62.01 Trends in Gender Representation at the Academic Surgical Congress

Posted on January 31, 2019

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

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

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

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

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

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

58.18 Pneumoretroperitoneum with Subcutaneous Emphysema after a Post Colonoscopy Colonic Perforation

Posted on January 31, 2019

S. Jaafar1, S. Hung Fong1, S. Misra1,2, K. Chavda1  1Brandon Regional Hospital,GME – Surgery,Brandon, FL, USA 2HCA,West Florida,Tampa, FL, USA

Introduction: Colonoscopy is considered one of the most commonly performed procedure for both diagnostic and therapeutic purposes. However, serious complications such as bleeding, and much rarely, colonic perforation can still occur at a rate of 0.03-0.8% Colonic perforation can be classified as intraperitoneal, extraperitoneal or a combination of both. Majority of the perforations are intraperitoneal, while extraperioneal perforations can manifest as pneumoretroperitoneum, pneumomediastinum, pneumothorax and/or subcutaneous emphysema. We report a rare case of post colonoscopy colonic perforation presenting with peritonitis, pneumoretroperitoneum and subcutaneous emphysema.

 

Methods: A case report was described of a 80-year-old female who underwent a routine colonoscopy and presented with colonic perforation associated with pneumoperitoneum, pneumoretroperitoneum, and subcutaneous emphysema and surgically treated with Hartmann procedure. Related articles were searched through Pudmed, Google Scholar and Cochrane and a review of literatures regarding risk factors; most common site of perforation and the mechanism of perforation; the difference of manifestations and management approach between intraperitoneum and extraperitoneum.

 

Results: Some of the risk factors include advance age, female sex, diverticulosis, previous abdominal surgery and colonic strictures. The most common site of perforation is the sigmoid colon followed by the cecum due to shearing forces applied during endoscopic insertion during dilation, biopsy and/or resection. Majority of the perforation are intraperitoneal, but extraperitoneal can manifest in the mediastinum, pleura, scrotum and subcutaneous tissue. 60% of the combined intraperitoneal and extraperitopeal perforations were treated surgically, while 75% of the isolated extraperitoneal perforation were treated conservatively.

 

Conclusion: Colonoscopy is considered the gold standard for screening colorectal cancer and is useful in the workup of many gastrointestinal conditions, but complication associated with colonic perforation is rare that can manifest intraperitoneal, extraperitoneal or a combination of both. Majority of the intraperitoneal perforation warrant a surgical intervention whereas isolated extraperitoneal perforation can mostly be managed conservatively. Understanding the manifestation of extraperitoneal perforation will help us properly identify the associated morbidities and preventing mortality in these patients.

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

Posted on January 31, 2019

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

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

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

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

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

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

Posted on January 31, 2019

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

Introduction:

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

Methods:

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

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

Results:

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

Conclusion:

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

 

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

Posted on January 31, 2019

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

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

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

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

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

 

43.07 Correlation between Altmetric Score and Citations in Pediatric Surgery

Posted on January 31, 2019

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

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

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

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

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

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

Posted on January 31, 2019

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

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

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

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

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

43.05 Assessing Knowledge of Biostatistics Among Residents and Medical Students

Posted on January 31, 2019

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

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

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

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

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

 

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

Posted on January 31, 2019

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

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

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

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

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

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

Posted on January 31, 2019

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

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

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

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

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

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

Posted on January 31, 2019

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

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

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

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

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

 

43.01 Use of Natural Language Processing to Interpret Resident Performance Evaluations

Posted on January 31, 2019

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

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

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

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

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

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

Posted on January 31, 2019

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

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

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

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

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

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

Posted on January 31, 2019

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

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

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

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

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

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

Posted on January 31, 2019

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

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

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

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

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

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

Posted on January 31, 2019

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

Introduction:

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

Methods:

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

Results:

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

Conclusion:

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

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

Posted on January 31, 2019

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

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

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

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

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

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

Posted on January 31, 2019

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

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

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

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

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

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

42.04 Evaluating Factors Affecting Surgical Grand Rounds Attendance:

Posted on January 31, 2019

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

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

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

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

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

 

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

Posted on January 31, 2019

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

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

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

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

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

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