal mentorship program (MP), which many residencies lack, possibly due to the perceived time and energy required to implement an impactful program. There is scant data evaluating the change in resident experience following introduction of a MP. We aimed to measure the difference in resident experience and perceptions after the implementation of a formal MP.

Methods:
An anonymous survey was distributed to all general surgery residents at a single academic institution before (PRE) and after (POST) implementation of a MP. The program involved assigned mentors for all residents, two social events, and a recommendation that mentors and mentees meet three times; all events and meetings were voluntary. Responses were recorded on a five-point Likert scale to assess differences in resident perception.

Results:
The PRE and POST respondents were similar in age, post graduate year, and gender (all p>0.05).  Half of respondents (n=17, 53%) attended at least one event, and over half (n=21, 66%) had at least one meeting with their mentor. The maximum number of meetings reported was 4 (n=4). The number of residents who identified a faculty mentor increased from 59% PRE intervention to 75% POST. Mean responses to most questions were improved on the POST survey, however this was not significant. The most influential aspect of the program was found to be interaction with mentors. When stratified by number of meetings, residents with two or more mentor meetings (n=12, 38%) were more likely to feel faculty were interested in teaching and cared about their development (both p<0.001). They were more likely to identify faculty they could speak to about academic (p<0.001), performance (p<0.02) and outside of work (p<0.005) concerns. These residents were also more likely to be satisfied with the amount of mentorship received (p<0.002), as well as their operative and clinical skill levels (p<0.05). Overall, active participation in the program resulted in a positive effect on resident perception (Table 1).

Conclusion:
Implementation of a formal mentorship program resulted in an improvement in resident perception of faculty involvement and support. Meeting as few as two times with a mentor resulted in a significant improvement in resident perception. Simply implementing a mentorship program can improve resident experience, and few interactions are needed to affect change.
 

19.11 Use of Oral Competency Exams Early in Residency: Improved Educational Value Over Traditional Exams

Posted on January 31, 2019

K. Y. Hu1, J. P. Dux1, P. N. Redlich2, R. W. Treat3, T. B. Krausert2, M. J. Malinowski2  1Medical College Of Wisconsin,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

Introduction:
Traditional surgical resident education is based on didactic curriculums with performance gains reliably assessed by time-honored multiple-choice question (MCQ) exams. This assessment tool is common for junior residents, then transitions to clinical scenario-based teaching with oral competency examinations (OCE) for senior residents. Standardized oral examinations during residency have been reported to significantly improve certifying examination pass rates; however, limited information exists on the impact of oral examinations at the junior resident level. We hypothesized that junior residents would report improved confidence in their clinical performance and increased satisfaction with inclusion of OCE compared to traditional written post-test evaluations following didactic lectures.

Methods:
We modified our PGY-1 protected block curriculum in June 2016 to include OCE while maintaining the traditional post-test MCQ exams. In each curriculum block, residents were assessed with OCE consisting of two clinical scenarios over 16 minutes in front of an audience of five to seven peers, covering topics addressed in the curriculum’s didactic sessions. At the end of each academic year (2016-2017 and 2017-2018), participants were asked to complete a survey rating the perceived impact of OCE using a combination of 5-point Likert scales (1=poor, 5=excellent) and dichotomous responses (yes/no). Analysis was generated with IBM® SPSS® 24.0.

Results:
Of the 24 PGY-1 residents (12 in each academic year) who completed the voluntary survey, 91% thought the oral examination experience led to improved clinical performance in complex patient scenarios. Residents perceived that OCE improved their understanding of surgical indications (71%), preoperative work-up (88%), postoperative care (83%), and surgical complications (88%). The majority of residents (88%) rated the quality of teaching during OCE to be good or excellent, correlating with 92% who found benefit in observing their colleagues being examined (Spearman rho=0.6, p=0.002). Overall, 87% of residents thought OCE served as a better review of didactic materials than a written exam, strongly correlating with those who thought OCE provided good or excellent value as an educational activity (88%, r=0.7, p<0.001). The dynamic quality of teaching during OCE was also significantly correlated to its value as an educational activity (r=0.6, p=0.001), as well as to the improved review of materials (r=0.6, p=0.001).

Conclusion:
Assessment using OCE during PGY-1 curriculum sessions coupled with peer observation has additional educational value and adds enhanced confidence in clinical performance compared to traditional MCQ testing. Further study is warranted on the impact of OCE on in-training exam scores and senior resident mock oral board examination performance.
 

19.10 Exposure to Non-Preferred Music May Alter the Learning Curve for Surgical Trainees

Posted on January 31, 2019

K. B. Gil1, T. J. Mouw1, M. Jones1, P. J. DiPasco1  1The University of Kansas Medical Center,Surgery,Kansas City, KANSAS, USA

Introduction:
Previous studies have tested the effect of music on surgeons’ performance. These studies have shown reduced autonomic reactivity, improved quality and time of wound closure, and improved suture tying and mesh alignment using a robotic surgical system, while listening to preferred music. There is growing evidence supporting the benefits of preferred music on task performance, however there is a paucity of data regarding the potential impact on surgical and procedural learners. Surgical residents and medical students are often subjected to the preferred music of the attending surgeon, which may often be a non-preferred genre for the learner. There is currently no data evaluating the impact of listening to nonpreferred music on the performance of untrained individuals who are learning new surgical tasks. 

Methods:
31 medical students at the University of Kansas Medical Center, Kansas City were recruited by email to participate. Each participant filled out a survey to collect demographic information, music preferences, and assign each participant to a randomization group. Each participant underwent three training modules on the Da Vinci Si simulator under silent conditions. Each participant was then randomized to perform the same experimental task twice while listening to both preferred music and non-preferred music. Randomization determined whether a participant would listen to preferred music on their first trial vs their second trial. This was done to control for improvement that a participant may show simply by repeating the task. Following completion, each participant was given a score calculated by the Da Vinci surgical system.  Scores range from 0-100 and are a composite based on metrics such as time to completion, number of errors, and economy of motion.

Results:
31 participants participated in this study. The group which began testing with preferred music and repeated the task with non-preferred music had no significant change in their test scores (72.73 vs 74.33, p=0.34). However, the group that began with non-preferred music and repeated the task with preferred music showed significant improvement between trial runs (70.31 vs 81.88, p<0.001). There was no significant difference between the initial runs for each group. When analyzed irrespective of group assignment, there was a significant increase in scores for preferred music vs non-preferred music (77.45 vs 72.26 p=0.025).

Conclusion:
Participants showed expected improvement with task repetition. This improvement may have been offset by exposure to non-preferred music during repeat runs. Our findings suggest that the impact of music was nearly as large as the impact of prior exposure to the task. This may have implications for environmental conditions during resident procedural training, especially early in residency training when new tasks are being introduced and the skill level of the learner is still low. 
 

19.08 Incoming Surgical Interns Benefit from Dedicated Opioid Education

Posted on January 31, 2019

K. A. Robinson1, K. Chhabra2, A. Gupta1, T. Kent1, M. M. Aner1, G. Brat1  1Beth Israel Deaconess Medical Center,Surgery,Boston, MA, USA 2Brigham And Women’s Hospital,Surgery,Boston, MA, USA

Introduction:  Surgeons prescribe opioids at high rates. In academic centers, most of the frontline pain management and opioid prescribing is completed by residents. Yet recent recent research has shown that only 10-20% of surgical residents complete opioid education. Further, graduating medical students heading into their intern year (pre-interns) are expected to start residency with a knowledge base that allows them to write opioid prescriptions. The present study evaluated pre-intern comfort with opioid prescribing and baseline knowledge about opioids as treatment for acute pain.

Methods:  An opioid educational curriculum was designed to teach basic pain management skills to pre-interns. All pre-interns took a validated 11 question opioid knowledge assessment with a final question on their comfort in prescribing opioids. Pre-Interns rated their comfort with their own knowledge and readiness to prescribe opiates for acute pain on a scale of 1-10. The survey was presented prior to and after a 75 minute educational session. The post-survey included an additional question to understand if the participant felt that the training would impact their practice. Pre- and post- survey score results were analyzed using a paired t-test after confirming score normality.

Results: There were 58 pre-interns (all beginning a surgical internship) included in the study from April-June 2018 over 3 separate classes. 57 completed both surveys. Prior to the class, 28% of pre-interns could identify an opioid tolerant patient, 37% could identify when to use a long acting opioid, and 51% could correctly identify equianalgesic doses of IV opioids. These numbers rose to 72%, 74% and 86% respectively after the class. The mean percentage of correct answers increased significantly from a prior score of 54% to 69% after the class (p <0.0001 with non-overlapping confidence intervals at 95%). Comfort with opioid prescribing increased from an average score of 2.5 before the class to 4.7 (out of 10) after the class (Figure 1). 98.2% of participants said that the training would impact their practice.

Conclusion: Pre-interns have significant knowledge gaps when tested using a standardized opioid assessment tool. Further, they report feeling uncomfortable with prescribing opioids. Objective knowledge and subjective comfort level increased with a 75 minute educational session. This study demonstrates the need for more education on this topic. Opioids are one of the most common medication classes prescribed by interns; the important safety ramifications of opioid management should encourage educators to expand existing curricula.

 

19.07 QIC: An Interactive, Team-Based Quality Improvement Curriculum for Surgical Residents

Posted on January 31, 2019

J. S. Colvin1, X. Feng1, J. Lipman3, J. French1, V. Krishnamurthy2  1Cleveland Clinic,General Surgery,Cleveland, OH, USA 2Cleveland Clinic,Endocrine Surgery,Cleveland, OH, USA 3Cleveland Clinic,Colorectal Surgery,Cleveland, OH, USA

Introduction:  Incorporation of quality improvement (QI) training is essential to meet the milestones set forth by the Accreditation Council for Graduate Medical Education (ACGME). However, there is currently no standardized curriculum for delivering QI education to residents. With the current training system, educational time must be used efficiently to incorporate all essential components, creating a need for a concise and time-efficient QI curriculum. We aimed to create such a curriculum through the integration of formal didactics and team-based, hands-on learning via the completion of resident-led QI projects relevant to patient care.

 

Methods:  An IRB-approved QI curriculum consisting of four interactive workshops was developed at a surgical residency with 10 categorical graduates annually. The workshops were scheduled over an 11-week period, with each workshop lasting 1.5 hours. The curriculum introduced the various components of QI in a step-wise fashion, with a focus on Plan-Do-Study-Act (PDSA) cycles in the latter sessions. Anonymous and voluntary pre and post-curriculum surveys were administered. Univariate analysis of responses was performed using Fisher’s exact, chi square, and students’ t-tests for categorical and continuous variables when appropriate.

 

Results: Fifty surgical residents participated in the curriculum and four QI projects were completed, with 23 residents completing both pre- and post-curriculum surveys.  Following the curriculum, residents were more confident in their ability to design a QI project (5.7 ± 2.6 vs 7.1 ± 1.9, p=0.02), write a problem statement (6.7 ± 2.5 vs 7.8 ± 1.1, p=0.04), and write an AIM statement (6.7 ± 2.6 vs 7.8 ± 1.2, p=0.04). Residents also improved in their perceived ability to lead a QI project (5.6 ± 2.9 vs 6.9 ± 1.9, p=0.05), knowing the steps to complete a QI project (6.0 ± 2.8 vs 7.4 ± 1.7, p=0.04), and familiarity with basic QI terminology (5.6 ± 2.6 vs 7.0 ± 1.9, p=0.03). There was also a trend towards improvement in the ability to create a process map, how to do a root cause analysis, and how to use data to make improvements.

 

Conclusion: Overall, we found that the curriculum was a success—residents were able to complete QI projects through participation in the curriculum. In addition, there was an improvement in perceived competency and confidence surrounding some of the steps necessary to complete a QI endeavor. The curriculum was well received and the majority of residents who completed the curriculum found it useful. Future areas of investigation include trialing the curriculum over a longer timeline and making the transition to leadership roles for the senior residents. Additionally, the curriculum can be expanded to other institutions and specialties.

19.06 Screening Surgical Residents’ Laparoscopic Skills: Who Needs More Time in the Sim Lab?

Posted on January 31, 2019

K. H. Perrone1, H. Mohamadipanah1, J. Nathwani2, C. Parthiban2, K. Peterson2, B. Wise1, A. Garren2, C. Pugh1  1Stanford University,Palo Alto, CA, USA 2University Of Wisconsin,Madison, WI, USA

Introduction:
Laparoscopic surgery presents a unique set of technical challenges compared to open surgery and continues to account for an increasing proportion of modern surgical practice. As a result, laparoscopy is critical for trainees to master. This study investigated the possibility of using Virtual Reality (VR) perceptual-motor tasks as a screening tool for laparoscopic ability using Laparoscopic Ventral Hernia (LVH) repair as an archetypical procedure. We hypothesized that perceptual-motor skills assessed using VR will correlate with and contribute to LVH repair performance.

Methods:
Surgical residents (N=37), from seven mid-west programs, performed two perceptual-motor tasks: 1) force matching and 2) target tracking, using a haptic interface device and a VR environment. Perceptual-motor skills were quantified using motion metrics including “peak deflection on force release”, “summation of distance from sphere”, “path length” and “maximum distance from sphere”. The residents also performed a partial LVH repair on a benchtop simulator with previously demonstrated validity evidence in multiple contexts. Outcome metrics for the partial LVH repair included final product score and endoscopic visualization errors. A parametric correlational analysis was performed to assess the relationship between performance on VR tasks and LVH.

Results:
For the LVH metrics, residents with a higher number of endoscopic visualization errors had significantly lower final product scores (r = -0.52, p<0.01). When assessing the relationship between metrics in the force matching module in VR and LVH performance, residents with poor performance on “peak deflection on force release” (r = -0.344, p<0.05) and “summation of distance from sphere” (r = -0.359, p<0.05) in VR also had significantly lower final product scores. Likewise, poor performance metrics in the VR-based target tracking task including “path length” (r = -0.488, p<0.05) and “maximum distance” (r = -0.365, p<0.05) correlated significantly with lower final product scores. In addition, longer “path length” values (r = +0.375, p<0.05) had a significant correlation with endoscopic visualization errors. (Table 1)

Conclusion:
This study showed significant correlations between poor performance on VR-based perceptual-motor tasks and basic laparoscopic skills during a partial LVH repair thus supporting the notion that VR could be used as a screening tool for perceptual-motor skill among junior surgical trainees. For trainees identified as having poor perceptual-motor skill through VR, focused curricula could be created, allowing trainees to hone their personal areas of weakness and maximize technical skill to more efficiently prepare for basic and advanced laparoscopic procedures.
 

19.05 ACGME Duty Hour Compliance for General Surgery Residents: Finding Solutions in a Teaching Hospital

Posted on January 31, 2019

B. J. Goudreau1, D. F. Grabski1, A. G. Ramirez1, J. Gillen1, W. M. Novicoff2, P. W. Smith1, B. Schirmer1, C. M. Friel1  1University Of Virginia,Department Of Surgery,Charlottesville, VA, USA 2University Of Virginia,Department Of Orthopaedic Surgery,Charlottesville, VA, USA

Introduction: The inception of work hour restrictions for resident physicians in 2003 created impactful and controversial change within surgery training programs. On a recent ACGME survey at our institution, we noted a discrepancy in low recorded duty hour violations and surgery residents' perception of poor duty hour compliance.  We sought to identify factors that lead to duty hour violations and encourage accurate reporting among surgical trainees.  We hypothesize that accurate reporting will permit program specific modifications that enhance educational and clinical opportunity while ensuring compliance with ACGME work hour limitations.

Methods: A3/Lean methodology, an industry derived systematic problem-solving approach, was used to investigate barriers to accurate duty hour reporting within the department of surgery at an academic institution.  In close partnership with our Graduate Medical Education office, we encouraged a 6-month trial period where residents were asked to accurately record duty hours and provide descriptive explanations of violations without consequence to the invididual or program.  Utilizing the A3/Lean session as the break point, we performed before and after analysis of duty hour violations. Quantitative analysis was used to elucidate trends in violations by post graduate year and rotation.  Qualitative evaluation by thematic area revealed resident attitudes and opinions about duty hour violations.  

Results:Through the A3/Lean process, residents reported fear of personal and programmatic punitive measures, desire to retain control of their surgical education, and frustration with the administrative burden following violations as deterrents to honest duty hour reporting.  The intervention was successful in changing logging behavior,10 total violations prior vs.179 violations after (p = 0.003) the A3/Lean evaluation. The increase was largely derived from Short Break violations (4 vs. 134, p = 0.021).   Analysis of violations revealed program-specific trends by post-graduate year (Table 1), rotation and weekend cross-coverage.  Systematic issues were identified and programmatic interventions were implemented.  Additional findings included lower than anticipated 80-hour work week violations despite high numbers of short break violations.  The ability to participate in cases/procedures and a sense of professional responsibility emerged as themes among residents describing violations.

Conclusion:Systematic evaluation of duty hour reporting within a surgical training program can identify structural and cultural barriers to accurate duty hour reporting.  Accurate reporting can identify program specific trends in duty hour violations that can be addressed through programmatic intervention.

 

19.04 Factors Associated with Burnout in Surgical Residents

Posted on January 31, 2019

F. Gleason1, S. Baker1, E. Malone1, R. Hollis1, K. Cofer1, J. Richman1, D. Chu1, B. Lindeman1  1University Of Alabama at Birmingham,Birmingham, Alabama, USA

Introduction:   Surgical residents are a population at high risk for burnout.  Some studies have demonstrated a strong inverse relationship between burnout and both Emotional Intelligence (EI) and job resources .  We hypothesized that burnout among surgery residents at our institution would also be inversely related to EI and job resources, but directly related to experienced disruptive behavior.

Methods:   All general surgery residents at a single institution were invited to complete a survey in 2018 that included: the 22-item Maslach-Burnout Inventory (MBI), 30-item trait EI questionnaire (TEIQ-SF), as well as focused questions assessing disruptive behaviors (8 items), job resources (8 items), and demographic characteristics (4 items).  Burnout was defined as scoring high in Depersonalization (≥10 points) or Emotional Exhaustion (≥27 points).  Student’s t-tests and Wilcoxon tests were used to compare continuous variables; Chi-square and Fisher’s exact tests were used to compare categorical variables, as appropriate.

Results:  Surveys were completed by 60 residents (response rate 87%).  Median respondent age was 30 (IQR 28-32), 51.7% were female, and 48.3% single.  Thirty-five met criteria for burnout (58%).  Of female respondents, 68% were burned out compared to 48% of male respondents, however this difference was not statistically significant (p=0.13). There was no significant difference in burnout rates between married and non-married residents (55.6% vs. 65.5%, p=0.45). Among married respondents, 75% without children were burned out compared to 27% of those with children (p=0.03).  Residents with burnout had significantly lower scores for job resources compared to residents without burnout (19 vs. 26, p<0.01).  Job resources sub-domain scores for meaningful feedback and professional development were significantly associated with burnout (p<0.01 for both).  Having experienced any disruptive behavior was significantly associated with burnout (68% vs. 32%, p=0.01).  Mean EI scores were also lower for those with burnout (5.18 vs. 5.64, p<0.01).  Among EI sub-categories, burnout was significantly associated with well-being and emotionality (p<0.01 and p=0.02, respectively).

Conclusion:  Burnout is prevalent among surgery residents at our institution.  Experiencing disruptive behaviors was associated with higher burnout scores, while higher scores in emotional intelligence and perceptions of job resources were associated with lower burnout scores. Further research is needed to determine if increasing resident EI and perceptions of job resources could decrease burnout.

19.03 What makes the difference for Mindfulness-Based Interventions for medical trainees?

Posted on January 31, 2019

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

Introduction:  Burnout and distress are high stakes issues in medicine, affecting patient care, satisfaction, and physician well-being. Surgical trainees appear to be particularly high risk, as evidenced by alarming rates of burnout, depression and suicidal ideation. Few successful interventions exist for this complex problem, which has been framed as involving institutional, systemic and individual components. In regard to the latter, Mindfulness-Based Interventions (MBIs) have been shown to be highly feasible and acceptable as well as subjectively and objectively beneficial in surgical trainees. However, focused modification of MBIs could optimize them for dissemination across medical specialties. We explored cultural factors critical for successful implementation of MBIs among surgical and non-surgical trainees at our institution, identifying those factors universally important across groups versus those that were specialty- or training level- specific. 

Methods:  Using mixed methods, we conducted three different studies at a tertiary academic center: a longitudinal pilot RCT with surgery interns (n=40), a cohort study of mixed level urology residents (n=20), and a registered clinical trial of interns from surgical and non-surgical specialties (n=45).  Qualitative data from field observations, focus groups and key interviews were analyzed using grounded theory. Common concepts of perceived need, acceptability, and barriers to participation were identified and coded in an iterative fashion with consensus reached on major themes.

Results: Three influential factors emerged regarding successful implementation of MBIs across groups: motivation, relevance, and cultural norms. Framing MBI training as a discipline for the development of a discrete skill set was universally motivating, and contextualization of skills within familiar professional and personal situations conferred relevance. For example, using defined breathing techniques to transition from work to home or between patients; heightening focus in a code or in the operating room; or using objective self-awareness to observe thoughts when spiraling into self-doubt or when struggling with a new procedure. Cultural norms, while universally influential, showed the greatest variation across specialties and training levels. For instance, surgical specialties were the least willing to discuss personal struggles and feelings, which necessitated activities that approached these subjects in an oblique fashion. Interns, regardless of specialty, were found to be more receptive to the idea of MBIs conferring a professional skill set, whereas senior trainees required objective evidence of MBI effectiveness in other fields.

Conclusion: Wider dissemination of MBIs within medicine may require involving both a cultural insider and a flexible MBI instructor for each new setting. The former, to provide nuanced understanding for optimized motivation, relevance and acceptability, and the latter to adapt the MBI accordingly.

 

19.02 Surgical Resident Education Improves ACS NSQIP Outcomes

Posted on January 31, 2019

Z. Li1, J. Coleman1, D. Naanaa1, C. D’Adamo2, V. Ahuja1  1Sinai Hospital of Baltimore,Surgery,Baltimore, MD, USA 2University Of Maryland,Surgery,Baltimore, MD, USA

Purpose: The validity of outcomes data depends on the consistency of documentation of reported measures. Resident understanding of diagnostic criteria may influence correct documentation and quality outcomes.  This study aims to evaluate whether surgical resident education concerning definition and documentation of ACS NSQIP (American College of Surgeons- National Surgical Quality Improvement Program) cardiac occurrences affects the quality of data in the NSQIP database.

Methods: Data were obtained using NSQIP morbidity report for all elective general surgery and vascular surgery procedures at a single institution.  Post-operative myocardial infarction (MI) incidences were reviewed from the NSQIP semiannual report from January to June 2015. Individual cases from 2015 were independently reviewed by a hospital cardiologist to evaluate accuracy of diagnosis. Data from January to June 2017 was then reviewed and compared to data from 2015 using Fisher exact test to evaluate whether education leads to better documentation and improved accuracy of NSQIP data.

Results: Approximately 1,000 surgical procedures in 2015 and 2017 were examined. There were 12 post-operative MIs in the 2015 period and 3 post-operative MIs in the 2017 period. A hospital cardiologist review of documented 2015 postoperative MI cases by residents raised concerns as these cases were troponin rise which did not meet myocardial demand ischemia criteria. NSQIP definition allows MI occurrence to be based solely on physician documentation of MI, irrespective of the electrocardiogram changes.  A false elevation of MI due to physician’s documenting the diagnosis in their progress note incorrectly showed our hospital to be a high outlier in MI. Education was then provided to surgical residents regarding documentation of postoperative MI only by cardiologist or based on the NSQIP definition.  After education, Fisher exact test showed the odds of having documented post-operative MI within the NSQIP database in 2017 was significantly lower (Odds Ratio = 0.2, p = 0.0346, 95% CI = [0.072, 0.92]) than in 2015.

Conclusions: Correct diagnosis of post-operative MI by surgical residents may significantly impact quality of NSQIP data.  This study shows surgical residents’ education can improve correct diagnosis and documentation of post-operative MI leading to better hospital NSQIP outcomes.

19.01 Illegal Questions and Bias as Experienced by Applicants to General Surgery Residency Programs

Posted on January 31, 2019

L. Theiss1, G. McGwin3, H. Chen1, J. Porterfield1, S. Theiss2  1University Of Alabama at Birmingham,Department Of Surgery,Birmingham, Alabama, USA 2University Of Alabama at Birmingham,Department Of Orthopaedic Surgery,Birmingham, Alabama, USA 3University Of Alabama at Birmingham,Department Of Epidemiology,Birmingham, Alabama, USA

Introduction: The National Resident Matching Program (NRMP) Code of Conduct stipulates that program directors shall refrain from asking applicants “illegal or coercive questions about age, gender, religion, sexual orientation and family status.” Despite this code, we hypothesize that applicants to general surgery residency programs are often asked illegal questions and that there is a bias against female applicants, who are asked illegal questions more often. Furthermore, we hypothesize these questions are more prevalent in general surgery interviews than other surgical subspecialties.

Methods: A survey was developed and sent to applicants to a university-based general surgery residency program. Applicants were asked questions about demographics and family status. The survey also asked applicants about the frequency of illegal questions about age, gender, religion, sexual orientation and family status. Data was analyzed using a Chi Square test.

Results: 1161 applicants were sent the survey, of which 309 responded. 40% of the applicants were female and 60% were male. Female general surgery residents were less likely to be married (p=0.03) and less likely to have children than their male colleagues (p=0.04). 19% of female applicants were asked questions relating to their gender, while 3% of males were asked about their gender (p<0.0001). 25% of female applicants and 13% of male applicants were asked about plans for pregnancy (p=0.02). There was a trend towards female applicants being asked about their age and marital status. 35% of female general surgery applicants stated that being asked an illegal question moved that program down their rank list, while only 14% of males said the same (p<0.0001).

Conclusion: In a survey of general surgery residency applicants, illegal questions as defined by the NRMP were frequently asked in a formal interview setting. More female applicants than male applicants were asked illegal questions. These findings do not only highlight the frequency of illegal questioning, it also highlights an inherit bias towards female applicants. This study will help programs become aware of the high prevalence of illegal questions during residency interviews and the gender bias of these questions related to women, particularly in general surgery.
 

104.20 Varsity Sports and Surgical Training Success

Posted on January 31, 2019

A. Tanious1, C. Jokisch2, H. McMullin2, L. T. Boitano1, P. A. Armstrong2, M. Harrington3, M. F. Conrad1, M. L. Shames2  1Massachusetts General Hospital,Vascular Surgery,Boston, MA, USA 2University Of South Florida College Of Medicine,Vascular Surgery,Tampa, FL, USA 3University Of South Florida College Of Medicine,Plastic Surgery,Tampa, FL, USA

Introduction:

Our goal was to understand if a correlation exists between participation in varsity level sports and positive experiences during one’s surgical clerkship or surgical residency.

Methods:

            Surveys were sent to the program directors of all surgical residencies, all surgical residents, as well as all third and fourth year medicals students at our institution. Data collected included level of training, participation in varsity sports, and the last level of competitive sports played.  Likert scales where used to assess the level of enjoyment of surgical education, teaching style (i.e. Socratic method), and surgical training.

Results:

            Seventy-eight of our surgical residents (48%), and 87 of our medical students participated in the study (26%).  Sixty-three percent of medical student responders and 82% of surgical resident responders participated in varsity level sports.  Significant correlations were found between participation in varsity level sports and enjoyment of teaching style during surgical residency (P = .04).  Individuals with higher levels of sports involvement (high school and collegiate level involvement) had significantly increased positive interactions with other trainees as well as level as significantly increased feelings of preparedness for surgical residency (P = .01 and P = .04 respectively).  Six of 10 program directors responded and showed no preference towards students who participated in varsity sports.

Conclusions:

            The opinions of trainees suggest that participation in varsity sports may aid in preparing one for surgical training. It may also improve interactions amongst trainees during residency. While program directors do not consider this an essential characteristic, it may help discern which applicants are better suited for the hardships faced by surgical training and its associated teaching methods.

104.19 Faculty mentoring: Early experience with a Formal Mentoring Committee

Posted on January 31, 2019

P. N. Redlich1, T. A. DeRoon-Cassini1, R. Treat1, R. Spellecy1, M. Zarka1, M. A. Zimmerman1, T. P. Webb1, B. D. Lewis1, D. M. Gourlay1, G. Lomberk1, K. R. Brown1, M. F. Otterson1, D. B. Evans1, T. S. Wang1  1Medical College Of Wisconsin,Surgery,Milwaukee, WI, USA

Introduction: Faculty represent the most important asset of academic departments. Effective faculty mentoring is the cornerstone of career success. Studies have demonstrated the importance of mentoring, yet only half of surgical departments have mentoring programs. Our department sought to enhance its mentoring program by establishing a formal Mentoring Committee (MC) in 2016 to supplement support by the Chair and Division Chiefs. The goals of this study were to obtain junior faculty perceptions on mentoring and their perceived value of the MC. In addition, senior faculty participation in the MC was tracked as a measure of interest in, and support of, junior faculty mentoring.

Methods:
The MC was constituted to have broad representation with 11 senior faculty members from 8 Divisions and one from another academic department. Concomitant with the formation of the MC, a questionnaire (Survey 1) was sent to all assistant and associate professors surveying demographics, perceived mentoring components, and past mentoring experiences. Assistant professors (both newly hired [NH] and those beyond their first year [BFY]) met individually with the MC. Attendance at meetings was recorded, including MC members and invited mentors of NH faculty. The MC reviewed the mentee’s current and planned clinical, academic and professional activities while providing detailed feedback, guidance, and support in a 45-60-minute session. Comprehensive minutes were provided within 2-3 weeks along with a post-meeting survey (Survey 2) to include invited feedback. Both surveys were constructed using a Likert scale from 1-5 (5=strongly agree; most important). Significance was determined by the Mann-Whitney U-test.

Results:
Survey 1 had a response rate of 44% (14/32). Highest rated items defining mentoring were: professional development advice (5.0 [median]), support in societies (5.0), support of scholarly projects (5.0), and assisting with research (4.0). Over 2 years, 10 BFY and 16 NH assistant professors met with the MC. Survey 2 had a response rate of 100% (26/26). The highest rated items included: information provided was valuable (5.0), meeting time allotted was sufficient (5.0), and post-meeting communications were helpful (5.0). “Pre-meeting materials were helpful” was rated higher by NH faculty (4.0 vs 3.5, p=0.011) whereas “meeting time allotted was sufficient” was rated higher by BFY faculty (5.0 vs 4.5, p=0.04). The mean number of senior faculty who attended meetings was 6.3 (SD=1.6; range 4-11).

Conclusion:
A formal MC was well-received by junior faculty and enthusiastically supported by senior faculty. A focused meeting of the MC devoted to an individual faculty member has created a visible symbol of the importance of career mentoring. Interest from other departments has provided impetus for enhanced mentoring across the institution. Long-term evaluation of specific outcomes of our MC is ongoing.
 

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