42.02 The Effect of Gender on Operative Autonomy in General Surgery Residents

Posted on January 31, 2019

S. L. Meyerson1, D. D. Odell1, J. B. Zwischenberger2, M. Schuller1, J. D. Bohnen4, G. L. Dunnington3, L. Torbeck3, J. T. Mullen4, S. P. Mandell5, M. A. Choti6, E. Foley7, C. Are8, E. Auyang9, J. Chipman10, J. Choi3, A. Meier11, D. S. Smink12, K. P. Terhune13, P. E. Wise14, N. Soper1, K. Lillemoe4, J. P. Fryer1, B. C. George15  1Feinberg School Of Medicine – Northwestern University,Department Of Surgery,Chicago, IL, USA 2University Of Kentucky,Department Of Surgery,Lexington, KY, USA 3Indiana University School Of Medicine,Department Of Surgery,Indianapolis, IN, USA 4Massachusetts General Hospital,Department Of Surgery,Boston, MA, USA 5University Of Washington,Department Of Surgery,Seattle, WA, USA 6Banner MD Anderson Cancer Center,Department Of Surgery,Gilbert, AZ, USA 7University Of Wisconsin,Department Of Surgery,Madison, WI, USA 8University Of Nebraska College Of Medicine,Department Of Surgery,Omaha, NE, USA 9University Of New Mexico HSC,Department Of Surgery,Albuquerque, NM, USA 10University Of Minnesota,Department Of Surgery,Minneapolis, MN, USA 11State University Of New York Upstate Medical University,Department Of Surgery,Syracuse, NY, USA 12Brigham And Women’s Hospital,Department Of Surgery,Boston, MA, USA 13Vanderbilt University Medical Center,Department Of Surgery,Nashville, TN, USA 14Washington University,Department Of Surgery,St. Louis, MO, USA 15University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA

Introduction: Despite an increasing number of women in surgery, bias regarding cognitive or technical ability may continue to impact the experience of female trainees differently than their male counterparts. The goal of this study is to examine differences between the degree of operative autonomy given to female and male surgical trainees.

Methods: A smartphone app was used to collect evaluations of operative autonomy measured using the 4-point Zwisch scale, which describes defined steps in the progression from novice (“Show and Tell”)  through increasing degrees of autonomy (“Active Help” to “Passive Help”) to competent to enter practice (“Supervision Only”). Autonomy was evaluated from both the faculty and resident perspectives. Differences in autonomy between male and female residents were compared using hierarchical logistic regression analysis.

Results: 412 residents and 524 faculty from 14 general surgery training programs evaluated 8900 cases over a 9 month period. Female residents received meaningful autonomy from faculty (“passive help” or “supervision only”) in 46.7% of cases (1053/2253) while male residents received meaningful autonomy in 52.7% of cases (1906/3614, p<0.001). Resident level of training and case complexity were the strongest predictors of autonomy. Even after controlling for potential confounding factors including level of training, intrinsic procedural difficulty, patient-related case complexity, faculty gender, and training program environment, female residents still received less operative autonomy than their male counterparts. The gap between autonomy granted to male and female residents was present from both the faculty and resident perspectives. The largest discrepancy was in the fourth year of training and both male and female faculty surgeons granted less autonomy to female residents.

Conclusion: There is a gender-based difference in the autonomy granted to general surgery trainees. This gender gap may affect female residents’ experience in training and possibly their preparation for practice. Strategies need to be developed to help faculty and residents work together to overcome this gender gap.

 

42.01 Surgical Trainees’ Sense of Responsibility for Patient Outcomes: A Multi-Institutional Appraisal

Posted on January 31, 2019

R. W. Randle1, S. L. Ahle2, D. M. Elfenbein5, A. N. Hildreth4, J. A. Greenberg3, P. J. Schenarts7, J. W. Kempenich6  1University Of Kentucky,Department Of Surgery,Lexington, KY, USA 2Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA 3University Of Wisconsin,Department Of Surgery,Madison, WI, USA 4Wake Forest University School Of Medicine,Department Of Surgery,Winston-Salem, NC, USA 5University Of California – Irvine,Department Of Surgery,Orange, CA, USA 6University Of Texas Health Science Center At San Antonio,Department Of Surgery,San Antonio, TX, USA 7University Of Nebraska College Of Medicine,Department Of Surgery,Omaha, NE, USA

Introduction:
Surgeon educators express concern about their current ability to impart a strong sense of patient ownership to trainees. We hypothesized that surgical residents’ sense of patient ownership would be associated with their perceived autonomy and other modifiable factors in the modern training environment. We aimed to compare resident and faculty perceptions on residents’ sense of personal responsibility for patient outcomes and to correlate patient ownership with resident and residency characteristics.

Methods:
An anonymous electronic questionnaire surveyed 373 residents and 390 faculty at 7 academic surgery residencies across the U.S. We used a modified version of a validated psychologic ownership scale to measure patient ownership among surgical trainees.

Results:
Respondents included 123 residents and 136 faculty (response rate 33% and 35%, respectively). Overall, 91.1% of resident respondents agreed that faculty modeled strong patient ownership, and 78.0% of faculty agreed that residents took personal responsibility for patient outcomes. 75.6% of residents perceived they felt a similar or higher degree of patient ownership than their faculty, but only 26.4% of faculty agreed. Faculty underestimated the proportion of residents that routinely checked on their patients when “off-duty” or “off-service” (36.8% vs 92.6% per resident report (p<0.001). Faculty and residents perceived that greater operative autonomy provided residents with a higher level of ownership (Figure). Almost all faculty (97.8%) reported providing more autonomy to residents who display strong patient ownership, but only 53.7% provide more autonomy in order to increase ownership.
Higher means on the patient ownership scale correlated with female sex (5.9 vs. 5.5 for males, p=0.009) and advanced PGY level (5.3, 5.5, 5.7, 5.8, 6.1, for PGY1-5, respectively, p=0.02). Additionally, residents who reported that patient outcomes affected their mood when off-duty achieved higher ownership means than those who claimed outcomes did not affect their mood (5.8 vs 4.8, p<0.001). Trainees who perceived better resident camaraderie (p=0.004), faculty mentorship (p<0.001), and that their program provided an appropriate degree of autonomy (p=0.03) felt greater responsibility for patient outcomes.

Conclusion:
Most faculty agree that residents assume personal responsibility for patient outcomes, but many still underestimate residents’ sense of patient ownership. Certain modifiable aspects of residency culture including camaraderie, mentorship, and autonomy are associated with patient ownership among trainees.
 

20.20 The Impact of Gender on Resident Operative Experience

Posted on January 31, 2019

L. Gade1,2, A. Watkins1, H. Yeo1  1Weill Cornell Medical College,Surgery,New York, NY, USA 2New York Hospital Queens,Surgery,Flushing, NY, USA

Introduction:  Studies assessing the practice patterns of attending surgeons have demonstrated gender based differences in subspecialty choice for surgeons who pursued fellowship and gender differences in the types of cases performed by general surgeons who did not pursue fellowship. It is possible that gender disparities in practice patterns at the attending level may be driven by exposure and experience at the resident level. However, gender differences in resident operative exposure have not been studied. In this study, we compare differences in case volume and case type based on resident gender.

 

Methods:  The cumulative 5 year ACGME resident case logs for all general surgery residents who completed training between 2015-2016 at two different surgery programs were obtained. 13 residents, 2 women and 11 men, were included. Cases were subdivided into 17 categories including 16 ACGME categories plus all cases labeled “Not for major credit” by assigning each current procedural terminology (CPT) code to one ACGME category using the ACGME’s “Tracked Codes Report”. CPT codes that fell under more than one category were assigned to one category. CPT codes from “Nonoperative Trauma” and “Critical Care” categories were removed. Total number of cases and cases performed in individual categories were stratified by gender. T-test and chi square were used where appropriate.

Results: Among the 13 residents, 16,414 cases were performed. There was no significant difference in the number of cases performed by men and women (1,285 +/- 188 vs 1,137 +/- 119, p=.156). Women performed significantly more breast (11.13% vs 7.31%, p<0.05) and endocrine (6.16% vs 2.70%, p<0.05) cases while men performed significantly more alimentary tract (10.32% vs 8.53%, p<.05), abdomen (14.9% vs 12.5%, p<.05), and vascular (8.39% vs 6.11%, p<.05) cases.

Conclusion:This pilot study demonstrates that while the volume of cases that male and female residents perform is similar, breast and endocrine cases comprise a significantly higher percent of female residents’ case volume while alimentary tract, abdomen, and vascular cases comprise a significantly higher percent of male residents’ case volume. Because their exposure is different than that of their male colleagues, this may affect female fellowship choice, confidence in underexposed subspecialties, and ultimately, career trajectory.  Poor representation of women attendings in multiple general surgery subspecialties may deferentially impact trainees’ access to role models and may perpetuate stereotypes and bias in general surgery. The gender difference in case distribution seen in this study may also be related to the underrepresentation of women attendings in multiple subspecialties. We are working to expand this pilot study on a larger scale to be more representative. Further research must be done on a national level to assess gender equity in surgical training.
 

20.19 Perioperative Educational Time Out: Building an Educational Framework

Posted on January 31, 2019

M. M. Esquivel1, I. Wapnir1, R. Yang1, M. L. Melcher1  1Stanford University,General Surgery,Palo Alto, CA, USA

Introduction:  

We previously introduced an Educational Time Out (ETO) tool to promote discussions between attendings and trainees about the patient presentation, indications for surgery and surgical plan immediately before an operation. Our goal was to build on the pre-operative ETO and to develop a post-operative ETO to encourage immediate feedback and promote discussions on post-operative considerations. The aim was to expand the perioperative educational framework. 

Methods:  

A working group of two attendings and two general surgery residents at our institution was formed. The group met with faculty and residents of several surgical specialties and asked open-ended questions regarding their opinions on important elements to be included in a Pre- and Post-Operative ETO. These interviews were completed from March to July 2018. The working group summarized and prioritized concepts from the interviews and developed a pre-operative ETO with specifics for several surgical specialties and cases, and a post-operative ETO to be used across all specialties.

Results: T

he pre-operative ETO that was developed is represented by the PREDICT mnemonic. PREDICT stands for Presentation, Risk factors, Examination findings, Diagnosis/Differential, Incision/Intraoperative steps, Concerns, and Treatment. The post-operative ETO developed is represented by the COPE mnemonic, which stands for Closure, Operation, Performance, and Extension of care. Specific PREDICT characteristics for three surgeries were defined, as well as a detailed description of COPE, and are presented here (Table 1).

Conclusion: 

We believe educational time outs, both pre- and post-operatively, should be a part of every surgical case. Education Time Outs not only promote communication between attendings and trainees, but they also foster resident education. Faculty can use PREDICT and COPE to provide a formal educational framework that reinforces key learning elements for trainees. These ETO models are simple and specific tools residents can use to organize their preparation for each surgical case. More research is needed to measure the impact of ETO use at our institution, with an implementation and control group.

 

20.18 Twitter as tool for Departments of Surgery: What is the role for Program Directors?

Posted on January 31, 2019

H. J. Logghe1, A. Salles2, K. A. Chojnacki1, C. J. Yeo1, R. Aggarwal1  1Thomas Jefferson University,Surgery,Philadelphia, PA, USA 2Washington University,Surgery,St. Louis, MO, USA

Introduction: Social media, Twitter (Twitter, Inc., San Francisco, CA) in particular, plays an increasingly influential role in academia and surgical education. Many surgical departments now have Twitter accounts, some with separate accounts for departmental divisions and residency programs. In this capacity, Twitter is used to develop departmental brands, celebrate departmental achievements, and disseminate science pioneered by faculty and residents. Currently few institutions measure social media activity for academic promotion and expectations of program directors to represent their programs on Twitter and other social media remain ambiguous.

Methods:  At Surgical Education Week 2018, an in-person workshop on Twitter use for surgery residency programs was held. Topics covered included 1) The importance of a strategic Twitter presence for program directors and residency programs, 2) Initial steps in establishing Twitter accounts as a program director and on behalf of the residency program, and 3) Strategies used to effectively develop a brand on social media for the purposes of enhancing program reputation and recruitment. At the close of the session, a survey was disseminated to all participants.

Results: Seventeen of 25 attendees completed the survey. Twelve of 17 respondents reported a personal Twitter account; 7/15 respondents reported a departmental Twitter account. Eight of ten respondents reported institutional social media guidelines. The majority of respondents strongly agreed residency programs should have a social media presence (1 = Strongly Disagree to 5 = Strongly Agree; mean 4.29, SD 0.81) and that program branding is part of the program director's role (mean 4.57, SD 0.59). Five of 15 respondents reported feeling well-equipped to fulfill that role. When asked “What are the three greatest challenges to successful residency program social media use?” responses fell into four categories: time (16); content, confidentiality and professionalism (14); institutional support (7); and inexperience (4). Key results are shown in the table.

Conclusion: The majority of program directors reported a personal Twitter account and just under half of their respective programs had departmental Twitter accounts. While the majority of respondents believed program branding is part of the program director's role, only one third felt equipped to fill that role. Respondents rated social media as a useful tool to increase dissemination of departmental research and to increase the number of program applicants. Future research should explore effective social media strategies to disseminate departmental research, promote positive branding, and reach potential users.

 

20.17 Incoming Residents’ Knot Tying and Suturing Skills: Are Medical School Boot Camps Sufficient?

Posted on January 31, 2019

R. McMillan1, P. Redlich1, R. Treat1, M. Goldblatt1, T. Carver1, C. M. Dodgion1, Z. Prewitt1, J. R. Peschman1, C. Davis1, J. Grushka2, T. Krausert1, L. Olson1, B. Lewis1, M. J. Malinowski1  1Medical College of Wisconsin,Surgery,Milwaukee, WI, USA 2McGill University Health Centre,Montreal, QUEBEC, Canada

Introduction:
Many medical schools offer M4 boot camps to improve student’s preparedness for residency. Significant faculty effort is expended in the design and teaching fundamental surgical skills in these courses. For three consecutive years, we studied the knot tying and suturing skills of incoming residents as part of a multi-day orientation program. We evaluated the impact of medical school boot camps on intern knot tying and suturing skills when measured at the start of residency.

Methods:
42 interns completed questionnaires over three-consecutive years regarding their M4 boot camp experiences.  In June of 2016-2018, interns were evaluated on suturing (18 one-point items), knot tying (16 one-point items), overall performance (1 five-point item, 5=high), and quality (1 five-point item) by three surgeons, blinded to the questionnaire results, using modified assessment forms published by the APDS/ACS for OSATS and global rating evaluation.  Descriptive statistics are reported with means (Mn) and standard deviation (s).  Scores were compared based on length of boot camp (≤ 10 days vs > 10 days), hours of supervised instruction (≤ 5 hours vs > 5 hours), and annual hours dedicated to practice of suturing and knot tying skills (≤ 10 hours vs > 10 hours).  The association of skills is reported with Spearman rho (SpR) correlations and inter-rater reliability determined by intraclass correlation coefficients (ICC). Analysis generated with IBM® SPSS® 24.0.

Results:

Over three years, 26 of 42 (62%) interns reported boot-camp training. In comparing groups with and without training, scores in suturing (9.6(4.6) vs 9.8(4.1), p<0.908), knot tying (9.1(3.6) vs 8.4(4.1), p<0.574), overall performance (2.0(0.6) vs 1.9(0.7), p<0.424), and quality (2.0(0.6) vs 1.9(0.7), p<0.665) demonstrated no statistical significance.  All six pairwise correlations of the four skill evaluations were significant (SpR range=0.75-0.95), p<0.001), and ratings were consistent (ICC(2,1)=0.23-0.63, p<.002).  There was no significant difference in any of the four assessment scores when split by completion of boot camp, length of boot camp, hours of supervised instruction, or hours dedicated to practice.

Conclusion:
Our study could not demonstrate a statistically significant benefit in knot tying and suturing skills of students who enroll in M4 boot camp courses as measured at the start of residency. However, suturing and knot tying ratings were strongly related to each other and overall quality and performance. This finding indicates that faculty are evaluating consistent levels of suturing and knot tying skills for each intern, and that the skills are strong indicators of overall performance.  Residency programs should be prepared to teach these skills to their entering residents. Further study is warranted to evaluate the benefit of boot camps on other technical skills of incoming residents.
 

20.16 The Cost of Integration of Robotic Surgery Training in the Curriculum of General Surgery Residency

Posted on January 31, 2019

M. Malekpour1, M. Fluck1, M. Alaparthi1, M. Shabahang1  1Geisinger Medical Center,Department Of General Surgery,Danville, PENNSYLVANIA, USA

Introduction:
Robotic-assisted surgery (RAS) is a newly-introduced technology with some General Surgery Residency programs recently integrating it into their curriculum. The cost-effectiveness of RAS training in general surgery residency is debated.

Methods:
All outpatient cholecystectomy cases from 2013 to 2017 were included in this study. Patients were divided into laparoscopic and robotic-assisted groups. We focused on comparison of the cost and length-of-stay (LOS) for cases based on the presence of residents.

Results:
During the 5-year study-period, 1774 cases were included. Residents were scrubbed in 70% of laparoscopic cases (1125 cases from a total of 1605 laparoscopic cholecystectomies) and 45% of robotic-assisted cases (75 cases from a total of 165 robotic-assisted cholecystectomies). Presence of residents were associated with significantly reduced costs in both laparoscopic and robotic-assisted cases (both p<0.0001). Although the presence of residents was associated with significantly longer LOSs in laparoscopic cases (12.6 vs 9.8 hours, p=0.0003), there was no association between the presence of residence and LOS in robotic-assisted cases (11.8 vs 9.6 hours, p=0.63).

Conclusion:
Presence of residence in outpatient robotic-assisted laparoscopic cholecystectomies was associated with less cost. General Surgery residency programs should consider integration of RAS in their curriculums.
 

20.14 The Readability of Surgical Consent Forms is Poor Across Three Countries

Posted on January 31, 2019

A. Chakrabarty1, E. Kaplan1, L. Wood1, I. Marques1, K. Kichler1, S. J. Baker1, J. W. Toh3, E. M. Muller2, G. D. Kennedy1, M. S. Morris1, J. S. Richman1, D. I. Chu1  1University Of Alabama at Birmingham,Birmingham, Alabama, USA 2University of Cape Town,General Surgery,Cape Town, WESTERN CAPE, South Africa 3University Of Sydney,Sydney, NSW, Australia

Introduction:
The American Medical Association (AMA) and the National Institutes of Health (NIH) recommend that education materials given to patients should not exceed a sixth-grade reading level. Consent forms are legal documents that patients are expected to read, understand and sign before any surgical procedure. It is unclear, however, how readable contemporary consent forms are and whether these levels vary internationally. We hypothesized that the readability of consent forms would be poor and exceed the recommended sixth grade reading level.

Methods:
Major surgery English-consent forms were collected from four tertiary-care referral-centers across three countries: USA, Australia, and South Africa. Consent forms were analyzed to assess readability using four instruments: Flesch-Kincaid Grade Level (FKGL) instrument, SMOG (Simple Measure of Gobbledygook), PEMAT (Patient Education Materials Assessment Tool), and PCR (Print Communication Rating). Three independent observers analyzed each form to assess readability. 

Results:
Seven consent forms were analyzed from three countries.  None of the materials were under sixth-grade reading level when analyzed with FKGL and SMOG with average grade-level scores of 12.0 ± 2.4 SD and 15.2 ± 2.0 SD, respectively. The range for FKGL was 9 to 15 while the range for SMOG was 13.5 to 17 where the higher scores indicate a higher reading level. While no significant differences existed between FKGL and SMOG scores by institutions, Australia had the best FKGL and SMOG scores, at 9 and 13.5 respectively. The average PEMAT scores were 70.8% ± 13.8 SD for understandability and 30.5% ± 25.8 SD for actionability, with scores closer to 100% being ideal. No significant differences in PEMAT scores were observed by institutions, but Australia had the highest PEMAT scores for both understandability and actionability, at 85.2% and 40%, respectively. The average PCR score was 40.1 ± 4.6 SD and all consent forms scored in the 24-47 score range, for which “augmented efforts to eliminate literacy-related barriers” are recommended. While no significant differences in PCR scores were observed by institution, Australia again had the highest score, at 43 ± 5.2 SD.

Conclusion:
The readability of major surgery consent forms from three countries varied but was overall poor and failed to meet the AMA/NIH recommended sixth-grade reading level. While consent forms are legal documents, considerations should be made to make consent forms more readable and understandable.
 

20.13 What Does the Average Person Know about Endocrine and Vascular Surgeons?

Posted on January 31, 2019

A. Aune1, A. Asban1, R. Mallick1, H. Chen1, B. Lindeman1  1University Of Alabama at Birmingham,Department Of Surgery,Birmingham, Alabama, USA

Introduction:
Surgical fields are becoming increasingly specialized. This can lead to misunderstanding or confusion about the scope of practice of different surgeons by the individual seeking specialized surgical care. To assess public understanding of sub-specialty surgeons, we sought to survey general knowledge of the specialty areas of Endocrine Surgery and Vascular Surgery. 

Methods:
A survey was conducted in three locations in Birmingham, Alabama: a local farmers market, a public park, and the University of Alabama at Birmingham Hospital (UAB). Fifty people were surveyed at random at each of the three locations, with hospital staff identified by wearing a hospital ID badges recruited at the UAB hospital location. Participants were asked to define both an endocrine surgeon and vascular surgeon, as well as identify aspects of their practice. Participant’s answers to the survey were recorded and coded by three evaluators (two MD, one PharmD candidate). Survey responses were assessed for correct definition of the specialty (Yes/No), recognition of being a surgeon (Yes/No), spectrum of practice (None, Partial or Complete), and presence of a common misconception (Yes/No). Inter-rater reliability (kappa) was calculated for each question. The Chi-square test was used to compare the difference in each answer between the two specialties. 

Results:
A total of 150 people participated in the study. The majority were female (58%) and approximately 50 years of age or less (65%). Inter-rater reliability from 0.32-0.84 was observed, and agreement from 40% to 98% between raters was achieved for all questions. Significantly more respondents recognized endocrine surgery as a surgical profession (21%) compared to vascular surgeons (18%) (p<0.001). However, significantly fewer could define what an endocrine surgeon does (14%) than could define what a vascular surgeon does (57%). Only 3% of respondents could identify the entire spectrum of practice of an endocrine surgeon, with 42% and 55% providing partially or completely incorrect responses, respectively. Significantly more respondents could identify all of a vascular surgeon’s spectrum of practice (11%), with 60% and 29% providing partial or completely incorrect responses, respectively (p<0.001). Endocrine surgeons were most often confused for endocrinologists (40%), while vascular surgeons were most often confused for cardiovascular surgeons (22%).  

Conclusion:
This study reveals an overall lack of understanding among the general public about what endocrine and vascular surgeons are and their spectrum of practice and shows that public understanding of the field of endocrine surgery is very low. More efforts need to be made to increase the visibility of these fields and communicate these surgeons’ specialized expertise. 

20.12 Improving Patient Education Material is Feasible at the VA

Posted on January 31, 2019

C. M. Rentas1, S. Baker1, E. Malone1, J. Richman1, G. Yang1, M. Morris1  1University Of Alabama at Birmingham,Birmingham, Alabama, USA

Introduction: Health literacy is a predictor of a patient’s health status. Despite variability of patient health literacy, patient education handouts remain the most widely used form of medical information. The American Medical Association (AMA) and National Institutes of Health (NIH) recommend that patient information be presented at 6th grade reading level or lower. Not only do patient education handouts need to be readable, the medical information presented should also be understandable to the general public. We hypothesized that patient education handouts at our local Veterans Affairs Medical Center general surgery clinic were written above a 6th grade reading level and contained information that was not understandable to the average patient.

Methods: Routine patient education materials were collected from the general surgery clinic. The Flesch-Kincaid Grade Level (FKGL) instrument was used to analyze the texts to generate a FKGL score without any correction of misspellings or grammatical errors. To assess understandability, we used the Patient Education Materials Assessment Tool (PEMAT) and recorded scores of “understandability” and “actionability” for each patient education handout. Then, patient education handouts were re-written using recommendations from the Centers for Disease Control and Prevention’s “Simply Put” guide for creating easy-to-understand materials and re-assessed using the FKGL and PEMAT tools.

Results: We collected 5 patient education handouts from the general surgery clinic covering various topics such as: colectomy, hernia repair, cholecystectomy. The overall average FKGL for the handouts was 7.94 (SD 0.49), exceeding the NIH/AMA standards sixth grade level by an average of 1.94 grade levels (95% CI=7.33-8.55; p <0.0002). The overall average PEMAT scores for both understandabilty and actionability were 40% (SD 6%). Handouts were then rewritten. The average time to rewrite a handout was 1 hour. Upon re-assessment the average FKGL for the rewritten handouts was 5.4 (SD 0.35, 95% CI=4.97-5.83) % below the grade level. The average PEMAT understandability and actionability scores for the rewritten material are 100% and 82%, respectively (SD 0, 2%), compared to 40% for both before.

Conclusion: The readability of patient education material in our VA general surgery clinic is poor and deviates significantly from AMA/NIH recommendations. With limited time and resources, the FKGL and PEMAT scores for the patient education handouts were improved using the “Simply Put” guidelines to ensure readability and understandability of medical information.

 

20.11 Medical Student Perceptions Following Participation in a Surgical Boot Camp – A Qualitative Analysis

Posted on January 31, 2019

E. Palmquist1, T. Feeney2, A. Chatterjee1, D. Nepomnayshy3, L. Chen1  1Tufts Medical Center,Department Of Surgery,Boston, MA, USA 2Boston University,Department Of Surgery,Boston, MA, USA 3Lahey Hospital & Medical Center,Department Of Surgery,Burlington, MA, USA

Introduction: There have been many changes to surgical education over the last few decades. With increased attention to patient safety, there is a push to better prepare our medical students prior to starting a surgical residency. We present our results from a pilot study of creating a senior medical student surgical boot camp including analysis of the learner’s perspectives of boot camps.

Methods: Graduating senior medical students entering a surgical residency underwent a voluntary three-day surgical boot camp. Pre-and post-surveys were used to evaluate confidence levels of common patient management issues as well as technical skills. Qualitative analysis of a focus group using a general inductive approach was used to develop themes surrounding students’ perceptions of boot camps.
 

 

Results: Ten medical students completed the boot camp. We found that most students were somewhat confident (3 on a 5-point Likert scale) in their abilities to manage common intern problems with increased variation among students for technical skills prior to the boot camp. Students all had improvements in confidence scores post boot camp for all measured tasks.

From our qualitative analysis we found that students prefer a voluntary, surgery specific boot camp at the end of medical school as oppose to the start of their residency. Being given the choice to partake in the intervention provided the participating students with more motivation during the boot camp, supporting adult learning theory. Some of the students’ major concerns include being the first point of contact for patient issues as well as being the first responder to patient emergencies. Students worry about their ability to multi-task and manage a large amount of information which differed from their experience as a medical student. In addition, students are realistic about their expectations from a preparatory boot camp and value it as an experience to help “jump start” their transition to residency.

 

Conclusion: Our pilot study suggests that surgical boot camps may successfully improve students’ confidence in patient management and technical skills prior to the start of their intern year. In addition, we found major themes surrounding students’ perceptions of boot camp which may assist with future development of these programs. Students prefer a voluntary boot camp and value the experience at a medical school level. In addition, they are realistic in that a preparatory course will not teach them all they need to know prior to residency but more as a tool to help their transition.  
 

20.10 How Case Specific Learning Goals are Born: The Evolution within Residents along Post-Graduate Year

Posted on January 31, 2019

I. Woelfel1, D. Strosberg1, B. Q. Smith2, A. Harzman1, R. Salani2, A. Cochran1, X. (. Chen1  1Ohio State University,Department Of Surgery,Columbus, OH, USA 2Ohio State University,Department Of Obstetrics And Gynecology,Columbus, OH, USA

Introduction:  Developing resident autonomy in the operating room (OR) is a complex process that involves resident readiness, preparation and flexibility; instructor feedback and guidance; and is impacted by environmental and patient factors. Resident-established case specific learning goals have long been promoted as a way to increase resident OR training efficiency and the preparedness for autonomy. However, little is known about residents’ experience of identifying learning goals for a given case. The aim of this study was to investigate the developmental process of residents’ case specific goals based upon residency training level. 

Methods:  After obtaining IRB consent, we conducted focus group interviews with 18 general surgery residents across five clinical postgraduate years (PGY) using convenience sampling. Audio recordings of each interview were transcribed and iteratively analyzed. Emergent themes were identified using a framework method. 

Results: A total of eight junior (PGY 1-2) and 10 senior (PGY 3-5) residents participated; 10 were female and 8 were male. Focus group participants indicated that the ability of residents to self-identify case specific learning goals for an upcoming surgical case is closely associated with residents’ medical knowledge and surgical experience throughout residency training. The more experience and knowledge gained, the easier for residents to identify a specific learning goal for a case. In the early stage of residency training, residents have difficulty self-identifying actionable case specific learning goals. Junior residents tend to rely on attending and/or senior residents to assign a learning goal. During the intermediate stage of residency training, residents were more comfortable in specifying a goal for some high-volume common procedures than the junior residents. Approaching the final stage of residency training, residents are able to articulate specific and achievable learning goals for most cases. However, they perceived practical challenges when serving as a Teaching Assistant in the OR with junior residents. Numerous internal and external factors influence the development of residents’ case specific learning goals, including resident operative experience, resident self-entrustment and entrustment of attending, as well as case assignment timeline, attending teaching style and attending reputation in granting operative autonomy. 

Conclusion: Although self-identifying case specific learning goals functions well for senior residents, it is not practical for junior residents to develop actionable, specific goals due to their limited medical knowledge and operative experience. Residency programs could provide a set of procedure-based learning goals for junior residents to enhance their training efficiency and to solidify their foundation for future OR autonomy. Resident-as-Teacher programs would be beneficial to enhance senior residents' identification of learning goals for their junior peers.

 

20.09 Perceptions of Residents' Autonomy in the Operating Room

Posted on January 31, 2019

Z. Rahaman1, M. Arafeh1, G. Munene1, L. Miller1, S. Shebrain1  1Western Michigan University Homer Stryker MD School of Medicine,Department Of General Surgery,Kalamazoo, MICHIGAN, USA

Introduction: Graded autonomy is an essential component of General Surgery training. This study compares perceptions of autonomy between residents and faculty in the operating room.

Methods:  Operative procedures performed by general surgery residents between July 2016 and June 2018 were each assigned an autonomy score by the operating surgeon and the surgical resident using the Zwisch score. The degree of agreement between the residents’ self-evaluated measure of autonomy and surgeons’ evaluation of resident autonomy was assessed.

Results: Over the study period, 23 faculty members and 24 residents scored 546 operative cases (total 1,092 evaluations) using the Zwisch scale. About half of these evaluations were completed by PGY5 (24.4%) and PGY2 (24.2%), while the rest were completed by PGY1 (16.3%), PGY3 (21.1%) and PGY4 (14.1%). Overall, there was moderate agreement between resident and faculty evaluation with Cohen’s Kappa of 0.50 (95% CI 0.41, 0.58). PGY5 and PGY1 residents appeared to have more agreement with the faculty (0.51, 0.50 respectively) than PGY2 (0.39), PGY3 (0.37) and PGY4 (0.47) residents. Spearman correlation between ranks of resident and faculty evaluations of resident autonomy was 0.31 (p<0.001). Case-difficulty did not affect perception of autonomy. 

Conclusion: Surgical faculty and residents appear to share similar perceptions of autonomy in the operating room.

 

20.08 Assessing The Adherence Of Operative Notes For Laparoscopic Appendectomy With The RCS Guidelines

Posted on January 31, 2019

F. Mannan1, R. Gill1, A. R. Alvi1  1The Aga Khan University Hospital,General Surgery,Karachi, SINDH, Pakistan

Introduction:

Operative notes are one of the most essential components of good surgical practice. It forms an important record of intervention performed on the patient with its medicolegal implications.Proper documentation of these notes ensures the patient continuity of care is maintained and quality of care is enhanced which may also have an impact on follow up and future management of the patient. Royal College of Surgeons has issued guidelines to standardize operative note documentation. We aimed to determine the frequency of adherence of laparoscopic appendectomy operative notes with the RCS guidelines at our tertiary care centre.

Methods:  

The Study was conducted at the Aga Khan University hospital Karachi over a six month period between January and June 2018 after seeking approval from the Ethics Review Committee. It was a crossectional study and data was analysed by using SPSS version 21. Descriptive analysis of continuous variables along with overall score of operative notes was deduced to assess the frequency of adequate practice compared to the RCS guidelines. Stratified analysis was done for effect modifiers and p value of < 0.05 was taken as statistically significant.

Results:

A total of 74 operative notes relating to laparoscopic appendectomy were reviewed during the study period. Majority of the cases were carried out as inpatient procedures (91.9%). The average age of resident writing the notes was 27 year +/-1.97.  Forty Six percent notes were written by year one residents. Female residents contributed to around 55 percent of operative notes. Twenty four percent operative notes showed adequacy of practice in concordance with RCS guidelines. The most lacking component in operative notes was mentioning of the operative time, port sites, intra operative complications and details of specimen removed. Stratified analysis of operative notes did not reveal any association between age, gender and level of training of residents to affect the adequacy of operative note documentation.

 

Conclusion:

There is a huge gap in documentation of operative notes compared to the Royal College of Surgeons guidelines for good medical practice. Only a quarter of our documentation fulfils the criteria for adequacy of practice. Residents need to be educated and familiarized with these guidelines to improve documentation of operative procedures. Strategies need to be formulated and tested to improve our performance.

 

 

 

 

 

 

20.07 Acquisition of Surgical Skills by Medical Students in State-Owned Medical Schools of Cameroon.

Posted on January 31, 2019

A. Chichom-Mefire1, G. N. Keith1, P. Fokam1, D. S. Nsagha1, M. Ngowe-Ngowe1  1Faculty of Health Sciences, University of Buea,Department Of Surgery,Buea, Cameroon

Introduction: Surgery plays an important role in provision and support of primary health care services. The World Health Organization recommends that basic surgical care be administered at the district level. Due to limited availability of qualified surgeons, general practitioners need to be competent in a number of practical surgical skills in order to reduce the number of referrals for emergency and selected elective surgical procedures. Curriculum of medical schools in low and middle-income countries must be designed accordingly. The aim of this study was to report the level of exposure of final year medical students to practical surgical skills.

Methods:

A descriptive cross-sectional study was carried out in the four state owned medical schools in Cameroon. The target population was final year medical students who have completed all clinical rotations. All final year medical students were approached.

A structured self-administered questionnaire was proposed to these students in order to assess their exposure to basic surgical skills and selected surgical procedures. Self-confidence in performing basic surgical skills (BSS) was assessed using a Likert scale. Adequate exposure for a given surgical procedure was defined as at least one of the following: (1) observing the procedure five or more times and participating as fist assistant at least four times and performing it at least once under supervision. (2) Observing the procedure five times and participating as first assistant at least five times. Data analysis was performed using EPI INFO version 7.2 and statistical significance was set at P < 0.05.

Results:
Of the 347 final year medical students approached, 304 returned filled questionnaires giving a response rate of 87.6%. Male to female ratio was 5:4 and females were significantly younger than males (P < 0.001). Their comfort in basic surgical skills ranged from 25% (manual surgical node tying) to 86% (surgical scrubbing). Adequate exposure to selected surgical procedures was 87% for perineal tear repair after vaginal delivery, 81% for caesarean section and incision and drainage of an abscess, 73% for cast immobilisation of a limb fracture, 55% for hernia repair and 53% for appendectomy. It was as low as 3% for bowel resection and anastomosis. The choice to perform extra-curricular activity for skills improvement was significantly associated with adequate exposure (P < 0.05).

Conclusion:
Overall, the performance rate of practical surgical skills by final year medical students in medical schools in Cameroon is poor. However, the majority of students are likely to be able to perform a sizeable number of surgical procedures by the end of their training. There is need to reinforce the training and assessment to ensure that medical students who do not master basic clinical skills and are not adequately exposed to common procedures are given an opportunity to be exposed before graduation.

20.06 #Ilooklikeasurgeon: 20-year Review of Gender and Racial Diversity in Academic General Surgery

Posted on January 31, 2019

L. Marcia1, A. Moazzez1,2, R. Miranda1, D. Y. Kim1,2, C. DeVirgilio1,2  1David Geffen School Of Medicine, University Of California At Los Angeles,Los Angeles, CA, USA 2Harbor-UCLA Medical Center,Surgery,Torrance, CA, USA

Introduction:  For years there has been ongoing efforts to diversify medicine as the United States (US) population continues to change. Our objective was to assess the past and current state of gender and racial diversity in general surgery.

Methods:  Demographic data from 1997-2016 was obtained from publications on graduate medical education by the Journal of American Medical Association, and the Association Medical Colleges. The percent change per year was calculated using a linear regression model.

Results: In 2016, women represented 50.8% of the US population, but only 10.4% of full professors, 20.0% of associate professor, 26.7% of assistant professors and 49.2% on instructors. The highest increase per year was seen among female instructor 1.16%, p<0.001) and the least among full professor (0.39%, p<0.001). From 1997 to 2016, the percentage of female general surgery residents increased from 20.5 to 38.4. Hispanic/Latino represented 17.8% of the population, but only 4.96% of faculty, and 8.24% of general surgery residents. African American represented 13.3% of population, but only 2.69% of faculty, and 5.50% of general surgery residents. American Indian/Alaskan Native represented 1.3% of population, but only 0.10% of faculty and 0.19% of general surgery residents.

Conclusion: In the last 20 years, there has been increase in gender and racial diversity in surgery. However, women, American Indian, African American and Hispanic continue to be underrepresented in certain categories of the surgical pipeline. 
 

20.04 Trends in United States Residency Match Rates for International Medical Graduates

Posted on January 31, 2019

C. Buonpane1, S. Hayek1, M. Fluck1, H. Ellison1, M. Shabahang1  1Geisinger Medical Center,General Surgery,Danville, PA, USA

Introduction: Every year the United States (US) Main Residency Match seeks to couple medical school graduates with available residency positions. Historically, there have been more applicants than available positions. The majority of applicants completed their undergraduate medical education in the US; however, a growing portion of applicants are coming from international medical schools. International medical graduates (IMGs) play a crucial role in the physician work force in the US, filling shortages that cannot be met by US allopathic and osteopathic graduates alone. This study seeks to examine the trends in match rates of IMGs into US allopathic residency positions over the past thirty years.

Methods: US residency match data was obtained from the National Resident Matching Program (NRMP) for the years of 1986 to 2016. Linear trends were used to evaluate match data over time and subspecialty analysis was performed. Longitudinal 10-year match rate projections were also made.

Results:

In 1986, IMGs composed 4,965 of 21,357 applicants and 27.8% of IMGs successfully matched into a US allopathic residency. In 2016, IMGs composed 6,638 of 35,476 applicants and 52% matched (87% increase). IMGs were then separated into American citizens (US-IMG) and those who did not have American citizenship (non US-IMG). From 1986 to 2016, US-IMG match rates increased by 40% and non-US IMG match rates increased by 110%. 

 

Allopathic residencies in primary-care specialties demonstrated overall growth in available positions over the study period and an increase in reliance on US-IMGs to fill those positions.  Internal medicine filled 4.8% of 4,682 positions with US-IMGs in 1986 and 14.6% of 6,938 positions in 2016 (204% increase).  Family medicine programs filled 4.3% of 1,960 positions in 1986 and 23.6% of 3,083 positions in 2016 (449% increase).  Longitudinal ten-year match rate projections suggest that 15.3% of internal medicine and 30.2% of family medicine US allopathic residency positions will be filled by US-IMGs in 2026.  

 

Categorical general and orthopedic surgery positions were also analyzed. In general surgery, US-IMG filled positions increased over 400% (from 1.3% of 1,249 positions in 1986 to 6.6% of 1,239 positions in 2016) with a projection of 8.1% of positions being filled by US-IMGs in 2026. In orthopedic surgery, US-IMGs filled 0.29% of 342 positions in 1986 and 0.83% of 717 positions in 2016 (186% increase).

 

During the study period, non US-IMG match rates also increased.  Non US-IMG applicant filled positions increased from 9-29% in internal medicine (222% increase), 1.8-12.4% in family medicine (589% increase), 3.8-4.6% in general surgery (21% increase) and 0.58-1.1% in orthopedic surgery (90% increase).

Conclusion:The percentage of IMGs filling US allopathic residency positions has increased over the last 30 years and is projected to continue increasing. This increase in reliance on IMGs has been particularly strong in primary care fields. 
 

20.03 Medical Student Grit: Impact of Third Year on Medical Students’ Perseverance of Effort

Posted on January 31, 2019

N. E. Anton1, M. A. Rendina1, K. Stanton1, J. N. Choi1  1Indiana University School Of Medicine,Department Of Surgery,Indianapolis, IN, USA

Introduction:
Grit, a psychological trait characterized by passion and perseverance for long-term goals, enables individuals to work towards the completion of long-term goals in spite of repeated challenges, failure, and adversity. Grit has been identified as a predictor of resident attrition in surgical residency, and a marker of residents at risk for poor psychological well-being in the future. Among medical students, grit is associated with learning and performance in gross anatomy, which may indicate that grit is an important element of medical student success. However, in United States medical schools, the third year of medical school (MS3) presents unique challenges related to patient care, interacting with diverse senior healthcare providers, and determining one’s eventual career path. Thus, unlike the first two years of medical school, the distinct challenges of MS3 may erode medical students’ grit. Accordingly, our goal in the present study was to assess the impact of MS3 on medical students’ grit.

Methods:
Incoming MS3s were recruited to voluntarily participate in our study at the start of their third year. Following informed consent, participating MS3s completed the Short Grit Scale, which is an eight-item self-report measure of grit. A single grit score is derived, in addition to two subscales, which include consistency of interest and perseverance of effort. At the conclusion of their third year, participating MS3s were contacted via electronic mail to complete Short Grit Scale again. Paired two-tailed t-tests were utilized to assess pre- to post-MS3 differences in grit and the two subscales. P-values less than 0.05 were considered significant.

Results:
One hundred and seven MS3s (39.8% Female) completed both Short Grit Scales. From pre-MS3 to post-MS3, there was a significant decrease in grit scores (Pre: 3.99±0.46 to Post: 3.87±0.49, p<0.001). Regarding subscale items, there were no differences in pre- to post-MS3 consistency of interest scores. However, there was a significant decrease in perseverance of effort from pre- to post-MS3 (Pre: 4.18±0.48 to Post: 4±0.51, p<0.001).

Conclusion:
Medical student grit, particularly perseverance of effort, may be at risk to decrease significantly due to the rigors of their third year, which consists of unique challenges that they have not been previously exposed to, as well as important decisions regarding their future career paths. It is currently unclear what specific factors contribute to medical students’ decreased grit during their third year, but it is apparent that there is a need for dedicated training to enhance medical student grit due to its importance for their psychological well-being in residency. Accordingly, interventions designed to promote medical student resilience and grit during their third year are warranted.
 

20.02 Medical Student Perception of Morbidity and Mortality Conference

Posted on January 31, 2019

A. P. Worden1, P. Kandagatla1, A. H. Gupta1, C. Steffes1  1Henry Ford Health System/Wayne State University,Surgery,Detroit, MICHIGAN, USA

Introduction:  Morbidity and mortality (M&M) conference has long been a vital educational tool for medical students, residents, and staff. It allows for learning and quality improvement through discussion of noteworthy cases. There is, however, a paucity of data on the how M&M is perceived by medical students, especially as a function of their interest, or lack thereof, in surgery. The objective of this study was to fill this void by measuring the perceptions of medical students regarding M&M conference.

Methods:  Medical students in a single medical school class voluntarily took part in a survey after their surgical rotation. The survey gauged students’ interest in surgery as a career and their overall rating of M&M. Students were specifically asked to recall if specific types of cases (resident at fault, medical error, non-therapeutic operation, pre- or post-operative mismanagement, multiple levels of error, and preventable or non-preventable error) were discussed. They were also asked to recall if tenets of surgical care (patient safety, quality improvement, root cause analysis, never events, time out/critical pause, complication vs preventable error) were discussed during M&M. Responses were tabulated and descriptive statistics were performed to summarize the data. Univariate analysis with a Chi-squared test, or Fisher’s Exact test when appropriate, was performed for association.

Results: A total of 251 students were surveyed over four clinical sites. Of these students, 236 (94.0%) felt they understood the purpose of M&M, and 233 (88.8%) students felt they understood quality improvement in medicine and surgery. However, only 136 (54.2%) students reported M&M as a valuable learning experience. Discussion of the following was associated with a positive experience: examples of patient safety (93.4% vs 84.3%, p=0.02), preventable (91.2% vs 75.4%, p<0.01) or non-preventable (76.5% vs 55.3%, p<0.01) errors, quality improvement (95.6% vs 71.9%, p<0.01), and root cause analysis (59.6% vs 40.4%, p<0.01). Students were less likely to have a positive experience if they perceived M&M as a resident ‘grilling session’ (31.6% vs 51.4%, p<0.01). There was no association between interest in a surgical subspecialty and perceiving M&M as a positive learning experience (48.5% vs 50.5%, p = 0.29).

Conclusion: Overall, only a very small majority of medical students view M&M as a positive learning experience. Introducing structured concepts focusing on quality improvement may serve as a viable strategy to enhance the learning experience. Prospective studies incorporating such a curriculum are warranted.

20.01 Correlation Between Burnout, Stress, Work-Family Conflict, and Self-Efficacy in Surgical Faculty

Posted on January 31, 2019

M. R. Smeds1, M. Harlander-Locke2, H. K. Sandhu3, S. Allen4, K. Amankwah5, P. Ansari6, K. Charlton-Ouw3, D. Hess7, P. Jackson8, M. Johnson9, M. K. Kimbrough10, D. Knight11, G. M. Longo12, B. Shames13, J. Shelton14, P. Yoo15, M. Smeds1  1Saint Louis University School Of Medicine,Division Of Vascular And Endovascular Surgery,St. Louis, MO, USA 2Lake Erie College of Osteopathic Medicine,Bradenton, FL, USA 3McGovern Medical School at UTHealth,Houston, TX, USA 4Penn State Hershey Medical Center,York, PA, USA 5State University Of New York Upstate Medical University,Syracuse, NY, USA 6Lenox Hill Hospital,New York, NY, USA 7Boston University,Boston, MA, USA 8Medstar Georgetown University Hospital,Washington, DC, USA 9University of South Dakota,Vermillion, SD, USA 10University of Arkansas for Medical Sciences,Little Rock, AR, USA 11Waterbury Hospital,Waterbury, CT, USA 12University Of Nebraska College Of Medicine,Omaha, NE, USA 13University of Connecticut School of Medicine,Farmington, CT, USA 14University Of Iowa,Iowa City, IA, USA 15Yale University School Of Medicine,New Haven, CT, USA

Introduction:
Burnout is a work-related syndrome involving emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment that has become prevalent in all areas of medicine.  We sought to understand factors associated with burnout in surgical faculty including self-efficacy, perceived stress, work-family relationship and depression.

Methods:
Anonymous electronic surveys consisting of demographic information as well as validated scales for burnout, depression, perceived stress, self-efficacy, social support, and work-family conflict were sent to all surgical faculty at 14 general surgery residency programs.  Respondents were grouped into quartiles based on burnout level, and predictors of burnout were determined using univariate and multivariate analysis comparing those in the highest quartile to all others.

Results:
Of 731 invitations sent, 240 (33%) surgeons responded.  Those in the highest quartile of burnout were younger (45.5 vs. 48.1, p=0.049), more likely to have higher perceived stress (p<0.001), work-family conflict (p<0.001), and moderate or severe depression (p<0.001) and lower perceived social support (p<0.001) and self-efficacy (p<0.001).  Amount of educational debt, years out from training, gender, marital status, proximity of immediate family, and having children did not correlate with burnout, nor did work-related factors of frequency of call, number of hospitals covered, percent clinical involvement, number of cases performed per week, attainment of divisional/departmental leadership roles or overall compensation.  On multivariate logistic regression analysis, higher perceived stress (OR 1.51, p<0.001), depression (OR 2.730, p=0.004), and work-family conflict (OR 1.2, p=0.012) were related to higher levels of burnout while self-efficacy was protective against burnout (OR 0.89, p=0.046).  Those with the highest levels were unlikely to select surgery as a career if they could do it all over again (OR 0.093, p=0.001).

Conclusion:
Burnout in surgical faculty is associated with depression, high perceived stress, increased work-family conflict, and low self-efficacy.  Improving work-family balance and self-efficacy and decreasing stress may improve levels of burnout in surgical faculty.
 

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