Association of Surgical Practice Patterns and Clinical Outcomes With Surgeon Training in University- or Nonuniversity-Based Residency Program

Approximate balancing weights for clustered observational study designs

In a clustered observational study, a treatment is assigned to groups and all units within the group are exposed to the treatment. We develop a new method for statistical adjustment in clustered observational studies using approximate balancing weights, a generalization of inverse propensity score weights that solve a convex optimization problem to find a set of weights that directly minimize a measure of covariate imbalance, subject to an additional penalty on the variance of the weights. We tailor the approximate balancing weights optimization problem to the clustered observational study setting by deriving an upper bound on the mean square error and finding weights that minimize this upper bound, linking the level of covariate balance to a bound on the bias. We implement the procedure by specializing the bound to a random cluster-level effects model, leading to a variance penalty that incorporates the signal-to-noise ratio and penalizes the weight on individuals and the total weight on groups differently according to the the intra-class correlation.

Establishment of hospital-based surgical residency programs as a health policy for surgical needs provision: an Indonesian perspective

Objective

One of the health interventions that can be implemented cost-effectively in developing countries is the provision of basic surgical procedures. One way to increase access to surgical services is to increase the production of surgeons, in this case through increasing the surgical residency program. There are similarities between university-based surgical residency programs and hospital-based surgical residency programs. However, in Indonesia, the differences between them are stark; the establishment of hospital-based surgical residency programs is challenging and requires collaboration between the government, university, college of surgery, and private sector.

Design

The author reviewed the literature on post-graduate medical education for surgical programs and the contrast between university-based and hospital-based surgical residency programs.

Setting

Information collected from the Indonesian Health Education Independent Accreditation Institution and varied literature was included.

Participants

Not applicable.

Result

In Indonesia, the implementation of an academic surgery environment in the hospital-based surgical residency program is challenging, and the implementation of the academic health system can increase student intake and provide more both from the university and the hospital-based surgical residency program.

Laparoscopic pyeloplasty proficiency during a residency program after adoption of a standardized simulation training program is maintained during the COVID pandemic despite reduced surgery volume

PURPOSE

To evaluate the effect of the standardized laparoscopic simulation training program in pyeloplasty, following its implementation and during the COVID-19 pandemic.

MATERIAL AND METHODS

A retrospective chart review was performed at Hospital de Clínicas de Porto Alegre, a tertiary referral center in south Brazil, in which 151 patients underwent laparoscopic pyeloplasty performed by residents between 2006-2021. They were divided into three groups: before and after adoption of a standardized laparoscopic simulation training program and during the COVID-19 pandemic. The main outcome was a combined negative outcome of conversion to open surgery, major postoperative complications (Clavien-Dindo III or higher) or unsuccessful procedure, defined as need for redo pyeloplasty.

RESULTS

There was a significant reduction in the combined negative outcome (21.1% vs 6.3%), surgical time (mean 200.0 min vs 177.4 min) and length of stay (median 5 days vs 3 days) after the adoption of simulation training program. These results were maintained during the COVID-19 pandemic (combined negative outcome of 6.3%, mean surgical time of 160.1 min and median length of stay of 3 days) despite a reduction in 55.4% of the surgical volume.

CONCLUSION

A structured laparoscopic simulation program can improve outcomes of laparoscopic pyeloplasty during the learning curve.

Video Coaching in Surgical Education: Utility, Opportunities, and Barriers to Implementation

OBJECTIVE

This review discusses the literature on Video-Based Coaching (VBC) and explores the barriers to widespread implementation.

DESIGN

A search was performed on Scopus and PubMed for the terms "operation," "operating room," "surgery," "resident," "house staff," "graduate medical education," "teaching," "coaching," "assessment," "reflection," "camera," and "video" on July 27, 2021, in English. This yielded 828 results. A single author reviewed the titles and abstracts and eliminated any results that did not pertain to operative VBC or assessment. All bibliographies were reviewed, and appropriate manuscripts were included in this study. This resulted in a total of 52 manuscripts included in this review.

SETTING/PARTICIPANTS

Original, peer-reviewed studies focused on VBC or assessment.

RESULTS

VBC has been both subjectively and objectively found to be a valuable educational tool. Nearly every study of video recording in the operating room found that subjects, including surgical residents and seasoned surgeons alike, overwhelmingly considered it a useful, non-redundant adjunct to their training. Most studies that evaluated skill acquisition via standardized assessment tools found that surgical residents who underwent a VBC program had significant improvements compared to their counterparts who did not undergo video review. Despite this evidence of effectiveness, fewer than 5% of residency programs employ video recording in the operating room. Barriers to implementation include significant time commitments for proposed coaching curricula and difficulty with integration of video cameras into the operating room.

CONCLUSIONS

VBC has significant educational benefits, but a scalable curriculum has not been developed. An optimal solution would ensure technical ease and expediency, simple, high-quality cameras, immediate review, and overcoming entrenched surgical norms and culture.

Benefits of developing graduate medical education programs in community health systems

The creation of new CMS-funded Graduate Medical Education (GME) cap positions by the Consolidated Appropriations Act 2021 offers a unique opportunity for systems in community and rural settings to develop and expand their training programs. This article provides a review of the evidence behind the value proposition for system administrators to foster the growth of GME in community health systems. The infrastructure needed to accredit GME programs may reduce the cost of care for both the patients and the system through improved patient outcomes and facilitation of system efforts to recognize and mitigate social determinants of health. Residents, fellows and medical students expand the capacity of the current healthcare workforce of a system by providing coverage during healthcare emergencies and staffing services in difficult-to-recruit specialties. Those trainees are the nucleus of succession planning for the current medical staff, can facilitate the creation and expansion of service lines, and may elevate the profile of the system through scholarly work and equity and quality improvement activities. While creating GME programs in a community health system may, at first glance, be perceived as cost-prohibitive, there are robust advantages to a system for their creation.

(Re)thinking the Residential in Residency: Modern Surgical Practice Continues to Move Away From the Inpatient Setting

PURPOSE

Despite the overall shift in care delivery to an ambulatory setting, the majority of general surgical education still relies on the experience of caring for inpatients. We aimed to investigate how the inpatient practice patterns of newly minted general surgeons (GS) have changed since 2008, in order to better inform education policies regarding both training approach and setting for modern surgical trainees.

METHODS

State discharge data from NY and FL (2008-2017) were linked to data on GS from the American Medical Association Masterfile, and to hospital data from the American Hospital Association annual survey. Mean annual inpatient case volume (CV) and case type breadth (CB) were compared between surgeons who were new-to-practice (0-3 years of experience) in 2008 and in 2013. Each new surgeon cohort was followed for 5 years. Case type was classified by organ system.

RESULTS

The 2008 cohort included 328 GS with a mean age of 37.1, 79.6% male and 94.2% board-certified. The 2013 cohort included 359 GS with a mean age of 36.2, 73.0% male and 93.9% board-certified. CV was higher among the 2008 cohort than the 2013 cohort for each year of practice in the study period. CB included at least 4 organ system types for all new GS with greater breadth among the 2008 cohort for each year in the study period.

CONCLUSIONS

Declining rates of inpatient surgery affect general surgeons who were new-to-practice in 2013 significantly more than those entering practice only 5 years ahead of them. New surgeons continue to start their practices broadly, suggesting a need to continue broad training while expanding formal educational policies to include the full spectrum of ambulatory surgery.

Laparoscopic appendectomy as an index procedure for surgical trainees: clinical outcomes and learning curve

Surgical training is essential to maintain safety standards in healthcare. The aim of this study is to evaluate learning curves and short-term postoperative outcomes of laparoscopic appendectomy (LA) performed by trainees (TRN) and attendings (ATT). The present study included the medical records of patients with acute appendicitis who underwent a fully LA in our department between January 2013 and December 2018. Cases were divided into trainees (TRN and ATT groups based on the experience of the operating surgeon. The primary outcome measures were 30-day morbidity and mortality. Preoperative patients' clinical characteristics, intraoperative findings, operative times, and postoperative hospitalization were compared. Operative times were used to extrapolate learning curves and evaluate the effects of changes in faculty using CUSUM charts. A propensity score matching analysis was performed to reduce differences between cohorts regarding both preoperative characteristics and intraoperative findings. A total of 1173 patients undergoing LA for acute appendicitis were included, of whom 521 (45%) in the TRN group and 652 (55%) in the ATT group. No significant differences were found between the two groups in terms of complication rates, operative times and length of hospital stay. However, CUSUM chart analysis showed decreased operating times in the TRN group. Operative times improved more quickly for advanced cases. The results of this study indicate that LA can be performed by trainees without detrimental effects on clinical outcomes, procedural safety, and operative times. However, the learning curve is longer than previously acknowledged.

Practice Locations of Michigan Ophthalmologists as a Model to Compare Practice Patterns of DO and MD Surgical Subspecialists

CONTEXT

While existing data demonstrate that osteopathic physicians (ie, DOs) in primary care are more likely than allopathic physicians (ie, MDs) to practice in rural areas, no data exist on practice patterns of DO surgical subspecialists, such as ophthalmologists. Michigan has a relatively high number of DOs and, formerly, the most osteopathic ophthalmology residency programs in the United States. Analyzing the distribution of ophthalmologists in Michigan may reveal patterns and predict trends about the geographic distribution of DO surgical subspecialists across the country.

OBJECTIVE

To compare geographic distributions of DO and MD ophthalmologists in Michigan and identify differences in community size and type (eg, urbanized area, urban cluster, or rural area) of practice.

METHODS

A list of Michigan's ophthalmologists practicing in 2018 was developed using the Centers for Medicare and Medicaid Services, the American Osteopathic College of Ophthalmology, and the American Medical Association data sets. DOs and MDs were then analyzed by determining where each ophthalmologist practiced, identifying the size and type of community in which they practiced, and finally by comparing the percentage of DOs and MDs who practiced in various community sizes and each community type as defined by the US Census Bureau. A χ2 analysis was used to determine whether a difference existed in practice locations.

RESULTS

A total of 643 ophthalmologists practiced in Michigan in 2018, including 85 DOs and 558 MDs. A greater proportion of DOs worked in rural areas and urban clusters (57 [67%]), whereas a greater proportion of MDs worked in urbanized areas (368 [66%]). Of DOs, 28 (33%) practiced in cities with a population of at least 50,000 vs 371 MDs (66%). Fourteen DOs (16%) practiced in communities with a population of at least 100,000 vs 207 MDs (37%). χ2 analysis showed a significant difference in the geographic distribution of ophthalmologist DOs and MDs (P<.01).

CONCLUSION

Higher proportions of DOs practice ophthalmology in smaller, more rural Michigan communities compared with MDs, implying that a subgroup exists that tends to serve underserved areas.

Variation in the Utilization of Postoperative Computed Tomography for Patients With Nonsyndromic Craniosynostosis: A National Claims Analysis

OBJECTIVE

Routine postoperative computed tomography (CT) imaging in nonsyndromic craniosynostosis remains controversial due to the hazards of radiation exposure. The extent to which postoperative head CTs are performed remains unknown. Therefore, we sought to measure the use of postoperative CTs in this population.

DESIGN

The authors reviewed insurance claims from OptumInsight, using Current Procedural Terminology codes to identify procedures and postoperative imaging. Multilevel logistic regression was used to describe the odds of undergoing postoperative CTs, adjusting for patient and provider covariates.

PARTICIPANTS

Craniosynostosis patients who underwent reconstruction between 2001 and 2017 were reviewed. Patients older than 5 years at surgery, postoperative lengths of stay >15 days, syndromic diagnoses, operative complications within 30 days of surgery, and cranial bone grafting merited exclusion.

MAIN OUTCOME MEASURE

Odds of postoperative head CTs after cranial vault reconstruction.

RESULTS

In this cohort (n = 1150), 326 (28.4%) patients underwent postoperative head CTs. The number of CTs ranged from 0 to 14. Older age at surgery (odds ratio [OR]: 1.32, P = .002), increasing years of follow-up (OR: 1.12, P < .001), and increasing comorbidities (OR: 1.21, P = .017) were associated with postoperative CTs. After adjusting for patient factors, provider factors accounted for 31.3% of variation in imaging.

CONCLUSIONS

Over a quarter of patients underwent head CTs following reconstruction, and provider factors accounted for a large percentage of the variation. Given the risks of radiation, neurosurgeons and craniofacial surgeons face a critical need to establish postoperative imaging protocols to reduce unnecessary imaging in these vulnerable patients.

Survey of surgical training and experience of associate clinicians compared with medical officers to understand task-shifting in a low-income country

Background

A workforce crisis exists in global surgery. One solution is task-shifting, the delegation of surgical tasks to non-physician clinicians or associate clinicians (ACs). Although several studies have shown that ACs have similar postoperative outcomes compared with physicians, little is known about their surgical training. This study aimed to characterize the surgical training and experience of ACs compared with medical officers (MOs) in Tanzania.

Methods

All surgical care providers in Pwani Region, Tanzania, were surveyed. Participants reported demographic data, years of training, and procedures assisted and performed during training. They answered open-ended questions about training and post-training surgical experience. The median number of training cases for commonly performed procedures was compared by cadre using Wilcoxon rank sum and Student's t tests. The researchers performed modified content analysis of participants' answers to open-ended questions on training needs and experiences.

Results

A total of 21 ACs and 12 MOs participated. ACs reported higher exposure than MOs to similar procedures before their first independent operation (median 40 versus 17 cases respectively; P = 0·031). There was no difference between ACs and MOs in total training surgical volume across common procedures (median 150 versus 171 cases; P = 0·995). Both groups reflected similarly upon their training. Each cadre relied on the other for support and teaching, but noted insufficient specialist supervision during training and independent practice.

Conclusions

ACs report similar training and operative experience compared with their physician colleagues in Tanzania.

Using a Problem/Case-Based Learning Program to Increase First and Second Year Medical Students' Discussions of Health Care Cost Topics

BACKGROUND

The rising costs of health care in the United States are unsustainable and gaps in physician knowledge of how to provide care at a lower cost remains a contributing factor. It has been suggested that learning about health care costs should be incorporated into existing, already overburdened medical school curricula.

OBJECTIVE

To increase the discussion of health care costs among first and second year medical students, we added a component of health care cost education to an existing problem/case-based learning (PBL/CBL) program without adding curricular time.

DESIGN

A total of 98 medical students participated in this study throughout the first 2 years of their educational program. Students were charged with researching and discussing health care cost topics as part of their weekly PBL/CBL case conferences. Faculty facilitators tracked each student's participation in discussions of health care cost topics as well as how often students initiated new conversations about health care cost topics during their case conferences.

RESULTS

100% of students engaged in conversations about health care cost topics throughout their first and second year PBL/CBL program. In addition, students increasingly initiated new conversations about health care cost topics as they progressed through their courses from the first to the second year (R ² = 0.887, P < .01).

CONCLUSIONS

Sensitizing medical students early during their educational program to incorporate health care cost topics into their PBL/CBL case conferences proved an effective means for having them engage in conversations related to health care costs. These results offer a new, time-efficient option for incorporating health care cost topics for schools with PBL/CBL programs.