Surgical resident education: what is the department's price for commitment?

Changing Frequency of the Use of Intraoperative Equipment Among Neurosurgeons, Neurosurgery Residency Faculty, and Neurosurgery Residents

Neurosurgical procedures have relied on the use of various intraoperative equipment since its advent. These include an operative microscope, ultrasound, and loupes with a headlight. The necessity of these pieces of equipment makes them vital in the training of residents as well. A national survey utilizing a Likert scale to determine how often loupes, microscopes, and ultrasound were used for various neurosurgeries was created. This was then compared to a single program’s responses, and it identified that the practice parameters of residents closely modeled those behaviors portrayed by their attending mentors. It appears that the higher frequency of use by residents when compared to faculty and neurosurgeons nationwide highlights the importance of this equipment in training neurosurgical residents. 

As such, they should be available to residents from the onset of training to promote the highest quality of learning. Faculty should encourage the use of this equipment by leading by example, and residents, in turn, should use all the available equipment as often as possible to maximize the quality of their training. Modulating the use of learning technologies can be accomplished if it is a nationally accepted practice, discussed in an academic setting with the residents, and modeled by the faculty.

Effectivity of Distance Learning in the Training of Basic Surgical Skills—A Randomized Controlled Trial

Background: Distance learning is an interactive way of education when teachers and students are physically separated. Our purpose was to examine its effectivity in training of basic surgical techniques and to provide an alternative sustainable methodology for the training of medical professionals. Methods: Sixty students were involved in our single blinded randomized controlled study. Six homogenized groups were created then randomized into three groups of distance learning and three groups of in-person teaching. The groups completed the same curriculum using our own “SkillBox”. All students took the same pre- and post-course test evaluated blindly. The students filled out an online feedback form after the course. A financial analysis was also made. Results: There was no significant difference in the post-course exam results (distance 28.200 vs. in-person 25.200). We managed to achieve significantly better improvements in the distance learning of suturing (distance 19.967 vs. in-person 15.900, p = 0.043). According to 93% of the study group students, the quality of teaching did not decrease compared to the traditional classes. Conclusion: The results of the students improved similarly in distance learning and in-person education. The online form of teaching was received positively among the students; they found it an effective and good alternative.

The Cost of Compliance: The Financial Burden of Fulfilling Accreditation Council for Graduate Medical Education and American Board of Surgery Requirements

OBJECTIVE

There has been a significant increase in the number of regulatory requirements for general surgery graduate medical education (GME) programs over the last 20 years from the governing bodies of the American Board of Surgery (ABS) and the Accreditation Council of Graduate Medical Education (ACGME). We endeavored to calculate the cost to general surgery GME programs of regulatory requirements.

DESIGN

We examined the requirements for General Surgery ABS Certification as well as the 2017 ACGME Program Requirements in General Surgery for all mandates that require funding by the surgery program to achieve. The requirements requiring funding include certification in Advanced Cardiac Life Support, Advanced Trauma Life Support, Fundamentals of Laparoscopic Surgery, Fundamentals of Endoscopic Surgery; access to medical references; simulation capability, program director protected time (30%); program coordinator salary (Association for Hospital Medical Education reported mean); and faculty time devoted to morbidity and mortality conference, journal club, Clinical Competency Committee, and Program Evaluation Committee. We then identified the cost of each mandate based on the average program in the United States of 5 residents per year in 5 clinical years.

RESULTS

Total cost for the average program per year as the result of ABS or ACGME mandate equaled a minimum of $227,043. The ABS associated costs are $8900 per year. The ACGME associated costs are $218,143. The cost of program director and faculty time to meet the minimum ACGME requirements equaled $159,600.

CONCLUSIONS

The most significant cost associated with mandates set forth by the ABS and ACGME are program director and faculty time devoted to resident education and evaluation. Recognition of this cost burden by institutions and policymakers for the allocation of funds is important to maintain strong general surgery GME programs.

Tutorial Assistance for Board Certification in Surgery: Frequency, Associated Time and Cost

BACKGROUND

Tutorial assistance is related to extra time and cost, and the hospitals' financial compensation for this activity is under debate. We therefore aimed at quantifying the extra time and resulting cost required to train one surgical resident in the operating theatre for board certification in Switzerland as an example of a training curriculum involving several surgical subspecialties. Additionally, we intended to quantify the percentage of tutorial assistance.

METHODS

We analysed 200,700 operations carried out between 2008 and 2012. Median duration of procedure categories was calculated according to four different seniority levels. The extra time if the procedure was performed by residents, and resulting cost were analysed. The percentage of procedures carried out by residents as compared to more experienced surgeons was assessed over time.

RESULTS

On average, residents performed about a third of all operations including typical teaching procedures like appendectomies. An increase in duration and cost of well-defined procedures categories, e.g. cholecystectomies was demonstrated if a resident performed the procedure. In less well-defined categories, residents seemed to perform less difficult procedures than senior consultants resulting in shorter durations of surgery.

CONCLUSIONS

The financial impact of tutorial assistance is important, and solutions need to be found to compensate for this activity. The low percentage of procedures performed by trainees may make it difficult to fulfil requirements for board certification within a reasonable period of time. This should be addressed within the training curriculum.

The Pareto Analysis for Establishing Content Criteria in Surgical Training

INTRODUCTION

Current surgical training is still highly dependent on expensive operating room (OR) experience. Although there have been many attempts to transfer more training to the skills laboratory, little research is focused on which technical behaviors can lead to the highest profit when they are trained outside the OR. The Pareto principle states that in any population that contributes to a common effect, a few account for the bulk of the effect. This principle has been widely used in business management to increase company profits. This study uses the Pareto principle for establishing content criteria for more efficient surgical training.

METHOD

A retrospective study was conducted to assess verbal guidance provided by 9 supervising surgeons to 12 trainees performing 64 laparoscopic cholecystectomies in the OR. The verbal corrections were documented, tallied, and clustered according to the aimed change in novice behavior. The corrections were rank ordered, and a cumulative distribution curve was used to calculate which corrections accounted for 80% of the total number of verbal corrections.

RESULTS

In total, 253 different verbal corrections were uttered 1587 times and were categorized into 40 different clusters of aimed changes in novice behaviors. The 35 highest-ranking verbal corrections (14%) and the 11 highest-ranking clusters (28%) accounted for 80% of the total number of given verbal corrections.

CONCLUSIONS

Following the Pareto principle, we were able to identify the aspects of trainee behavior that account for most corrections given by supervisors during a laparoscopic cholecystectomy on humans. This strategy can be used for the development of new training programs to prepare the trainee in advance for the challenges encountered in the clinical setting in an OR.

Financial Contribution of Residents When Billing as "Junior Associates" in the "Surgical Firm"

OBJECTIVE

There is an increasing number of proposals to change the way Graduate Medical Education is funded. This study attempts to estimate the potential financial contribution of surgical residents using an alternative funding mechanism similar to that used by law firms, which would allow surgery departments to bill for resident activity as "junior associates."

METHODS

Following 24 residents over a period of 12 weeks, we were able to estimate the annual revenue that they generated from operating room procedures, independent consultations, patient management, and minor procedures using Medicare reimbursement rates. The appropriate first assistant modifier was used to calculate the operating room procedure fees, but full price was used to calculate the revenue for minor procedures, patient management, and consultations done independently. We adjusted for vacation time and academic activities.

RESULTS

Including postgraduate year 1 residents, the estimated yearly revenue generated per resident in first assistant operative services was $33,305.67. For minor procedures, patient management, and independent consultations, the estimated yearly revenue per resident was $37,350.66. The total estimated financial contribution per resident per year was $70,656.33. Excluding postgraduate year 1 residents, as most states require completion of the intern year before full licensure, the estimated yearly revenue generated per resident in first assistant operative services was $38,914.56. For minor procedures, patient management, and independent consultations, the estimated yearly revenue per resident was $55,957.33. The total estimated financial contribution per resident per year was $94,871.89.

CONCLUSIONS

Residents provide a significant service to hospitals. If resident activity was compensated at the level of supervised "junior associates" of a surgery department, more than 75% of the direct educational costs of training could be offset. Furthermore, we believe this value is underestimated. Given the foreseeable changes in Graduate Medical Education funding, it is imperative that alternative approaches for funding be explored.

Alternative Considerations for Surgical Training and Funding

Since the late 1880s surgical residency programs have existed in forms that are similar to our current models. Many important variations have been introduced over time. On aggregate this system has worked remarkably well; though as economic, demographic, and cultural changes continue to evolve, one must wonder if we were to change our models how might we do that and what reasoning could we use. This article's focus is to take a stratospheric view of what could be done, particularly in the United States, rather than characterize what happens in other countries with other health economic systems.

e-Learning in Surgical Education: A Systematic Review

OBJECTIVE

e-Learning involves the delivery of educational content through web-based methods. Owing to work-hour restrictions and changing practice patterns in surgery, e-learning can offer an effective alternative to traditional teaching. Our aims were to (1) identify current modalities of e-learning, (2) assess the efficacy of e-learning as an intervention in surgical education through a systematic review of the literature, and (3) discuss the relevance of e-learning as an educational tool in surgical education. This is the first such systematic review in this field.

DESIGN

A systematic search of MEDLINE and EMBASE was conducted for relevant articles published until July 2014, using a predefined search strategy. The database search was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

A total of 38 articles were found which met the inclusion criteria. In these studies, e-learning was used as an intervention in 3 different ways: (1) to teach cases through virtual patients (18/38); (2) to teach theoretical knowledge through online tutorials, or other means (18/38); and (3) to teach surgical skills (2/38). Nearly all of the studies reviewed report significant knowledge gain from e-learning; however, 2 in 3 studies did not use a control group.

CONCLUSIONS

e-Learning has emerged as an effective mode of teaching with particular relevance for surgical education today. Published studies have demonstrated the efficacy of this method; however, future work must involve well-designed randomized controlled trials comparing e-learning against standard teaching.

It was the night before the interview: perceptions of resident applicants about the preinterview reception

OBJECTIVE

Hosting a reception for prospective interns the evening before the interview has become a well-established expectation. It is thought that these initial impressions significantly influence the ranking process. Despite these well-held beliefs, there has been a paucity of studies exploring the preinterview reception.

DESIGN

A survey tool was created and piloted to ensure validity. The survey was then administered to a fourth-year class of allopathic medical students immediately after interviews but before Match Day.

SETTING

A university, teaching hospital.

PARTICIPANTS

Fourth-year allopathic medical students.

RESULTS

The response rate was 100% (n = 69). Ninety-six percent of programs hosted an event. Although these events were minimally stressful (86%), the same percent felt that not attending would limit their knowledge of the program, and 66% felt that it would negatively affect their application. Forty percent believe this event to be extremely important to residency programs in selecting interns. Ninety-five percent are attended by residents only, and approximately half were at a casual restaurant. Most applicants (97%) never paid for their own meal, and 69% felt that if they did, it would leave a negative impression of the program.

CONCLUSIONS

Candidates believe the preinterview reception is important in the selection process, that failing to attend would negatively affect their application, and provides insight about the program. Alcohol is often provided but rarely has a negative effect. Applicants prefer an informal setting with unfettered interactions with the residents.