63.10 How do Surgeons Value the Marginal Cost of Operating Room Time?

Posted on January 31, 2019

C. P. Childers1,2, B. Zhao3, J. Tseng4, R. F. Alban4, B. M. Clary3, M. Maggard-Gibbons1  1University Of California – Los Angeles,Surgery,Los Angeles, CA, USA 2University Of California – Los Angeles,Fielding School Of Public Health, Department Of Health Policy & Management,Los Angeles, CA, USA 3University Of California – San Diego,Surgery,San Diego, CA, USA 4Cedars-Sinai Medical Center,Surgery,Los Angeles, CA, USA

Introduction:
New surgical instruments are often proposed to improve operative efficiency, but at added cost. The marginal savings from reducing operative time are small, with previous estimates well under $10/minute. If surgeons overestimate the value of operative efficiency they may choose instruments which add unnecessary costs to the system.

Methods:
A web-based survey was distributed to 100 attending general and subspecialist (eg, colorectal) surgeons at 3 academic health systems. The outcome was the surgeon’s opinion of the marginal cost of one minute of operating room (OR) time, asked through a willingness to pay framework (Figure). Multivariable models were fit to assess factors associated with mean or outlier (top quintile) values. Covariates included institution, gender, fellowship, years after training, specialty, and, for a small subset (n=35), publicized salary information.

Results:
The overall response rate was 83% (83/100) with 75 surgeons providing numeric and reasonable (i.e. ≥ $0) estimates for the marginal cost of OR time. Mean (SD) and median (IQR) values were $28.53 ($27.92) and $21.43 ($7.14-$35.71).  Thirteen (17.3%) responses were  ≥$40 (top quintile). None of the studied covariates were associated with mean or outlier estimates except that surgeons at one institution had consistently higher estimates than those from the other two.  There was no association between marginal cost and surgeon salary.

Conclusion:
On average, surgeons believed it was reasonable for hospitals to spend $20-30 to save one minute in the OR – values likely much larger than the actual money saved. The wide variability in estimates, along with the absence of a significant predictor, may suggest a relative lack of education on the topic. These findings suggest financial education may be necessary to enable surgeons to make the best value decisions in the OR.
 

63.09 Why Can’t Surgeries Start on Time?

Posted on January 31, 2019

J. Y. Zhao1, A. Engelman1, O. Plante1, R. Perez1, G. Yang1, P. L. Elkin1, S. D. Schwaitzberg1  1State University Of New York At Buffalo,Surgery,Buffalo, NY, USA

Introduction:  Errors in surgical case scheduling can lead to inefficiencies, patient and staff dissatisfaction, and direct and indirect cost burdens to the hospital. Perioperative efficiency is difficult to optimize due to a lack of understanding of the causes behind nonadherence to the surgical schedule. Our study aimed to delineate the points along the perioperative process amenable to targeted interventions to promote scheduling accuracy. 

Methods:  During a six-month period, a prospective study was performed to evaluate the perioperative process of adult patients undergoing elective surgeries. Patients were directly monitored from registration all the way through to post-anesthesia care. Scheduled times were compared to actual times. Reasons for nonadherence to scheduled times were recorded. Mid-way through the study, attending surgeons began receiving text notifications as soon as their patients were intubated.

Results: A total of 82 surgical cases were observed. Multiple reasons for surgery schedule nonadherence were noted. Most modifiable barriers leading to delays occurred in the preoperative phase; more than half of these barriers could be attributed to organization-related factors. Staffing-related factors were the cause of two-thirds of the delays that occurred once the patient was already in the operating room. Delays preventing patients from leaving the operating room after surgery occurred infrequently, and when they did occur, were most commonly due to a patient-specific reason. After attending surgeons began receiving text notifications that their patient was ready in the operating room, reductions were appreciated in the number of case delays that would have otherwise occurred equal to or less than 30 minutes. 

Conclusion: Our prospective time analysis study revealed multiple points in the perioperative process where inefficiencies were introduced and jeopardized adherence to the surgery schedule. Delays beyond thirty minutes will likely occur regardless of how timely an attending surgeon is in arriving to the operation room. Interventions that target organizational and staffing barriers are more likely to be met with success, as patient-specific factors will be less amenable to modifiable intervention. 

 

63.08 Gender Variance in NIH K-series Grant Funding in Surgery

Posted on January 31, 2019

J. M. Juprasert1, H. L. Yeo1  1NewYork-Presbyterian Hospital/Weill Cornell Medical Center,Department Of Surgery,New York, NY, USA

Introduction: Over the past 15 years, the number of women in academic surgery has increased dramatically, however, even as recently as 2015, women only accounted for 25% of assistant professors of surgery and <10% of full professors. Based on the current trajectory, women will not reach parity in academic surgery for over 100 yrs.  There is a concern that part of the disparity at the top levels may be attributed to gender discrimination, lack of visible role models, or lack of support and mentorship.  Because early funding is so important in an academic career, we sought to evaluate gender differences in NIH career development funding.

Methods:  Secondary analysis of prospectively collected data from fiscal year 2017 and 2018 from the NIH RePORTer database.  NIH K-series funding awards to principal investigators (PIs) were obtained and used to examine faculty from surgery departments for academic rank and gender.  Awardees with at least an M.D. were included in the study to focus our cohort on clinical academic surgeons.  K1, K07, K08, K22, K23 were included in the study to investigate early career awards; K24 recipients were excluded because they are for mid-career investigators.  The Scopus and Pubmed databases were used to ascertain publication statistics of these PIs.  Statistical trend tests were performed using t-test, ANOVA, and chi-squared test wherever appropriate with STATA v13.1.

Results: 63 surgical PIs (33% women vs 67% men) were identified who received a K-series grant from the NIH between 2017-18. The average number of first author publications for these awardees was 14.5 (+/-10) for women and 15.7 (+/-11) for men (p=0.67). The average number of senior author publications for these K awardees were 9.9 (+/-9) for women and 12.2 (+/-13) for men  (p=0.47).  The average number of total publications for K awardees was not significantly different for women (43.6+/-24) vs. men (53.2+/-32.2, p=0.23). The mean H-index for female faculty was 14.0 (+/-5) and 16.4 (+/-7) for men (p=0.15). Of the grants that were granted, 38 (60%) were basic science, 16 (25%) were translational, and 9 (14%) were health services related.  32 recipients were assistant professors (31% were women).  30 recipients were associate professors (37% were women).  The University of Michigan had the most recipients of any institution with 10 PIS (4 of whom are women) receiving grants; Northwestern University and University of Pennsylvania had the second highest with 5 PIS.  31 total institutions had at least one recipient.

Conclusion: The NIH K grant funding for early career women surgeons has not been previously described. There do not appear to be major gender related discrepancies in early career funding for surgeons.

 

63.06 Training Disparities & Expectations of Our Future Workforce: A Survey of Trauma Fellowship Candidates

Posted on January 31, 2019

S. A. Moore1, R. Maduka3, P. M. Reilly2, J. C. Morris2, M. J. Seamon2, D. N. Holena2, L. J. Kaplan2, N. D. Martin2  3Yale University School Of Medicine,New Haven, CT, USA 1University Of New Mexico HSC,Albuquerque, NM, USA 2Hospital Of The University Of Pennsylvania,Philadelphia, PA, USA

Introduction:

Fundamental training in Acute Care Surgery (ACS) is an integral component of general surgery residency and serves as a critical base experience for the added educational qualifications of fellowship.  How this training varies between programs is not well-characterized. We sought to describe the variation in clinical exposure between residencies and characterize the educational expectations (clinical and non-clinical) in a sample of residents applying to an ACS fellowship. We also sought to characterize the expectations of applicants for fellowship and future career plans. We hypothesized that applicants to an academic trauma, surgical critical care, and emergency surgery training program have significant variations in clinical exposure as well as unique and specific expectations for educational experiences.

Methods:
We offered an anonymous 70-question survey focused on residency clinical exposure and self-perceived confidence in key areas of ACS training, as well as fellowship training and career expectations to all applicants interviewed at a large, urban, academic, level one trauma, critical care, & emergency surgery fellowship program. Responses were assessed via absolute numbers and confidence via a 5-point Likert scale; data is reported using descriptive statistics and linear regression models.

Results:
Forty-two out of 44 interviewing applicants completed the survey, for a response rate of 96%. Applicants reported heterogeneous levels of comfort across most ACS domains. There was poor correlation between experience and comfort in several key areas where despite little experience respondents reported high levels of comfort (FIGURE 1). During fellowship training, respondents placed the highest priority on operative experience, with 43% rating this as their highest priority, followed by penetrating trauma experience (33%), a heavy clinical ICU exposure (17%) and leadership training (12%).The majority of respondents (58%) envisioned a career that was comprised of 50% trauma, 25% emergency general surgery, and 25% critical care.

Conclusion:
We found significant variations in both experience and comfort within key ACS domains amongst fellowship applicants. Applicants with little experience still reported high level of comfort with fundamental ACS skills. Collaboration between general surgery residency and ACS fellowship governing bodies may help address areas of limited exposure prior to entry into clinical practice. Understanding the expectations of fellowship applicants is essential in demonstrating the elements of a program that resonate with applicants to aid rendering an informed program selection. ACS fellowship programs must balance these expectations with realistic experiences during training and in the job market.
 

63.05 GoogleGlass for Surgical Tele-proctoring in Low-Resource Settings: A Feasibility Study in Mozambique

Posted on January 31, 2019

M. C. McCullough5, L. Kulber2, P. Sammons5, P. Santos3, D. Kulber5,6  2Mending Kids, International,Los Angeles, CA, USA 3Matola Hospital,Plastic And Reconstructive Surgery,Matola, Mozambique 5University Of Southern California,Plastic And Reconstructive Surgery,Los Angeles, CA, USA 6Cedars-Sinai Medical Center,Plastic And Reconstructive Surgery,Los Angeles, CA, USA

Introduction: Untreated surgical conditions account for one third of the total global burden of disease, and a lack of trained providers is a significant contributor to the paucity of surgical care in low and middle-income countries (LMICs). Wearable technology with real-time tele-proctoring has been demonstrated in high-resource settings to be an innovative method of advancing surgical education and connecting providers, but application to LMICs has not been well-described. We share our six-month experience with Google Glass in Mozambique and demonstrate the feasibility of using wearable technology with tele-proctoring to expand access to training opportunities in reconstructive surgery in this low resource setting.

Methods:  Google Glass with live-stream capability was utilized to facilitate pre and intra-operative tele-proctoring sessions between a surgeon in Mozambique and a reconstructive surgeon in the United States over a six month period.  At the completion of the pilot period a survey was administered regarding the acceptability of the image quality as well as the overall educational benefit of the technology in different surgical contexts.  Additional narrative interviews were conducted with both participants to gain further insight into potential challenges and limitations of the program. 

Results: Twelve surgical procedures were remotely proctored using the technology.  No complications were experienced in any patients.  Survey results demonstrate the biggest limitations to the experience, from the perspective of both participants, were issues related to image distortion.  Image quality was sufficient for the mentor surgeon to perceive and to comment on pertinent anatomical structures, instrument handling, positioning and technique, but distortion due to light over-exposure, motion artifact and image resolution were rated as moderate impairments.  Video-stream latency and connection disruption were also cited as limitations. Despite image distortion, both surgeons found the technology to be highly useful as a training tool in both the intraoperative and perioperative setting.  

Conclusion: Our experience in Mozambique demonstrates the feasibility of wearable technology to enhance the reach and availability of specialty surgical training in LMICs. Surgical aid to LMICs has long been dominated by short-term trips by high-income country volunteers, and creative solutions are needed to re-focus efforts on surgical education and prioritize the development of local surgeons within their countries and local practice settings.  Despite shortcomings in the technology and logistical challenges inherent to international collaborations, this educational model holds promise for connecting surgeons across the globe, introducing expanded access to education and mentorship in areas with limited opportunities for surgical trainees and generating discussion around the potential for innovative technologies to address needs in training and care delivery in LMICs. 

 

63.04 Improving Resident Feedback by Evaluating Perioperative Skill

Posted on January 31, 2019

C. McDaniel1, N. Samra1  1Louisiana State University Health Sciences Center Shreveport,Department Of Surgery,Shreveport, LA, USA

Introduction:
There is currently no mechanism in place at our institution for detailed resident feedback regarding perioperative planning and skill. No structured curriculum exists for teaching perioperative skills. In this study we implement a rubric for evaluating surgical resident performance in the operating room and assess its acceptance amongst surgical residents in our institution.

Methods:
Surgery residents of all levels were presented the proposed rubric for surgical performance evaluation. A survey was distributed with several questions regarding the perceived utility of this rubric. Each question was rated with a 5-point scale. Data analysis was performed and statistical comparisons were made using the Mann-Whitney-U test. The null hypothesis selected is that residents will not find the proposed rubric useful. A secondary hypothesis was that there will be no difference in opinion between upper and lower level residents.

Results:
Overall the response was positive with the mean response being 3.86 (1-5). There was no statistical difference between the responses of upper and lower level residents (p=0.261). Most comments left on the survey reflected the desire of residents to have verbal attending feedback face-to-face.

Conclusion:
Based on these data we reject the null hypothesis that residents would not find the proposed rubric useful. The data show that the majority of residents favored the rubric, especially if done in a face-to-face setting at the end of the rotation. We accept our null hypothesis that there was no difference in opinion between upper and lower level residents.
 

63.03 Feasibility of Using Resident-Specific Outcomes to Measure Individual Performance

Posted on January 31, 2019

A. N. Kothari1, T. Qu1, C. P. Fischer1, M. J. Anstadt2, P. P. Patel1, M. Singer1, G. J. Abood1  1Loyola University Medical Center,Surgery,Maywood, IL, USA 2Loyola University Chicago Stritch School Of Medicine,Maywood, IL, USA

Introduction:  The development and use of novel measures of resident performance have gained the attention of national regulatory and accrediting bodies. With improvements in the availability of surgical quality improvement data and improved risk adjustment, a potential opportunity is to leverage resident-specific patient outcome data to evaluate resident performance. The objective of this study was to determine the feasibility of using surgical outcomes data to measure individual resident performance.

Methods: Institutional NSQIP data were obtained for all patients that underwent colectomy on a single surgical service from January, 2016 – December, 2017. A composite outcome of the following postoperative occurrences was used to develop risk-adjusted models: surgical site infection, wound disruption, unplanned intubation, pulmonary embolism, renal insufficiency, urinary tract infection, c. diff infection, readmission, death. These were chosen using a nominal group technique to identify occurrences potentially modified by resident involvement by program faculty. Resident-level outcomes were estimated from 2-level, random effects models.

Results: A total of 280 cases for 12 chief residents were analyzed. Resident case volume ranged from 15 to 32 with unadjusted composite occurrence rates ranging from 11.1% to 53.3%. No residents were classified as low outliers with better than expected outcomes, while one resident was classified as a high outlier with worse than expected outcomes (risk-adjusted rate: 41.8%). The proportion of variation in outcomes attributable to the resident was 0.03 (model intra-class correlation). Reliability of estimates was a median of 0.02 (0.01 – 0.06).

Conclusion: Resident-specific surgical outcomes cannot be reliably used to determine individual resident performance on an institutional level. Variation in measured outcomes can only minimally be attributed to the operating resident. Efforts to use resident-specific patient outcomes to measure performance should be avoided.

 

63.02 Investigating the Medico-Legal Impact on Surgical Training

Posted on January 31, 2019

E. L. Chang1, A. M. Williams1, R. C. Boothman1, J. Thompson-Burdine1, R. M. Minter2, G. Sandhu1  1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 2University Of Wisconsin,Department Of Surgery,Madison, WI, USA

Introduction:  Achieving an appropriate level of supervision remains a national problem in surgical education. Often, the regulations regarding resident supervision are in reference to “the critical portion of a case.” We sought to develop a better understanding of ‘key and critical portions’ of surgical cases, pertaining to intraoperative resident supervision and patient safety.

Methods:  Hospital risk managers and legal counsel from cross the United States were surveyed using an online, qualitative questionnaire from May to June 2018. Snowball sampling, a subset of purposive sampling, was used to identify and develop a population of 47 risk managers. Interpretive description was used to analyze qualitative data. Individual responses were coded with NVivo software with simultaneous categorization and assessment of underlying relationships. Response variation was discussed among the research team and resolved accordingly.

Results: Overall, 25 of 47 (53%) risk managers completed the survey. Qualitative responses could be organized into three major themes: (1) “differing expectations”, (2) “variations in defining the ‘key and critical’ portions of a case, and (3) “developing trusting relationships in the operating room.” Little consensus was found regarding an attending’s role in the operating room and how “key and critical” portions of a procedure are defined. However, all participants agreed regarding the importance of patient safety and need for developing intraoperative trust among all parties in the operating room.

Conclusion: Expectations and definitions remain highly variable regarding “key and critical” portions of a surgical case. Even among risk managers, who have a considerable influence on guidelines and definitions for health systems, multiple interpretations may exist. Continuing to develop and highlight the transparency of “key and critical” portions of a case will support optimizing the teaching-learning experience within the safety net of supervised surgical resident training.

 

63.01 Impact of Trainee Operative Experience on Anastomosis and Total OR Time in Kidney Transplant

Posted on January 31, 2019

J. K. Ewing1, M. T. LeCompte2, S. Walia1, A. C. Sayce1, D. E. Pereira1, J. R. Robinson1, K. Terhune1, D. Shaffer3, R. C. Forbes3  1Vanderbilt University Medical Center,Department Of Surgery,Nashville, TN, USA 2Washington University,Department Of Surgery, Division Of Hepatobiliary-Pancreatic & GI Surgery,St. Louis, MO, USA 3Vanderbilt University Medical Center,Department Of Surgery, Division Of Kidney And Pancreas Transplantation,Nashville, TN, USA

Introduction:  Surgical trainees’ operative proficiency improves with experience, but it is unclear how cumulative operative experience affects trainees’ ability to learn and perform specific operative procedures.  We aimed to determine if resident trainees’ cumulative operative experience, reflected by time within postgraduate training year (PGY), affects key time metrics in kidney transplant.

Methods:  We performed a retrospective cohort study of all living donor kidney transplants at a tertiary care academic hospital from 2006-2016.  We included all procedures performed by a single attending surgeon with PGY3 residents.  Trainees participated in all operative steps and sewed the lateral half of both vascular anastomoses. Multiple linear regression was used to determine if vascular anastomosis or operating room (OR) time varied between operations performed by residents early in PGY3 (July-December) versus late in PGY3 (January-June).  Analyses controlled for recipient body mass index (BMI), gender, operative site laterality, and allograft laterality.

Results: Of the 355 included transplants, 179 (50.4%) were performed early in PGY3 and 176 (49.6%) were performed late in PGY3. Anastomosis time (mean+/-SD ) was 20.0+/-3.1 minutes and total OR time was 198+/-38 minutes.  There was no significant difference in anastomosis time between the early (20.2 minutes) versus late (19.8 minutes) groups (p = 0.466).  Anastomosis time was shorter for right versus left donor kidneys (p = 0.002) and shorter in recipients with lower BMI (p = 0.020).  Total OR time trended towards (p = 0.051) shorter times in the late group (195 minutes) versus the early group (201 minutes), but this did not meet statistical significance. Total OR time was not significantly affected by recipient gender, BMI, allograft laterality, or operative site laterality.

Conclusion: Vascular anastomosis and total OR times were similar in kidney transplants performed by residents early versus late in PGY3, suggesting that cumulative operative experience may not strongly affect performance of specialized skills.  More work is needed to determine which operations and techniques are most affected by cumulative operative experience and to characterize the learning curve for specific surgical skills.  These findings support the need to assess skilled procedural learning with competency-based outcome measurements rather than cumulative training time in surgical education.

43.10 Are Academic Half Days the Proper Didactic Method for General Surgery Residency Training?

Posted on January 31, 2019

M. Malekpour1, J. Dove1, H. Ellison1, M. Shabahang1  1Geisinger Medical Center,Department Of General Surgery,Danville, PENNSYLVANIA, USA

Introduction:
Dedicated didactic time is now an innate part of any residency training yet the appropriate method is debated. Academic half days (AHD) have been adopted by many medical residencies and some surgical ones. In this study, we aimed to compare the outcome of AHD versus daily morning didactics (MD) in an accredited General Surgery residency training program.

Methods:
The didactic method of 2015-2016 academic-year had been 7-8 AM weekday MD and the didactic method of 2016-2017 academic-year had been once-a-week AHD. We studied the changes in American Board of Surgery In-Training Exam (ABSITE) and the number of cases that were missed annually for each didactic method. We also used a questionnaire to investigate the residents’ and attending physicians’ subjective assessment for each didactic method.

Results:
No person-to-person or class-to-class change in the ABSITE score was observed with the AHD (both p>0.5). With MD, residents had missed 35 cases whereas 319 cases were missed by residents with AHD over a one year period. Although the majority of attending physicians (70.9%) assessed the academic activities to be more organized with AHD, the same number (70.9%) were under the impression that residents had missed more cases, which aligns with the objective data. The majority of residents (61.5%) found AHD to have made academic activities organized yet less than half (46.1%) of the residents were under the impression that more cases had been missed with AHD.

Conclusion:
AHD was associated with more missed cases and was not associated with improved ABSITE scores. This should be taken into consideration by general surgery residency programs in their tailored didactic method.
 

43.09 A Multifaceted Research Engagement Program Improved General Surgery Residents' Academic Productivity

Posted on January 31, 2019

W. C. Frankel1, B. G. Scott2, N. Massarweh2,3, E. J. Silberfein2, Q. Zhang2, T. K. Rosengart4,5, S. A. LeMaire4,5, B. W. Trautner2,3  3Michael E. DeBakey Veterans Affairs Medical Center,Center For Innovations In Quality, Effectiveness, And Safety (IQuESt),Houston, TX, USA 4Baylor College Of Medicine,Division Of Cardiothoracic Surgery, Michael E. DeBakey Department Of Surgery,Houston, TX, USA 5Texas Heart Institute,Department Of Cardiovascular Surgery,Houston, TX, USA 1Baylor College of Medicine,Houston, TX, USA 2Baylor College Of Medicine,Michael E. DeBakey Department Of Surgery,Houston, TX, USA

Introduction:

The ACGME requires residency programs to create an environment of scholarship with an active research component. In 2013, to increase research engagement within our general surgery residency program, the program directors launched a multifaceted intervention to provide education and infrastructure to support residents’ research. We evaluated the efficacy of this intervention on the academic productivity of surgery residents, as measured by manuscripts published.

Methods:

The multifaceted intervention began in 2013 by making residents’ travel funding for their chief trip contingent upon submitting three manuscripts by the chief year. A formal research curriculum was implemented, along with a Department of Surgery Residents’ Research Day. Infrastructure to support residents’ research, including a biostatistician and medical editor, was provided and publicized widely.

We measured academic productivity by the mean number of manuscripts published per chief resident graduating in a given year, for the four years prior to launching the program (2010-2013; n=28) and the four years following implementation (2014-2017; n=29). Manuscripts were identified by searching PubMed by resident’s name plus our institution, and were included if published within one year of residency graduation. Chief residents were stratified by research track (n=23) versus non-research track (n=34). We applied independent two-sample t-tests or Mann-Whitney U tests to compare research productivity before and after program implementation.

Results:

Implementation of the multifaceted program led to a significant increase in research productivity overall (see Figure), with chief residents, on average, publishing 2.3 manuscripts before and 8.5 manuscripts after implementation (difference of 6.2, 95% CI: 2.1, 10.4; p=0.01). For the research track residents specifically, their average publications were 6.3 prior to and 15.4 after the new program, not significantly increased (difference of 9.1, 95% CI: -2.4, 20.6; p=0.10). The median publications for non-research track residents was 0.9 (IQR: 0.5, 1.0) prior to and 1.3 (IQR: 1.2, 8.6) after the new program (difference of 0.4; p=0.03). 

Conclusion:

Implementation of a multifaceted intervention to increase academic productivity was associated with a significant increase in the number of manuscripts published per resident overall and among the non-research track residents. The research track residents had higher productivity at baseline, and their increased publications did not achieve statistical significance. Our results suggest that surgery residents, particularly the non-research track residents, benefit from structured research education and support. Given the ACGME requirement that residents engage in research, some of the components of our intervention might have value to other programs, and in turn the ACGME may consider creating program metrics around  these components.

 

43.08 Impact of learner or teacher gender on intra-operative performance ratings of endocrine surgeries.

Posted on January 31, 2019

A. Wagle1, H. Chen1,2, J. Porterfield1,2, T. Wang1,2, E. P. Buczek1,3, B. Lindeman1,2  1University Of Alabama at Birmingham,School Of Medicine,Birmingham, AL, USA 2University Of Alabama at Birmingham,Department Of Surgery,Birmingham, AL, USA 3University Of Alabama at Birmingham,Department Of Otolaryngology,Birmingham, Alabama, USA

Introduction:  A recent study reported that female surgeons have lower mortality rates compared to male surgeons. While others have begun to question the impact of gender on teaching and learning in the operating room, and some have reported discordance between attending and resident perceptions of autonomy and performance during a procedure, there remains insufficient knowledge about the impact of women as compared to men in the surgical environment, both as teachers and learners.

Methods:  All residents performing a thyroidectomy or parathyroidectomy with 5 surgeons from October 2017-July 2018 were invited to complete an operative performance evaluation (OPE) at case completion. This consisted of supervision and performance ratings using the Zwisch scale for all steps of each operation, plus an overall rating of independence readiness. Attending surgeons completed the same survey and scores were compared using paired t-tests.

Results: A total of 198 paired attending and resident surveys from 99 parathyroidectomies and 99 thyroidectomies were received. Of the 32 resident participants, 15 were female (46.9%) and completed 110 surveys (55.6%). Of the attending surgeons, 2 were female (40%) and completed 59 surveys (29.8%). In PGY5 residents, attendings gave significantly higher ratings to females compared to males on critical operative steps (parathyroid identification 3.75 vs. 3.41, p<0.01; recurrent nerve avoidance 3.78 vs 3.34, p<0.01, respectively). Attending ratings of independence readiness for thyroidectomy were significantly higher than female residents’ self-ratings (0.71 vs. 0.52, p<0.02, respectively). For both procedures, attendings rated female PGY 5 residents as being independence ready significantly more often than male PGY 5 residents (parathyroid 0.96 vs 0.80, p = 0.02, thyroid 0.89 vs. 0.64, p<0.01, respectively). Compared to male peers, female PGY5 residents scored their performance and supervision significantly lower on 8/18 parathyroid steps and 7/20 thyroid steps, but no differences were observed between male and female PGY1 residents. Male PGY5 ratings for supervision or performance were never significantly lower than female PGY5 ratings for any thyroid or parathyroid step. Male attendings rated female residents significantly higher on more steps than male residents (76% vs. 29%, respectively, p<0.01). This was not observed in female attending ratings (female 34% vs male 37%, p = 0.77).

Conclusion: These findings suggest that gender of either learner or teacher can influence the perception of supervision and performance during a procedure. Self-rated gender differences were most pronounced in PGY-5 residents. Scores indicative of independence readiness were only affected by attending gender, with male attendings giving higher ratings to female residents.

 

43.07 Correlation between Altmetric Score and Citations in Pediatric Surgery

Posted on January 31, 2019

J. Chang1, N. Desai1, A. Gosain1,2  1University of Tennessee Health Science Center,Division Of Pediatric Surgery, Department Of Surgery,Memphis, TN, USA 2Children’s Foundation Research Institute, Le Bonheur Children’s Hospital,Division Of Pediatric Surgery,Memphis, TN, USA

Introduction:  The impact of a scientific manuscript has traditionally been measured by the impact factor of the journal it is published in and the number of times it is cited. However, citations have a lag period before the true impact of a manuscript can be determined. The Altmetric score has emerged as a measure of the digital dissemination of a scientific manuscript across multiple platforms, including Tweets, Facebook likes, and other social & popular media mentions. We hypothesized that Altmetric score would correlate with citations and journal impact factor in Pediatric Surgery.

Methods:  Using the previously identified the fourteen core journals of Pediatric Surgery, the top ten most-cited articles from each of these journals were identified for the year 2012, allowing for 5+ years of follow-up. For each article, we determined the number of times cited and the Altmetric score. For each journal, the 2012 impact factor and year in which the journal’s Twitter account was established was determined. Descriptive statistics and Pearson’s correlation coefficients were determined using GraphPad PRISM software.

Results: Citation information for n=140 articles was obtained. Articles were cited 56159 times (Median 192, IQR 83-403). Median Altmetric score was 8 (IQR 2-58). Citations correlated strongly with journal impact factor (r=0.82, p<0.0001). Altmetric score did not correlate with journal impact factor (r=0.08, p=0.32). Altmetric score weakly correlated with citations (r=0.189, p=0.03) with wide variability amongst journals (range -0.21 to 0.96). When analyzed on an individual journal basis, decreasing age of a journal’s Twitter account resulted in decreasing correlation between Altmetric score and citations (r=-0.299, p=0.0003).

Conclusion: This study is the first to link traditional bibliometric measures with newer measures of digital dissemination for publications in Pediatric Surgery. While the Altmetric score of the top cited manuscripts did not correlate with journal impact factor, it did weakly correlate with citations. Interestingly, this correlation was strongest for journals with well-established Twitter accounts, indicating that, over time, the Altmetric score may emerge as a tool to predict future citations. Currently, the Altmetric and traditional bibliometric measures appear to have distinct, but complementary roles in measuring dissemination and impact of scientific manuscripts in Pediatric Surgery.

43.06 Evaluation of Advanced GI, Bariatric, Flexible Endo, HPB, and Advanced GI MIS Fellowship Web Sites

Posted on January 31, 2019

C. H. Mullins1, S. Goyer2, C. Cantrell1, B. Corey2,3  1University Of Alabama at Birmingham,School Of Medicine,Birmingham, AL, USA 2University Of Alabama at Birmingham,Department Of Surgery,Birmingham, AL, USA 3University Of Alabama at Birmingham,Birmingham Veteran’s Affairs Medical Center,Birmingham, AL, USA

Introduction:  For over a decade, the number of surgery residents wishing to pursue additional fellowship training has continued to increase. Candidates often utilize web sites to evaluate and search for programs within their desired field. The presence of these websites and the information available through them has the potential to influence applicant decisions. The objective of this study was to analyze what data is available from Advanced GI, Bariatric, Flexible Endo, HPB, and Advanced GI MIS fellowship web sites.

Methods:  The programs evaluated were chosen based on their inclusion in The Fellowship Council directory (FCD), the accrediting body for MIS fellowships. The FCD was used to find functional links to program websites; websites were also identified through a systematic Google® search. In addition, all program specific data available through the FCD itself was accessed and analyzed separately from the institutionally based websites. The websites were evaluated based on the presence or absence of 21 previously established individual content criteria. 

Results: In total, the FCD listed 144 programs. Of those, each program had a dedicated page within the directory itself, 104(72%) had functional links listed, and 96(66.6%) of those links were identified as being specific webpages to the fellowship program through a Google® search. Overall, the FCD website contained 53% of the data points assessed, with only 27% of criteria available through programs’ institutional websites. The most common criteria met for both the FCD and institutional websites was program description at 97% and 62% respectively. The least common data point identified, the medical school or residency of current fellows, was 0% from the FCD and 6% from program specific websites. The mode for the number of data points filled was 11 for the FCD and 6 for institutionally based webpages when present. Less than half the programs fulfilled over 50% of identified criteria through the FCD templated directory, with one-third of programs listed failing to provide any program specific information via a website outside the FCD. When such websites were present, the average criteria met remained at 40%.

Conclusion: Information available online for MIS fellowship programs is lacking, with many institutionally supported webpages absent altogether outside of the FCD. In addition, the presented content is inconsistent and variable across programs and information sources. A more thorough approach to online fellowship information availability can allow for more tailored application and interview choices by candidates and programs alike, potentially decreasing costs and time spent on the interview process.
 

43.05 Assessing Knowledge of Biostatistics Among Residents and Medical Students

Posted on January 31, 2019

P. Kandagatla1, A. Worden1, A. Woodward1, A. H. Gupta1  1Henry Ford Health System/Wayne State University,Department Of Surgery,Detroit, MICHIGAN, USA

Introduction:  Previous studies have shown a lack of required biostatistical knowledge among residents. There are few data on the departmental variation of biostatistical knowledge among residents. Furthermore, there is a paucity of data comparing residents and medical students. We hypothesized that residents’ biostatistical knowledge varies across departments and there are individual characteristics that may serve as predictors for increased knowledge.

Methods:  We surveyed residents and medical students rotating at our institution. The survey tool included questions on demographics, prior biostatistics exposure, educational history, and confidence in biostatistics. The remainder of the survey included a previously validated 17-question biostatistics quiz. Descriptive statistics are used to summarize the responses. Univariate and bivariate analyses were done to compare means and calculate correlation, respectively. Multivariate analysis was performed to derive independent predictors of increased knowledge.

Results: A total of 218 participants completed the survey. Twenty-five (11.5%) were medical students and 193 (88.5%) were residents. The overall mean (SD) percent correct on the quiz was 48.3% (14.5%), and average correct was not different between students and residents(50.4% SD 13.2% vs 48.2% SD 14.6%, p = 0.45). There was a significant difference in the mean scores across all departments (range: 39.2-58.1%, p<0.01), which included Anesthesia, Emergency Medicine, Family Medicine, General Surgery, Internal Medicine, Neurosurgery, Ob/Gyn, Orthopedic Surgery, Radiology, and Urology. Ninety-three (42.7%) participants had a prior epidemiology course, 133 (61.0%) had a biostatistics course, and 117 (53.7%) had an evidence-based medicine course. There was no significant difference in the mean scores between those that had each type of course compared to those that did not. There was no significant correlation between average journal articles read per week (r = 0.09, p = 0.2), previous research publications (r = 0.12, p = 0.08), number of biostatistics didactics (r = -0.07, p = 0.33), and level of training (r = -0.01, p=0.84) with percent correct. Journal club attendance, however, was correlated with performance (r = 0.22, p<0.01). Confidence in participants’ understanding of statistical terms (r = 0.11, p = 0.11) was not correlated with performance. Linear regression revealed journal club attendance (b = 1.5, 95% CI 0.11-2.88, p = 0.03) and number of articles read per week (b = 2.8, 95% CI 0.11-5.45, p = 0.04) to be the only significant independent predictors for increased performance.

Conclusion: There was a significant variation in biostatistical knowledge across residency departments. Future educational interventions attempting to increase knowledge of biostatistics should perhaps focus on increasing journal club attendance and regular reading of medical literature. 

 

43.04 Identifying Naturalistic Coaching Behavior among Practicing Surgeons in the Operating Room

Posted on January 31, 2019

J. C. Pradarelli1,4, M. Delisle2,4, A. Briggs3, D. S. Smink1, S. J. Yule1,5  1Brigham And Women’s Hospital,Surgery,Boston, MA, USA 2University of Manitoba,Surgery,Winnipeg, MB, Canada 3Dartmouth Medical School,Surgery,Lebanon, NH, USA 4Ariadne Labs,Boston, MA, USA 5STRATUS Center for Medical Simulation,Boston, MA, USA

Introduction: Opportunities to improve surgical performance are limited for practicing surgeons; surgical coaching is one strategy to address this need. To develop peer coaching programs that integrate with surgical culture, a better understanding is needed of how surgeons routinely discuss performance in an operative context. The aim of this study was to identify examples of naturalistic coaching behavior among practicing surgeons operating together by categorizing intraoperative discussion with existing coaching principles.

Methods:  As part of a “co-surgery” quality improvement program, 20 faculty surgeons at a single academic hospital were randomized into 10 co-surgery dyads, comprising an “attending” and an “assistant” surgeon, who performed 1 operation together. Intraoperative discussion was transcribed in real time. De-identified transcripts were co-coded systematically by 2 researchers. Deductive reasoning was applied to categorize data into themes based on existing principles of surgical coaching: 1) self-identified goals, 2) collaborative analysis, 3) constructive feedback, and 4) peer learning support. Surgical coaching principles were cross-referenced with surgical coaching content, including technical skills (respect for tissue, exposure, instrument handling, time and motion, and flow of operation) and non-technical skills (situation awareness, decision-making, communication/teamwork, and leadership). A c-coefficient was calculated to assess the strength of the association between pairs of themes (range 0 to 1, with 0 meaning no co-occurrence and 1 meaning that the themes always occurred together).

Results: Overall, 44 coaching examples were identified in 10 operations. Of the 4 principles of surgical coaching, only self-identified goals and collaborative analysis were identified consistently in naturalistic conversations between two practicing surgeons in the operating room. Self-identified goals were most associated with discussions regarding “instrument handling,” “tissue exposure,” and “flow of operation” for technical skills (c-coefficient: 0.14, 0.17, 0.15, respectively) and “situation awareness” for non-technical skills (0.13). Collaborative analysis was most strongly associated with discussions regarding “respect for tissue” and “flow of operation” for technical skills (0.42 and 0.38, respectively) and “communication/teamwork” for non-technical skills (0.52).

Conclusion: In naturalistic conversations between practicing surgeons in the operating room, numerous examples of innate coaching behavior were identified that focus on intraoperative performance, including self-identified goals and collaborative analysis. However, prominent gaps were also observed in the natural behavior of surgeons with respect to coaching principles. For example, constructive feedback and peer learning support were rarely, if at all, identified. Surgical coaching programs will need to address these gaps to train surgeons as effective surgical coaches.

43.03 Timing of Surgery and Internal Medicine Clerkships and Surgery Shelf Exam Scores

Posted on January 31, 2019

A. Phares1, C. Sauder1, E. Salcedo1, D. Leshikar1, C. Irwin1, G. Middleton2, H. Phan1  1University Of California – Davis,Department Of Surgery,Sacramento, CA, USA 2University Of California – Davis,Office Of Medical Education,Sacramento, CA, USA

Introduction:
The third-year of medical school is a stressful time for students as they transition from the classroom to the clinics and wards. Students strive to perform well clinically with their patients and teams as well as academically on their assignments and exams. Many students believe that rotation sequence effects their success. At UC Davis, students interested in surgery believe that completing the internal medicine (IM) clerkship before the surgery clerkship will help improve their surgery shelf exam scores. We hypothesized, despite our students’ impressions, that students who completed the IM clerkship prior to the surgery clerkship did not receive higher surgery shelf examination scores than the students who did not.

Methods:
Deidentified academic data for all third-year UC Davis School of Medicine medical students from 2012-2017 were collected. Data included undergraduate GPA, MCAT scores, USMLE Step 1 scores, and NBME shelf exam scores for surgery. Students who did not complete all six core clerkships during the standard third-year time frame were excluded. The average shelf exam scores were analyzed using a 2-tailed t-tests both in aggregate and by individual rotation slot. Z-scores were also calculated for the average shelf exam scores by rotation slot.

Results:
Data from 424 students were included in the study. 214 students completed the IM clerkship before the surgery clerkship and 206 did not. Average undergraduate GPA, MCAT scores, and USMLE Step 1 scores were compared between the two groups, and no significant differences were found. In aggregate, average shelf exam scores of students who completed the IM clerkship prior to the surgery clerkship were significantly higher than those of students who did not (77.0% vs 73.8%, p value < 0.001). Additionally, average shelf exam scores for all students increased over the academic year. When the average shelf exam scores for the two groups were analyzed by rotation slot, no significant difference was found between the two groups (Table 1).

Conclusion:
When the shelf exam scores were analyzed in aggregate, students who completed the IM clerkship before the surgery clerkship scored higher on their surgery shelf exams. However, the surgery shelf scores were higher as the academic year progressed. Students who completed the surgery clerkship later in the academic year were more likely to have completed the IM clerkship already. When examining the two groups by rotation slot, we found no difference between the students who had already completed the IM clerkship and those who had not. These data suggest that students' scores on the surgery shelf exam are related to experience gained and are independent of the timing of the IM rotation in relation to the surgery rotation.
 

43.02 Utilization of Nurse Practitioners Improves Surgical Resident Education and ABSITE Scores

Posted on January 31, 2019

A. Hussain1, D. Golden1, S. Casos1, L. Mitchell1, S. Tsirgotis1, J. Ragan1, A. Pamula1, J. Miner1, B. Cagir1, R. Behm1  1Guthrie Clinic,General Surgery,Sayre, PA, USA

Introduction: The American Board of Surgery In Training Examination (ABSITE) is a proven marker for successful first time passing of both the qualifying and certifying general surgery board examinations. Resident work hour restrictions and protected didactic time limit the residents’ ability to perform clinical duties. Nurse practitioners (NPs) have been shown to positively impact patients’ outcomes and overall hospital costs when utilized on an Acute Care Surgery (ACS) service. We describe a model of adding NPs to a busy ACS service in order to protect resident didactic time and decrease resident work load thereby improving resident education and ABSITE scores.

Methods: With declining board pass rates in our general surgery residency program, a new educational model was created increasing protected didactic time four-fold and protecting an hour at the end of the day to finish all work prior to handoffs. The addition of 3 full and one part time NP allowed the ACS service to function nearly independent of residents. The NPs provided ICU, trauma activation and emergency general surgery coverage during resident protected time. They also absorbed some of the resident daily workload allowing the ACS service to focus on resident education rather than clinical responsibilities. ABSITE scores were evaluated before and after these changes.

Results: Only those ABSITE scores earned before and after the implementation of the program reform were included. Eleven residents’ scores met inclusion criteria. To analyze pre-and post-intervention ABSITE scores, we used a mixed model with time and level-of-training as fixed effects and each resident as a random effect. We showed that the effect of taking the test before or after the intervention was not significantly different between the levels of training; however, when simply controlling for the main effect of level of training, we showed a significant and similar increase in scores after the intervention for all levels of residents (standard score increased 77.3; p=0.001, percent correct increased 5.9; p=0.0023 and percentile increased 23.8 p=0.0229). Prior to the reform, 45% of the residents' ABSITE scores were below the 35th percentile putting them at risk of failing their board exams on the first try. After the reform, no residents were below the 35th percentile.

Conclusion: Utilization of NPs on an ACS service has previously shown to have a positive impact on patient outcomes and overall hospital costs. We have shown NPs are vital to a training program as they provide critical patient care coverage allowing the residents the time needed to learn and prepare for surgical board examinations. 

 

43.01 Use of Natural Language Processing to Interpret Resident Performance Evaluations

Posted on January 31, 2019

K. L. Abbott1, C. M. Harbaugh2, N. Matusko2, G. Sandhu2, P. G. Gauger2, J. V. Vu2  1University of Michigan Medical School,Ann Arbor, MI, USA 2University of Michigan,Department Of Surgery,Ann Arbor, MI, USA

Introduction: Residents receive feedback from performance evaluations in the form of quantitative scores and qualitative comments. Quantitative scores can quickly be compared with other numerical ratings, but they may lack adequate meaning and often show little variation over time. Qualitative comments may be highly specific, but it is difficult to recognize or analyze trends in comments dispersed across evaluations. We explored the use of natural language processing (NLP) to interpret qualitative data with the goal of generating high-yield, easily accessible feedback.

Methods: We examined faculty and peer evaluations for general surgery residents training at a single academic institution from 2008-2017. Evaluations assessed nine performance domains using rating scales and a free text field. NLP uses artificial intelligence to interpret language, and sentiment analysis is a type of NLP that extracts information related to opinions—for example, negative or positive feeling. We used the Google application programming interface for NLP to generate sentiment scores for qualitative evaluations. To characterize performance scales, we calculated Cronbach’s α and completed exploratory factor analysis. To ascertain the relationship between performance ratings and sentiment scores, we calculated a Pearson correlation coefficient. To graphically represent word frequency and sentiment score, we generated word clouds for an example resident.

Results: We analyzed 3,467 performance evaluations from 18 residents, averaging 192 evaluations per resident. The nine performance questions had high inter-item reliability (Cronbach’s α = 0.97). Exploratory factor analysis indicated that the nine domain questions measured a single construct. Averaged domain rating and evaluation-level sentiment score were weakly correlated (r = 0.36, 95% CI = 0.32-0.39, p < 0.001). The words “instruction” and “understanding” had negative sentiment in the PGY-1 word cloud, but did not appear in the PGY-5 word cloud. The word “leader” in the PGY-5 word cloud had a frequency of 5 and an average sentiment score of 0.54 (range 0-0.9), but did not appear in the PGY-1 word cloud.

Conclusion: Our results demonstrate that NLP can be used to process valuable qualitative information not captured by performance ratings. Thematic analysis of qualitative data is labor-intensive, but NLP facilitates rapid aggregation and visualization of qualitative data from multiple sources. These methods could be used to aggregate changing or contradictory information from multiple evaluations and present trainees with feedback that helps them identify strengths and specific areas for improvement.

20.21 Prospects and challenges of research in pediatric surgery in Nigeria

Posted on January 31, 2019

P. M. Mshelbwala1, O. O. Osagie1  1University of Abuja-Teaching Hospital,Department Of Surgery,Gwagalada, FCT, Nigeria

Background: Pediatric surgery is a relatively young speciality in Nigeria which is still evolving. Trainees must develop a research topic and defend a thesis as part of their final examination aimed at stimulating them to incorporate research into their clinical practice.

Aim: To review the potentials and current challenges in research faced by pediatric surgeons in Nigeria.

Materials and Methods: A review of data from the two regional postgraduate surgical colleges regarding thesis presented by pediatric surgeons and abstracts presented at annual scientific meetings of the national pediatric surgical association over a 15-year period was done. An online survey of pediatric surgeons using a semi-structured questionnaire was also carried out.

Results: Twelve thesis have been successfully defended in 14 years at the National Postgraduate Medical College of Nigeria (NPMCN). While the West African College of Surgeons (WACS) received 32 in four years. The Association of Pediatric Surgeons of Nigeria(APSON) had 599 abstracts presented at its annual scientific meetings from 2003 to 2017; an average of 40 per year.

The survey was sent to 142 of the 185 registered pediatric surgeons in Nigeria, out of which 68 responded, with more than 76% practicing in tertiary teaching hospitals.

In the last three years, 46 surgeons were involved in one to four research studies, 82.3% of which were observational and none clinical trials. Seven had not participated in any research. Institutional support for research was available to about 70% of the surgeons which comprised secretarial support(57.44%), funding(21.3%), protected time(13.2%), research assistants(10.6%) and provision of research mentorship(8.5%).

Factors hindering research included incomplete patients’ records, difficulty in accessing funds, limited internet access, lack of interest, inability to develop research collaborations, difficulty in publishing findings. Others were limited research capacity, dearth of ideas and lack of protected time.
Recommendations ranged from additional training on research methodology & grant writing, the use of electronic medical records (EMS), increased collaboration among pediatric surgeons to improved access to funding and journals.

Conclusion: The volume and quality of research in pediatric surgery in Nigeria is relatively low and the inclusion of a thesis into residency training has not translated into increased research clinical practice. Relevant institutional support may enhance the output and impact of research amongst pediatric surgeons.
 

« Previous Page
Next Page »