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.

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

Posted on January 31, 2019

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

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

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

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

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

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

Posted on January 31, 2019

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

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

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

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

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

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

Posted on January 31, 2019

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

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

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

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

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

 

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

Posted on January 31, 2019

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

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

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

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

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

 

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

Posted on January 31, 2019

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

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

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

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

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

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

Posted on January 31, 2019

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

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

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

Results: 

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

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

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

62.14 Smartphone Use as an Educational Tool for Trainees

Posted on January 31, 2019

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

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

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

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

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

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

Posted on January 31, 2019

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

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

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

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

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

62.12 Gender Representation in Pediatric Surgery Authorship

Posted on January 31, 2019

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

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

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

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

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

 

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

Posted on January 31, 2019

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

Introduction:

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

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

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

 

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

 

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

Posted on January 31, 2019

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

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

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

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

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

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

Posted on January 31, 2019

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

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

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

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

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

 

62.08 Prospective Cohort Study of Burnout in General Surgery Residents

Posted on January 31, 2019

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

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

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

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

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

 

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

Posted on January 31, 2019

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

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

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

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

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

 

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

Posted on January 31, 2019

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

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

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

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

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

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

Posted on January 31, 2019

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

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

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

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

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

62.04 Provider Education Decreases Opioid Prescribing After Pediatric Umbilical Hernia Repair

Posted on January 31, 2019

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

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

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

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

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

 

62.03 Gender Differences within Surgical Fellowship Program Directors

Posted on January 31, 2019

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

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

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

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

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

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

Posted on January 31, 2019

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

Introduction:

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

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

Results:

In all four conferences over the 5-year period:

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

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

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

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

During the review period, the percentage of female:

·  moderators increased from 19.5% to 26.7%.

·  invited speakers increased from 23.25% to 32.7%. 

·  abstract presenters increased from 17.8% to 27.3% and

· poster presenters increased 24.5% to 36.9%.

 

Conclusion:

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

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