The state of general surgery training: a different perspective

Surgical confidence when operating among residents in surgery - a cross-sectional study (SCAR study)

BACKGROUND

Self-confidence, is one of the critical variables influencing surgical resident's abilities, and lack of confidence maybe a reason for not entering medical practice immediately. Measuring the level of confidence of senior surgical residents (SSRs) is a crucial step in assessing preparedness to practice. In this study, we aim to measure their confidence level and the factors that might contribute to it.

METHODS

Cross-sectional survey conducted at King Abdulaziz University Hospital on SSRs in Saudi Arabia (SA). We approached 142 SSRs, 127 responded. Statistical analysis was performed using RStudio v 3.6.2. Descriptive statistics were performed using counts and percentages for categorical variables and using mean ± standard deviation for continuous variables. Multivariate linear regression (t-statistics) was used to assess the factors associated with confidence in performing essential procedures, while the association between demographics and residency-related factor with the number of completed cases was tested using Chi-square. The level of significance was determined as 0.05.

RESULTS

Response rate was 89.4%. Among surveyed residents, 66% had completed < 750 cases as a primary surgeon. More than 90% of SSRs were confident in performing appendectomy, open inguinal hernia repair, laparoscopic cholecystectomy, and trauma laparotomy, while 88% were confident in being on-call in level-I trauma center. No difference was noted in confidence level in relation to the number of performed cases. Residents from the Ministry of Health accounted for 56.3% of the study population and showed a higher confidence level compared to others. 94% of SSRs plan to pursue fellowship training program.

CONCLUSION

The study showed that the confidence of SSRs in performing common general surgery procedures was as expected. However, it's important to recognize that confidence doesn't necessarily reflect competence. Considering the majority of SSRs planned to pursue fellowship training programs, it may be time to consider changing the structure of surgical training in SA to a modular format to allow earlier and more intensive exposure.

Needs assessment in head and neck surgical oncology training: A qualitative study of expert opinions

BACKGROUND

Few studies have investigated the needs of head and neck surgery trainees and areas for improvement of fellowship programs.

METHODS

We conducted a qualitative study by interviewing a nationally representative sample of program directors and national leaders in head and neck surgery. We asked about the current state and strengths of training; and areas for further improvement. All interviews were independently coded and analyzed by two reviewers.

RESULTS

All experts (100%) believed that the current training provides a strong foundation and furthermore, a standardized curriculum is beneficial. Multidisciplinary training (80%), participation in tumor boards (75%), and a syllabus (60%) were the most frequently mentioned components. Most believed that a formal certification process would be beneficial (73%), though there was no consensus on the format.

CONCLUSION

Experts in head and neck surgery are generally in favor of a standardized curriculum. Further discussions of a formal certification process might be warranted.

Resident Perceptions of Faculty Behaviors Promoting Learner Operative Skills and Autonomy

OBJECTIVE

To better understand the resident perceived faculty factors associated with the promotion of resident operative skill and autonomy DESIGN: Qualitative retrospective analysis utilizing anonymous open-ended comments from residents on department of surgery faculty teaching evaluations and cross references them to observed faculty entrustment scores SETTING: Single tertiary midwestern allopathic academic medical center using data obtained between January 2016-August 2019 PARTICIPANTS: Forty-six resident and fourteen faculty surgeons from general, plastic, thoracic, and vascular surgery sections.

RESULTS

Themes of personal traits, the working environment created, and teaching techniques employed were identified across resident promoting attendings and resident limiting attendings. Promoting attendings employed preoperative goal setting, increased operative autonomy, and postoperative feedback while creating environments conducive to learning by promoting teamwork and collaboration. Alternatively, limiting attendings used more ineffective teaching techniques including micromanaging, lack of delegation, and treating residents as observers. Additionally, trainees described these operating room environments as stressful and strained.

CONCLUSIONS

Qualitative analysis of resident teaching evaluations of attending surgeons highlights the importance of relationships between learner and teacher, the learning environment, and teaching techniques. Continuous professional development programs centered on entrustment and promoting behaviors have the potential to disseminate strategies to enhance educator skills among surgeons.

The Relationship Between Self-Efficacy and Well-Being Among Surgical Residents

OBJECTIVE

Residency is a challenging time in the lives of physicians. In this study, we examined the relationship between general self-efficacy, defined as the belief in one's own capabilities in a variety of situations, and burnout and psychological well-being in a sample of surgical residents.

DESIGN

In the context of a larger study, a cross-sectional survey was administered to residents. The survey included measures of general self-efficacy, the emotional exhaustion and personal accomplishment domains of burnout, and general psychological well-being. We examined correlations between self-efficacy and these well-being outcomes and used multivariable linear regression models that controlled for age, gender, postgraduate year, ethnicity, and the interaction between gender and self-efficacy.

SETTING

We surveyed residents at Stanford Health Care, a tertiary care center, between the fall of 2010 and the spring of 2013.

PARTICIPANTS

One hundred and seventy nine residents from 9 surgical subspecialties responded to the survey for a response rate of 76%.

RESULTS

Residents reported high levels of self-efficacy, and over a third reported high emotional exhaustion. Eighty-nine percent of residents had average or high personal accomplishment. In adjusted regression analyses, general self-efficacy was negatively predictive of emotional exhaustion (B = -0.43, p = 0.0127) and positively predictive of personal accomplishment (B = 0.33, p = 0.0185) and general psychological well-being (B = 0.34, p = 0.0010). There was no interaction between gender and general self-efficacy in regression analyses (ps ≥ 0.6776).

CONCLUSIONS

Among other factors, self-efficacy appears to be significantly predictive of resident well-being. High self-efficacy suggests that residents feel prepared and capable. Interventions to improve residents' general self-efficacy should be explored as a possible mechanism to improve well-being.

Work-Related Quality of Life of US General Surgery Residents: Is It Really so Bad?

PURPOSE

The quality of working life of US surgical residents has not been studied, and given the complexity of interaction between work and personal life there is a need to assess this interaction. We utilized a validated Work Related Quality of Life (WRQoL) questionnaire to evaluate the perceived work-related quality of life of general surgery residents, using a large, nationally representative sample in the United States.

METHODS

Between January 2016 and March 2016, all US general surgery residents enrolled in an ACGME general surgery training program were invited to participate. The WRQoL scale measures perceived quality of life covering six domains: General Well-Being (GWB), Home-Work Interface (HWI), Job and Career Satisfaction (JCS), Control at Work (CAW), Working Conditions (WCS) and Stress at Work (SAW).

RESULTS

After excluding for missing data, the final analysis included 738 residents. The average age was 30 (±3) years, of whom 287 (38.9%) were female, 272 (36.9%) were from a community hospital, and 477 (64.6%) were juniors (postgraduate year ≤ 3). Demographically, the respondents matched expected percentages. When male and female residents were compared, males had statistically better HWI (p<0.001), better GWB (p = 0.03), more CAW (p = 0.0003) and WCS (p = 0.001). Junior residents had a lower JCS (p = 0.002) and CAW (p = 0.04) compared to seniors. There were no differences between university and community residents in any of the domains of WRQoL. Although residents were more stressed than other professions but the overall WRQoL was comparable.

CONCLUSIONS

The nature of surgical residency and a surgical career may in fact be more "stressful" than other professions, yet may not translate into a worsened Quality of Life. Our findings suggest further study is needed to elucidate why female residents have or experience a lower perceived WRQoL than their male colleagues.

Confidence Crisis Among General Surgery Residents: A Systematic Review and Qualitative Discourse Analysis

Importance

In the surgical community, there is concern that general surgery residents are choosing subspecialty training in large numbers because of a crisis in confidence at the end of training. Confidence is an essential quality of surgeons, and recent studies have attempted to quantify and measure it in graduating general surgery residents.

Objectives

To systematically review the quality of evidence provided and to critically analyze the language used to describe the findings using quantitative methods.

Evidence Review

A systematic review of the PubMed indexed literature on general surgery resident confidence was performed in March 2015. A summative table of each study's hypothesis, definition of confidence, quality using the Medical Education Research Study Quality Instrument, influence using Web of Science citations, results, and conclusions was created, and qualitative coding was applied to identify emerging themes. No date restrictions were used in the search.

Findings

Fifteen survey studies have been performed that measure confidence or readiness to practice. Although 5 studies had neutral or positive conclusions, most studies reported low confidence in general surgery graduates. There are conflicting data about definitions of confidence. The relationships between confidence, autonomy, and competence are varied and complex. Comparisons with the past are frequent.

Conclusions and Relevance

Confidence is difficult to define and measure. Despite limitations, survey studies are used to shape discourse and influence policies. Social and cultural factors influence self-efficacy, and focusing on operative volume and autonomy alone may not address all of the reasons that some residents express concerns about readiness to practice.

Effects of the reduction of surgical residents' work hours and implications for surgical residency programs: a narrative review

BACKGROUND

The widespread implementation of resident work hour restrictions has led to significant alterations in surgical training and the postgraduate educational experience. We evaluated the experience of surgical residency programs as reflected in the literature from 2008 onward in order to summarize current challenges and identify key areas in need of further research.

METHODS

We searched MEDLINE and EMBASE for English-language articles published from January 2008 to December 2011 related to work hour restrictions in surgical residency programs, including those pertaining to personal well-being, education and training, patient care, and faculty experiences.

RESULTS

We retrieved 240 unique abstracts and included 24 studies in the current review. Of the 10 studies examining effects on operating room experience, 4 reported negative or mixed outcomes and 6 reported neutral outcomes, although non-compliance was demonstrated in 2 of these studies. Effects on surgical faculty perceptions were consistently reported as negative, while the effect on patient outcomes and professionalism were found to be neutral and unchanged.

CONCLUSIONS

Further studies are needed to characterize operative experience at varying levels of training, particularly in the context of strict adherence to new work hours. Research that examines the effect of the work hour limitations on professionalism and non-operative educational activities, such as reading and simulation-based training, as well as sign-over practices, would also be of benefit.

The ACGME case log: general surgery resident experience in pediatric surgery

BACKGROUND

General surgery (GS) residents in ACGME programs log cases performed during their residency. We reviewed designated pediatric surgery (PS) cases to assess for changes in performed cases over time.

METHODS

The ACGME case logs for graduating GS residents were reviewed from academic year (AY) 1989-1990 to 2010-2011 for designated pediatric cases. Overall and designated PS cases were analyzed. Data were combined into five blocks: Period I (AY1989-90 to AY1993-94), Period II (AY1994-95 to AY1998-99), Period III (AY1999-00 to AY2002-03), Period IV (AY2003-04 to AY2006-07), and Period V (AY2007-08 to AY2010-11). Periods IV and V were delineated by implementation of duty hour restrictions. Student t-tests compared averages among the time periods with significance at P < .05.

RESULTS

Overall GS case load remained relatively stable. Of total cases, PS cases accounted for 5.4% in Period I and 3.7% in Period V. Designated pediatric cases declined for each period from an average of 47.7 in Period I to 33.8 in Period V. These changes are due to a decline in hernia repairs, which account for half of cases. All other cases contributed only minimally to the pediatric cases. The only laparoscopic cases in the database were anti-reflux procedures, which increased over time.

CONCLUSIONS

GS residents perform a diminishing number of designated PS cases. This decline occurred before the onset of work-hour restrictions. These changes have implications on the capabilities of the current graduating workforce. However, the case log does not reflect all cases trainees may be exposed to, so revision of this list is recommended.

General surgery vs fellowship: the role of the Independent Academic Medical Center

OBJECTIVES

To compare career choices of residency graduates from Independent Academic Medical Center (IAMC) and University Academic Medical Center (UAMC) programs and evaluate program directors' perceptions of residents' motivations for pursuing general surgery or fellowships.

DESIGN

From May to August 2011, an electronic survey collected information on program characteristics, graduates' career pursuits, and career motivations. Fisher's exact tests were calculated to compare responses by program type. Multivariate logistic regression was used to identify independent program characteristics associated with graduates pursuing general surgery.

SETTING

Data were collected on graduates over 3 years (2009-2011).

PARTICIPANTS

Surgery residency program directors.

RESULTS

Seventy-four program directors completed the survey; 42% represented IAMCs. IAMCs reported more graduates choosing general surgery. Over one-quarter of graduates pursued general surgery from 52% of IAMC vs 37% of UAMC programs (p = 0.243). Career choices varied significantly by region: over one-quarter of graduates pursue general surgery from 78% of Western, 60% of Midwestern, 40% of Southern, and 24% of Northeastern programs (p = 0.018). On multivariate analysis, IAMC programs were independently associated with more graduates choosing general surgery (p = 0.017), after adjustment for other program characteristics. Seventy-five percent of UAMC programs reported over three-fourths of graduates receive first choice fellowship, compared with only 52% of IAMC programs (p = 0.067). Fellowships were comparable among IAMC and UAMC programs, most commonly MIS/Bariatric (16%), Critical Care/Trauma (16%), and Vascular (14%). IAMC and UAMC program directors cite similar reasons for graduate career choices.

CONCLUSIONS

Most general surgery residents undergo fellowship training. Graduates from IAMC and UAMC programs pursue similar specialties, but UAMC programs report more first choice acceptance. IAMC programs may graduate proportionately more general surgeons. Further studies directly evaluating surgical residents' career choices are warranted to understand the influence of independent and university programs in shaping these choices and to develop strategies for reducing the general surgeon shortage.

Surgical residents' perception of competence and relevance of the clinical curriculum to future practice

INTRODUCTION

General surgery residents maintain a case log throughout residency in order to achieve a targeted number of designated operations. Program directors must certify that each graduate is competent to enter general surgery practice without direct supervision. Our purpose was twofold, to determine: 1) graduates' perception of competence and relevance of specific operations to their practice; and 2) if case volume is related to competence.

METHODS

Six classes from a general surgery residency program (n=26) were surveyed one year after graduation. The survey was piloted and revised base on findings. It listed 67 operations encompassing all facets of general surgery. Each operation corresponded to two four-point scales (strongly agree to strongly disagree). One scale was headed with "I was well prepared to work-up, independently perform the operation, and effectively care for the patient post-operatively" and the other "This operation is relevant to my current practice profile". A linear regression analysis was utilized to study the relationship between total case volume and overall competence. An unpaired T-test was utilized to study the relationship between volume of specific operations and perceptions of competence.

RESULTS

Twenty-two graduates completed the survey (85% response rate). All respondents felt prepared to perform 24% (16/67) of the operations. Fifty percent or more of respondents felt prepared to perform 91% (61/67) of the operations. Fifty percent or more did not feel competent performing the surgical treatment of necrotizing enterocolitis, orchiopexy, transhiatal esophagectomy, adrenalectomy, and open/endovascular abdominal aortic aneurysm repair. Twenty-six operations were felt to be irrelevant to the practice of 50% or more of graduates. No operation was unanimously felt to be relevant. For 12% of operations (8/67) at least 10% of graduates felt the operation was relevant to their practice but were not comfortable performing it. These operations (abdominoperineal resection, transanal excision of tumor, transhiatal esophagectomy, superficial inguinal lymph node dissection, right hepatectomy, whipple, colonoscopy, and adrenalectomy) were considered to be in need of educational improvement at a program level. After analyzing individual case logs, increased case volume only correlated with competence for esophagectomy (5 vs. 1 p = .014), EGD (32 vs. 9 p = .018), orchiopexy (2.5 vs. 0 p = .03), and adrenalectomy (3 vs. 1 p = .001). Total major operations performed did not correlate with overall competence (p = .12).

CONCLUSION

As program directors must document graduates' competency they must do so with confidence. Our results suggest graduates to not feel competent performing many operations, and several are relevant to their practice. Competence in all aspects of general surgery may be unrealistic, even with robust volume. These findings might help in the restructuring curricula of residency.

WeBSurg: An innovative educational Web site in minimally invasive surgery--principles and results

Internet has dramatically changed clinical practice and information sharing among the surgical community and has revolutionized the access to surgical education. High-speed Internet broadcasting allows display of high-quality high-definition full-screen videos. Herein, Internet access to surgical procedures plays a major role in continuing medical education (CME). The WeBSurg Web site is a virtual surgical university dedicated to post-graduate education in minimally invasive surgery. Its results measured through its members, number of visitors coming from 213 different countries, as well as the amount of data transmitted through the provider LimeLight, confirm that WeBSurg appears as the first Web site in surgical CME. The Internet offers a tailored education for all levels of surgical expertise as well as for all types of Internet access. This represents a global multimedia solution at the cutting edge of technology and surgical evolution, which responds to the modern ethos of "always, anywhere, anytime."

Resident/fellow assistance in the operating room for endocrine surgery in the era of fellowships

BACKGROUND

Historically, a high percentage of endocrine surgical procedures are performed by general surgeons in nonteaching environments. With the institution of accredited fellowships, we sought to determine whether that dynamic is changing.

MATERIALS AND METHODS

The American College of Surgeons-National Surgeons Quality Improvement Program was queried for all thyroid, parathyroid, and adrenal operations performed during 2005-2008. Resident assistance was classified as none, junior (postgraduate years 1-3), senior (postgraduate years 4 and 5) or fellow (≥ postgraduate year 6). Data were also examined for associations between resident/fellow assistance and surgical outcomes.

RESULTS

In all, 24.7% of endocrine operations (7,140/29,161) were performed by an attending surgeon operating alone (17.1% adrenals, 27.4% thyroids, and 20.6% parathyroids). Fellows assisted in 6.6% of operations (18.3% adrenals, 4.7% thyroids, and 8.2% parathyroids; 2006: 586 operations, 2007: 629 operations, and 2008: 720 operations). Comparing attending surgeons operating alone with those assisted by residents/fellows, they had shorter operative times (P < .001), longer surgical duration of stay (parathyroid: 1.73 days, thyroid: 1.80 days, P < .001), and a higher prevalence of obese, diabetic, or octogenarian patients. However, no significant difference was found in the rates of wound infections, medical complications, return to the operating room, or overall morbidity.

CONCLUSION

Even with the increase in endocrine surgery fellowships, almost one fourth of all endocrine operations are still performed by attending surgeons operating alone. Although operations assisted by residents/fellows took longer and patients had a greater duration of stay, there were no significant differences in measured outcomes.

Enhancing resident interest in a state surgical meeting

OBJECTIVES

To stimulate increased interest in the annual American College of Surgery (ACS) chapter meeting, a state-wide mock oral examination for senior level surgical residents was organized. The purpose of this study was to evaluate the impact of and the results from our state's initial attempt to conduct a state-wide mock oral examination.

METHODS

The mock oral examination was structured as a 90-minute assessment in 9 content areas. Residents at or above the postgraduate year (PGY)-3 level were offered the examination and every attempt was made to ensure that examiners were from institutions different than the examinee's training program. Examinations were scored as satisfactory, marginal, or unsatisfactory. Each examinee received a written assessment of their performance.

RESULTS

Thirty-eight volunteer examiners committed to participate and 37 of the state's 82 senior-level residents appeared for the mock oral examination. The examiners included faculty from all 7 of the state's training programs and 10 private practice surgeons. The residents represented 6 of the 7 programs with 10 PGY-3, 12 PGY-4, and 15 PGY-5 residents completing the examination. The overall performance on the examination included 15 (40.5%) residents rated as satisfactory, 15 (40.5%) assessed as marginal, and 7 (18.9%) received a rating of unsatisfactory.

CONCLUSIONS

With rare exception, faculty examiners and resident examinees indicated by survey that the mock oral examination was a useful educational experience and increased the level of interest in attending the state's annual ACS meeting.

The future of academic surgery

Academic surgery is a microcosm of the greater academic medical enterprise-albeit with some admitted idiosyncrasies. Most of the issues and challenges are common to other areas of academic practice, but the means by which academic surgeons meet these challenges will be different. Along with continuous process improvement, future innovation is imperative in virtually all areas. Some specific solutions to challenges in clinical care that academic surgeons should pursue include promoting both evidenced-based and more uniform, quality surgical clinical care; incorporating more efficiency into the clinical care environment; continuing to develop minimally invasive technology and techniques; and implementing the use of prospective clinical databases in real time. Goals of surgical education should include using simulation technology, standardizing technical evaluation techniques, incorporating more basic science, and focusing more on professionalism. Lastly, the surgical research enterprise needs restructuring (including a new process for making decisions regarding who receives resources), strategies to improve extramural funding, and new approaches for selecting foci for surgical research efforts that build on differentiated strengths related to surgical practice.