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

Posted on January 31, 2019

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

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

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

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

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

 

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

Posted on January 31, 2019

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

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

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

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

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

 

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

Posted on January 31, 2019

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

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

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

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

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

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

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

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

Posted on January 31, 2019

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

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

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

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

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

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

Posted on January 31, 2019

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

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

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

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

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

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

Posted on January 31, 2019

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

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

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

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

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

71.09 Effects of Mentorship Using Surgical Simulation For Economically Disadvantaged High School Students

Posted on January 31, 2019

T. P. Williams1, A. R. Wenholz1, T. S. Reynolds1, I. C. Okereke2  1University Of Texas Medical Branch,Department Of Surgery,Galveston, TX, USA 2University Of Texas Medical Branch,Division Of Cardiothoracic Surgery,Galveston, TX, USA

Introduction:
Economically disadvantaged (ED) high school students are less likely to graduate from high school and enroll at a college or university.  Our institution recently began a mentorship program, in which students participated in a structured career coaching program and then attended sessions in a surgical simulation laboratory.  Our goal was to determine whether the mentorship program affected the likelihood that these students would pursue formal education after high school.

Methods:
Students enrolled in an urban, ED high school who accepted an invitation to the program were given multiple lectures by one attending surgeon about college admission requirements, strategies to overcome potential socioeconomic and cultural obstacles and sources of funding for college tuition.  Thereafter the students were brought to the surgical simulation laboratory and participated in basic surgical skills such as knot-tying and laparoscopic simulation exercises.  The students were asked to complete an anonymous survey both before and after the program gauging their level of self-confidence and likelihood of attending a college or university after high school (Figure 1).  All participation was voluntary.

Results:
Twenty students participated in the program.  Eighty percent (16/20) were female.  Seventy percent (14/20) of students resided in a household with an income under $25,000.  Sixty-five percent (13/20) were Black/African American, and 35 percent (7/20) were Latino/Hispanic.  Upon completion of the program the average survey score increased significantly for having a major chosen for college (p = 0.04), feeling more prepared for the academic obligations of college (p = 0.02) and being interested in pursuing a career as a surgeon (p < 0.01).

Conclusion:
In-person mentorship can make high-risk students more likely to pursue education at a college or university.  Exposure to surgical simulation can raise students’ interests in a surgical career.  Further longitudinal studies are needed to see the effects that mentorship using surgical simulation can have on graduation rates and the probability of obtaining a degree at a college or university.
 

63.21 Surgeons Are Leaders in Healthcare. Are They Prepared for the Role?

Posted on January 31, 2019

D. R. Heller1, V. Kurbatov1, M. R. Freedman-Weiss1, G. Chao1, R. A. Jean1, P. S. Yoo1  1Yale University School Of Medicine,Surgery,New Haven, CT, USA

Introduction:  Surgeons function as team leaders on the wards, in the operating room, and at all levels of training and practice. Yet leadership skills are not an ACGME core competency, nor is leadership training a standard curricular requirement for residents. We explored resident perceptions and experiences with leadership to assess for unmet educational needs.  

Methods:  An anonymous survey was electronically distributed to all General Surgery residents at a university-affiliated hospital (Qualtrics Survey Software). Questions centered on perceptions and experiences around physician leadership in healthcare and formal leadership training. Leadership experiences were defined as participation in healthcare-related administrative roles or committees. Leadership training was defined as participation in symposia or conferences teaching leadership theory and skill-building.  

Results: Of 70 residents, 56 (80.0%) responded to the survey. Males comprised 57.1% and each post-graduate year 1–5 had majority representation, ranging from 68.8% – 100%. Almost all respondents, 98.2%, ranked physician leadership in healthcare as somewhat or very important vs. neutral or unimportant. A large majority, 87.3%, ranked leadership training during residency as somewhat or very important. Far less reported exposure to leadership experiences (37.0%), and less still reported receiving leadership training during residency (24.1%). Senior residents had significantly more exposure to leadership experiences (p=0.01) and training (p=0.01), and married residents with higher incomes saw a trend toward association with leadership experiences. Among those who received formal education, roughly half were trained by the hospital/university or external healthcare organizations; only 14.3% reported training by the residency program. When polled about the leadership style most often employed by surgical residents, a majority reported “pacesetting” (31.2%) and “commanding” (22.2%); the “visionary” and “affiliative” styles were least-often employed (7.4% and 9.3%, respectively). 

Conclusion: At a large academic surgical residency, nearly all residents perceive physician leadership in healthcare systems and formal leadership training as important. Yet roughly a third are exposed to leadership roles and a quarter to leadership training at a given point in residency. Since leadership development is not an ACGME requirement, opportunities for experience and education during residency may be lacking, and trainees may preferentially acquire a narrow band of skills rather than the balanced spectrum requisite for effective leadership. Hospitals and training programs should mind this educational gap and aim to expand opportunities for residents during the critical years of professional development. 

63.19 Effect of Operating Room Personnel Generation On Perceptions and Responses to Surgeon Behavior

Posted on January 31, 2019

J. G. Luc1, E. M. Corsini2, K. G. Mitchell2, N. S. Turner2, A. A. Vaporciyan2, M. B. Antonoff2  1University Of British Columbia,Cardiovascular Surgery,Vancouver, British Columbia, Canada 2University Of Texas MD Anderson Cancer Center,Thoracic And Cardiovascular Surgery,Houston, TX, USA

Introduction: As surgeons, we rely on allied health professionals in our day-to-day work in the operating room and care of patients; as such, it is imperative for us to learn about and embrace generational and sex-specific differences in their perceptions and responses to our behavior. The present study aims to study the effect of allied health respondent sex as stratified by generation on their perceptions and responses to various surgeon behaviors through five realistic intraoperative scenarios.

Methods: A prospective, randomized study was conducted in which operating room personnel were asked to assess surgeon operating room behavior across a standardized set of five scenarios via an online survey. For each scenario, respondents were asked to identify the behavior as either acceptable, unacceptable but would ignore, unacceptable and would confront the surgeon or unacceptable and would report to management. Chi-squared analyses were used to compare respondent assessment of surgeon behavior with respondent generation and sex. 

Results: The response rate was 4.4% (3101/71143) of which 41% of respondents were baby boomers (n=1280; 249 male, 1031 female), 31% were Gen X (n=955; 197 male, 758 female) and 28% were Gen Y (n=866; 130 male, 736 female). Overall tolerance of surgeon behavior by scenario is shown in the Figure. Baby boomer males were more likely to find it inappropriate and would report the surgeon compared to baby boomer females in regards to surgeon impatience in the operating room (Male 8.8% vs. Female 1.9%, p<0.001) and surgeon lateness for a case (Male 10.4% vs. Female 6.0%, p=0.013). Whereas baby boomer females were more likely to find surgeon swearing to be inappropriate and would report the surgeon (Male 24.1% vs. Female 32.0%, p=0.015). In terms of a surgeon forgetting a timeout, baby boomer females (Male 44.6% vs. Female 59.3%, p<0.001) and Gen X females (Male 40.1% vs. Female 54.2%, p<0.001) were more likely to find it inappropriate and would talk to the surgeon directly than males. Baby boomer females were also more likely to find surgeon shouting in the operating room in a crisis to be inappropriate but would let it go when compared to baby boomer males (Male 9.6% vs. Female 17.1%, p=0.004). 

Conclusion: Results of our prospective randomized study demonstrate that operating room respondent generation and sex affects their perceptions and response to surgeon behavior. Awareness of generational and sex-specific differences in perceptions of surgeon behavior is key to improving the intraoperative environment for all. 

 

63.18 Beyond Donate Life: Utilization and Re-perfusion of Unused Organs for Simulation and Education

Posted on January 31, 2019

S. M. Wrenn1, S. R. Russell1, M. N. Barnett1, F. Hirashima1, C. E. Marroquin1  1University Of Vermont College Of Medicine / Fletcher Allen Health Care,The Robert Larner College Of Medicine,Burlington, VT, USA

Introduction: It is imperative that trainees obtain adequate surgical skills for independent practice. However, autonomy must be balanced with patient safety. Simulation has become a popular method of developing competency-based curriculums. Unfortunately, simulation often (whether cadaveric or synthetic) lacks the fidelity and realism of true operative tissue.

Methods: Solid abdominal and thoracic organs (heart, lung, kidney, pancreas, and liver) deemed unsuitable for transplantation were provided for simulation and research. Organs were kept fresh and then re-perfused using a roller pump-based perfusion circuit with pigmented blood substitute. Organs were sewn in-line to create a closed loop circuit. Residents and medical students participated in multiple workshops designed to improve surgical techniques, including transplant-based interventions. These educational sessions were led by attending surgeons from both cardiothoracic, abdominal organ transplant, and hepato-biliary services. Residents and medical students were queried on their perceptions of the workshop after completion via electronic survey.

Results:Multiple simulations were attended over a 12-month period. Skills performed included vena cava, portal vein and hepatic arterial anastomosis and dissection. Hepatic “re-animation” was followed by cholecystectomy, biliary dissection, and hepatic resection. Residents performed renal allograft anastomosis and vessel repair. Superior mesenteric and portal veins were sewn into a closed circuit and the “pancreatic tunnel” developed to allow division of the pancreatic neck. Finally, coronary artery bypass and aortic valve replacement was performed.

Of the 17 responding residents or students surveyed, 9 had participated in the workshops (22% medical students, 11% intern, 22% junior residents, and 44% senior residents). Participants rated the workshops as valuable and more realistic than traditional cadaveric or synthetic based simulation workshops. Respondents rated tissue fidelity and realism as 8 out of 10 (range, 6-9). 100% of participants reported that the simulations improved their operative skills, that they would attend further sessions, and that the sessions were a valuable use of the organs.

Conclusion: Use of fresh solid organs unfit for transplantation provides an opportunity for operative simulation of high fidelity and quality. There remains a large national opportunity to integrate these organs into surgical education. This proof of concept study demonstrates a novel means of creating realistic and reproducible surgical education for improvement in educational paradigms while allowing surgical educators to preserve the public trust by ensuring residents are ready to operate on living patients.
 

63.17 How Many Clicks Does It Take to Get to the Center of a Department-wide Wellness Initiative

Posted on January 31, 2019

M. E. Hadley1, A. Coughlan1, J. G. Chipman1, C. J. Tignanelli1,2,3  1University Of Minnesota,Department Of Surgery,Minneapolis, MN, USA 2University Of Minnesota,Institute For Health Informatics,Minneapolis, MN, USA 3North Memorial Health Hospital,Department Of Surgery,Minneapolis, MN, USA

Introduction:
Burnout is a public health crisis that affects over 50% of healthcare providers and results in adverse patient outcomes, poor physician job satisfaction, depersonalization, and increased rates of depression, substance abuse, and physician suicide. Our institution developed a unique Department of Surgery wellness program to combat this issue, reduce stress, and promote wellbeing. The aim of this study was to evaluate user interaction with our program vis-à-vis a monthly newsletter as a dissemination tool.

Methods:
Our wellness program is sponsored by the Department of Surgery Wellness Committee and includes the following regular activities: chair yoga, wellness walks, photography club, craft lunch, visiting seasonal farmers market and music on the plaza, sitcom break, and themed potlucks. Additionally, it includes wellness insights from faculty and opportunities to participate in University of Minnesota fundraisers such as the annual Turtle Derby or Chainbreaker events. A regular wellness newsletter was developed to disseminate this program which is sent to Department of Surgery housestaff, faculty, and staff, with approximately 350 subscribers. Mailchimp® (marketing automation platform, Atlanta, GA) was used to evaluate subscriber interaction with the newsletter from April, 2017 – July, 2018. Interactions were defined as the number of subscribers opening each newsletter and the number of subscribers who clicked on linked content within the newsletter. The Mailchimp® industry average for health and fitness newsletters was used a reference standard.

Results:
The average number of subscribers who opened the newsletter each month was 178, or 51% compared to the industry average of 16% (Table 1). There was an average of 18 subscribers clicking content per newsletter. Thus, of the people who received the newsletter, 5% of subscribers opened and then clicked for further content. This is higher than the industry average of 2%. All employee types equally opened the newsletter; however, staff were most likely to click individual content within each newsletter.  

Conclusion:
A wellness newsletter is an effective tool to disseminate a wellness program within a Department of Surgery and is interacted with more than the industry average. Future directions should focus on identifying ways to further improve interaction with and better integrate surgical wellness programs for faculty and housestaff. A wellness newsletter may be an important way to reach healthcare workers who are at risk for burnout.
 

63.15 Trends in Medical Education Research: A Look at Abstracts from the Academic Surgical Congress

Posted on January 31, 2019

M. Mankarious1,2, E. Palmquist1, L. Chen1  1Tufts Medical Center,Department Of Surgery,Boston, MA, USA 2Tufts University School of Medicine,Boston, MA, USA

Introduction:

Medical education research is a quickly growing field of interest that has attracted many brilliant minds over the last decade that address this multifaceted landscape. With the surgical educational environment undergoing many significant changes, new topics emerged with increasing trends and interesting results. In this study, we utilize available abstracts from Academic Surgical Congress (ASC) over the past years to examine emerging topics and trends in medical education research.

Methods:

ASC abstracts over the past four years were obtained from the ASC website. University and state affiliation of the first author for each abstract was collected. Abstracts were categorized according to topic (Curriculum/Teaching, Innovations, Assessment, Program Evaluation, Wellbeing/Burnout, and Miscellaneous) and design (Descriptive, Test Assessment, Relational, and Qualitative) based on previously published categories. Miscellaneous topics were recategorized based on theme.

Results:

A total of 429 abstracts were obtained from previous four ASC meetings. 405 abstracts were from within the United States and 24 from other countries. 29.6% of abstracts within the USA came from Wisconsin, Illinois, California, and Texas.

Overall number of abstracts nearly doubled from 77 in 2015 to 140 in 2018. Descriptive studies were the most common research design (41%), followed by test assessment (20%), qualitative (18%), relationship (18%), and experimental (3%). Annual topic proportions were considerably stable with 21% curriculum and teaching, 26% technical and performance assessment, 6% wellbeing and burnout, and 5% program evaluations. 33% of the abstracts belonged to the miscellaneous category. Of the miscellaneous, most common topics addressed Global Health (19.15%) and Gender/Race (14.18%). Remainder of miscellaneous topics included personality traits of students, residents, and surgeons, experience and overall trends in practice, impact and utilization of social media, resident work-hour limits, and financial questions in surgical training.

Conclusion:
Research into medical education is a transforming and evolving field. Since 2000, there has been an increasing number of studies as well as new prominent topics that are more relevant to the current educational environment. Up to date knowledge of these current topic trends in medical education may inform future research. For instance, the increasing trend towards evaluating and restructuring global health programs points to the increasing prevalence of the topic to residency programs as it becomes an integrated aspect of many residency programs. Similarly, research regarding gender and racial inequalities in the surgical environment points to the changing landscape and the importance of creating a more inclusive environment. 

63.14 Educating Surgeons on Skills in Outpatient Communication

Posted on January 31, 2019

S. E. Raper1, J. Joseph1  1University Of Pennsylvania,Quality And Risk Management/Surgery/Medicine,Philadelphia, PA, USA

Introduction: Good communication remains a keystone of patient care, yet there is a dearth of literature on educating surgeons in this critical element. With the shift to progressively more care in the outpatient setting, skills specific to outpatient communication have assumed greater importance. We hypothesized that a short course in outpatient communication for academic surgical faculty could be presented with high levels of participation and satisfaction.

Methods: Four separate courses (general, cardiac, plastics, urology) were taught to maximize attendance and provide particularized data. The course first introduced topics important to the health system: evolution of the physician practice plan and patient satisfaction initiatives. The status of transparency initiatives with respect to Consumer Assessment of Healthcare Providers and Systems (CAHPS) satisfaction survey scores was amplified with the ranked data for each individual departmental surgeon. Also the Centers for Medicare and Medicaid Services Merit-based Incentive Payment System (MIPS). Next, benefits of and barriers to good communication were discussed. This material was augmented by use of a short video clip simulating patient interactions serving to sharpen communication skills. Lastly, of the many options for improving physician communication skills, we focused on the critical role of listening.

Results:A voluntary, anonymous six question Likert-type survey assessed participant satisfaction: Q1) Goals were clearly communicated; Q2) Practice plan information was instructive; Q3) CAHPS & MIPS- information was instructive; Q4) Public reporting and transparency information was instructive; Q5) Benefits of good communication was instructive; Q6) Listening as a critical communication skill was valuable. 84/105 (80%) faculty participated and 54% returned the survey. Survey, questions 1, 4, 5, 6 all had responses ≥ 4.5. For Q2 & Q3, the average was <4.5. For Q2, the average was statistically significant by t-test (Table).

Conclusion:Turnout was robust, mediated in part by using regularly scheduled, conflict-free educational slots and provision of CME credit where possible. Satisfaction was high, with the benefits of good communication and material on listening given the highest and material on changes in the practice plan and CMS reimbursement given the lowest scores. The data suggest that focusing specifically on direct communication strategies may be better received. Our experience in course development for teaching outpatient communication highlights an important topic in contemporary surgery, and can be readily expanded to any surgical program with material that is relevant to all, yet particularized with institution and surgeon-specific data.

 

63.13 Objective Assessment of General Surgery Trainee Performance

Posted on January 31, 2019

Y. N. AlJamal1, D. R. Farley1  1Mayo Clinic,Rochester, MN, USA

Introduction:

While surgical educators have a variety of options to evaluate trainees’ surgical skills, program directors have historically used operative case volume as the gold standard of operative competence1. Given better objective assessments of skills competency, we reviewed the current literature on the use of objective tools to assess general surgery trainees’ skills competency.

Methods:

A literature review (2000-2017) in PubMed using keywords (objective assessment, surgery, and competence) was conducted. The methodologies of the assessment tools are examined.

Results:

A total of 420 publications were identified. Only 39 papers focused on the objective assessment of surgical trainee performance in general surgery. Of these 39, 26 assessed open surgical skills, 11 looked at laparoscopic skills and 2 assessed both skills. Most open (57%) and laparoscopic (81%) skill assessments used objective structured assessment tools. Assessment using simulation options did occur: open skills = 65%, laparoscopic = 27%. Publications focusing on actual competency (12%) were less common.

Conclusion:

Publications involving objective assessments of general surgery trainee skills competency is varied: open skills assessment predominates with most occurring in a simulated setting; laparoscopic assessment is more prevalent in the operating room. Defining actual competency is uncommon and suggests further efforts are needed to better evaluate general surgery trainee performance.

 

63.12 Acceptance of Xenotransplantation Among Nursing Students

Posted on January 31, 2019

W. Paris1, L. Padilla2, Z. Aburjania6, R. Bgainer3, K. Jang1, D. Cleveland6, Y. Lau4, S. Floyd6, D. Mauchley6, R. Dabal6, D. K. Cooper5  1Abilene Christian University,School Of Social Work,Abilene, TX, USA 2University Of Alabama at Birmingham,Department Of Epidemiology,Birmingham, Alabama, USA 3Texas Tech University Health Sciences Center,School Of Nursing,Lubbock, TX, USA 4University of Alabama at Birmingham,Division Of Pediatric Cardiology,Birmingham, AL, USA 5University Of Alabama at Birmingham,Department Of Surgery, Xenotransplant Program,Birmingham, AL, USA 6University Of Alabama at Birmingham,Department Of Surgery, Division Of Cardiothoracic Surgery,Birmingham, AL, USA

Introduction: Organ donation rates have not kept pace with the global incidence of end-stage organ failure. Given recent experimental progress, xenotransplantation (XTP; i.e., pig to human) has the potential to provide an unlimited supply of donor organs, but will present with many challenging public health issues for consideration. The objective of the study was to identify and report the most recent information relevant to XTP clinical trials; and report initial acceptance about the procedure.

Methods: A cross-sectional study among 70 nursing students from a large mid-western public university was conducted (July, 2017). An email was forwarded with a 35 item survey developed by the research team using a weblink after online consent.

Results: Regression analysis found that their willingness to consider receiving a XTP was being an organ donor themselves (p<0.01).  Only 7% were aware that pig donors must be genetically modified (to prevent rejection) before they could be used as sources of organs for transplantation into humans.  Wilcoxon Rank-Sum procedures found that anticipation of poorer medical outcomes with XTP (when compared to than human organ donation) was significantly associated with greater concern about potential psychosocial sequlae (p<0.01). 

Conclusion: The most commonly related factors towards acceptance of XTP among healthcare professionals were being an organ donor, and the expectation of positive medical results.  Findings suggest that even among healthcare professional’s knowledge of the process and immunology is limited.  The findings highlight the need to increase knowledge and awareness of XTP among healthcare professionals as an incremental step in public education and preparation for clinical trials.  

 

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.

 

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